A Mixed-Method Study of the Effects of a Mindfulness-Based Relapse Prevention Aftercare Program on Clients with Opioid Addictio

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A MIXED-METHOD STUDY OF THE EFFECTS OF

A MINDFULNESS-BASED RELAPSE PREVENTION AFTERCARE PROGRAM ON

CLIENTS WITH OPIOID ADDICTION IN A COURT-ORDERED POPULATION

A Dissertation

Presented to

The Graduate Faculty of the University of Akron

In Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy

Andrew J. Davis

August 2020

A MIXED-METHOD STUDY OF THE EFFECTS OF

A MINDFULNESS-BASED RELAPSE PREVENTION AFTERCARE PROGRAM ON

CLIENTS WITH OPIOID ADDICTION IN A COURT-ORDERED POPULATION

Andrew J. Davis

Dissertation

Approved: Accepted:

______Advisor School Director Dr. Robert C. Schwartz Dr. Varunee Faii Sangganjanavanich

______Committee Member Acting Dean of the College Dr. Kristin Koskey Dr. Timothy McCarragher

______Committee Member Acting Dean of the Graduate School Dr. Varunee Faii Sangganjanavanich Dr. Marnie M. Saunders

______Committee Member Date Dr. Victor E. Pinheiro

______Committee Member Dr. Seungbum Lee

ABSTRACT

The purpose of this study was to investigate the effects of mindfulness-based relapse prevention (MBRP) aftercare program on participants who were in court-ordered opioid addiction treatment. This study utilized a mixed-methods ex post facto single group pretest posttest research design and analyzed archival data to determine (1) the results of changes in mindfulness, self-compassion, and impulsivity, and (2) the findings of clients’ experiences, and (3) the meta-inferences which could were drawn from integrating both quantitative results and qualitative findings. Archival data was from a previous MBRP aftercare program and included adult women (n=15) and men (n=9) in a court-ordered opioid addiction treatment program in northeast Ohio. Three instruments were used for quantitative data from (N=24) participants including the Five Factor

Mindfulness Questionnaire, the Self-Compassion Scale – Short Form, and the Barratt

Impulsiveness Scale. Semi-structured interviews were conducted with nine of the participants. Results included one statistically significant increase (p < .05) in the nonreacting component of mindfulness from pretest to posttest. All other quantitative results, while not reaching statistical significance, showed a change in mean scores for increased mindfulness and self-compassion, and decreased impulsivity from pretest to posttest. Qualitative findings showed three types of client experiences emerged from the data: engaged, transitional, and disengaged. These experiences were comprised of five

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facets: sentiment, attitude, motivation, learning and relationships. Convergence was found between quantitative results and qualitative findings for mindfulness, self- compassion, and impulsivity. Implications for counselor practice, counselor trainees, counselor educators and supervisors, and future research were discussed.

DEDICATION

To my wife & love, Christine. – “I am the luckiest man in the world!”

To each of my kids, Anne, Maximilian, Grace, Elise & Isabelle.

Remember the words of your Grand-mère, “You can be anything you set your mind to!”

ACKNOWLEDGEMENT

I would like to thank my advisor and dissertation chair, Dr. Robert Schwartz who has supported me throughout this entire journey with his unfailing encouragement, patience, and openness to my ideas and dreams. He helped me persevere and gave me an outstanding model of a counselor educator and supervisor. To Dr. Kristin Koskey, I give thanks for her encouragement and teaching me the ropes of mixed methodology research.

To my committee members Dr. Varunee Faii Sangganjanavanich, Dr. Seungbum Lee and

Dr. Victor Pinheiro, I thank you for your guidance, example and working with me through this dissertation process. You have all given me light for the path, more than you know.

To my family – Chris, Anne, Max, Grace, Elise & Isabelle, you have given me your constant support and encouragement throughout the doctoral program. You amaze and inspire me by your own creative pursuits, and accomplishments. Your love sustains me. Thank you.

To my friends and colleagues who may have thought I was crazy, in over my head, but still were willing to be there, provided guidance, and helped me stay focused – I give you my gratitude – Fred Neugebauer, Mark Ballard, Fr. G. David Bline, Deacons

David Kushner and Robert Youngblood, my colleagues at Catholic Charities and

Signature Psychiatry Associates, and my faith community at St. Vincent de Paul Parish in

Akron, OH.

To all the teachers who taught me mindfulness practice for clinical work, I give you thanks – especially Zindel Segal, Susan Woods, Neha Chawla, and Joel Grow.

To the Summit County Alcohol, Drug, and Mental Health Board who grant funded the original MBRP project and to the staff at Oriana House Inc., in Akron who made this study possible, thank you!

Finally, to all the participants in the study, to those who struggle with addiction, and to those who demonstrate recovery is possible – you are a gift to us all. Thank you for sharing your life and teaching us for the benefit of all.

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TABLE OF CONTENTS

LIST OF FIGURES ...... xii

LIST OF TABLES ...... xiii

CHAPTER

I. INTRODUCTION ...... 1

Introduction to Opioid Addiction and Treatment ...... 1

Mindfulness-Based Relapse Prevention Aftercare ...... 4

Mindfulness, Self-Compassion and Impulsivity ...... 8

Statement of the Problem ...... 13

Purpose of the Study ...... 14

Research Questions ...... 15

Definition of Terms...... 16

Summary of Chapter ...... 18

II. A REVIEW OF THE LITERATURE ...... 19

Overview of Opioid Addiction and Treatment ...... 19

Aftercare Treatment and Continuing Care ...... 22

Impulsivity in Opioid Use Disorder ...... 26

Overview of Self-Compassion in Substance Addiction...... 32

Overview of Mindfulness and Opioid Addiction...... 37

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Overview of MBRP for Substance Addiction ...... 46

Mindfulness, Self-Compassion, Impulsivity and Opioid Addiction ...... 63

Summary of Related Research Literature ...... 68

Rationale for Study ...... 77

III. METHODOLOGY ...... 79

Hypotheses ...... 80

Description of Independent and Dependent Variables ...... 81

Research Design...... 82

Participants and Delimitations ...... 86

Procedures ...... 91

Instruments ...... 93

Data Analysis ...... 101

Validity and Credibility ...... 106

Researcher Subjectivity ...... 109

Summary of Methodology ...... 110

IV. RESULTS ...... 111

Quantitative Results ...... 112

Summary of Quantitative Results ...... 122

Qualitative Findings ...... 122

Summary of Qualitative Findings ...... 154

Integration of Quantitative Results and Qualitative Findings...... 156

Summary of Results and Findings ...... 163 ix

V. DISCUSSION ...... 166

Descriptive Summary and Interpretation of Statistical Results ...... 166

Discriptive Summary and Interpretation of Qualitative Findings...... 170

Integration and Meta-Inferences of Qualitative and Quantitative Analysis ...... 178

Implications for Counselor Practice in Court-Ordered Settings with Participants Recovering from Opioid Addiction ...... 179

Implications for Counselor Education Programs ...... 182

Implications for Future Research ...... 185

Limitations ...... 188

Conclusions ...... 189

REFERENCES ...... 191

APPENDICES ...... 233

APPENDIX A. IRB APPROVAL LETTER ...... 234

APPENDIX B. PERMISSION TO CONDUCT RESEARCH, OHI ...... 235

APPENDIX C. DEMOGRAPHIC QUESTIONNAIRE...... 236

APPENDIX D. FIVE FACECT MINDFULNESS QUESTIONNAIRE ...... 237

APPENDIX E. SELF-COMPASSION SCALE – SHORT FORM ...... 239

APPENDIX F. BARRATT IMPULSIVITY SCALE - 11 ...... 240

APPENDIX G. SEMI-STRUCTURED INTERVIEW GUIDE ...... 241

APPENDIX H. INFORMED CONSENT FORM ...... 243

APPENDIX I. INDIVIDUAL PARTICIPANT SCORES...... 244

APPENDIX J. FALSE REFUGES EXERCISE ...... 245

APPENDIX K. CODE BOOK ...... 246

LIST OF FIGURES

Figure Page

1 Phase 1 MBRP Aftercare Program Intervention & Archival Data Collection ...... 83

2 Phase 2 Analysis of Archival Data from Phase 1 ...... 84

3 Coding & Analysis Process ...... 108

4 Nonreacting Effect Size (Cohen’s d) between Pretest and Posttest Scores ...... 114

5 Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group A ...... 118

6 Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group B ...... 119

7 Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group C ...... 120

8 Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group D ...... 121

9 Joint Display: Integrating Qualitative Findings of Participant Experience and Outcomes with Quantitative Results for Mindfulness, Self-Compassion and Impulsivity ...... 164

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LIST OF TABLES

Table Page

1 Outline of MBRP Session Content ...... 51

2 Impulsivity and MBRP Components ...... 66

3 Summary of Data Analysis ...... 85

4 Participant Demographics ...... 88

5 Counselor Demographics ...... 90

6 Data Analysis for Qualitative Data ...... 103

7 Mixed-Method Analysis ...... 105

8 Descriptive Statistics for Pretest and Postest FFMQ, SCS-SF, and BIS-11 Scores (N = 24) ...... 113

9 Participants’ Difference Between Pretest and Posttest Mindfulness, Self- Compassion and Impulsivity ...... 115

10 Frequency of Participants’ Scores Increasing, Decreasing or No Change ...... 116

11 Comparison of Differences in Mean Group Scores by Counselor Group ...... 116

12 Summary of Three Types of Participants’ Experiences & Related Facets in MBRP ...... 124

13 Number of Participants’ Coded References (Qual) from Interviews Corresponding to Level of Significance for FFMQ (and subscales), SCS-SF and BIS-11 Outcome Scales ...... 157

14 Quantitative Results and Participant Quotes for Mindfulness, Self-Compassion and Impulsivity ...... 158

15 Participants’ Type of Experience Compared to Quantitized Number of References to Experience Facet Codes ...... 162

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CHAPTER I

INTRODUCTION

Introduction to Opioid Addiction and Treatment

Opioid addiction in the United States has escalated to epidemic levels since the early 1990’s (Runyan et al., 2017). This acceleration was fueled in large part by the introduction in 1995 of OxyContin, an extended release formulation of oxycodone manufactured by Purdue Pharma (Kolodny et al., 2015) and the medical profession changing its philosophy on prescription opioid use for treating pain as seen in 1999 by the Veterans Administration using pain severity as one of the fifth vital signs of health

(Mularski et al, 2011). The Centers for Disease Control and Prevention (2016) lists opioid overdose prevention to one of its top ten public health challenges.

In Ohio, unintentional drug overdose was the leading cause of injury-related death in

2015, ahead of motor vehicle traffic crashes. For example, between 2000 and 2012 there was a 366% increase in drug overdose deaths, and since 2012 there has been a significant shift upward in opioid overdose deaths (Massatti et al., 2014). In Summit County, from

January 1, 2016 to October 31, 2016, emergency rooms serving Summit County residents have treated an estimated 1,917 drug overdoses. After seeing the year’s highest spike hit the community on Labor Day weekend of 2016, the community experienced its highest spike in overdoses per day at 19.7, after which the overdose rate dropped sharply to just under seven per day by the third week of September. Overdoses had fluctuated between seven and 10 per day for the remainder of 2016 (Summit County Public Health, 2016).

Local overdose data parallel national trends of rapidly increasing opioid overdoses, and three out of five drug overdose deaths involve an opioid and have increased by more than five times since 1999. Opioid overdoses killed more than 42,000 people in 2016. (Centers for Disease Control, 2018).

The American Society of Addiction Medicine (ASAM) defines addiction as “a primary, chronic disease of brain reward, motivation, memory, and related circuitry,” with a “dysfunction in these circuits” being reflected in “an individual pathologically pursuing reward and/or relief of withdrawal symptoms by substance use and other behaviors” (Mee-Lee et al., 2013, p. 10). In ASAM’s treatment guide for opioid addiction, the preferred term by ASAM for this serious bio-psycho-social-spiritual illness would be “addiction involving opioid use” (Kampman & Jarvis, 2015, p. 3).

Alternatively, Opioid Use Disorder is a relatively new diagnostic term developed by the

American Psychiatric Associate (2013) to describe the phenomenon of and criteria for problematic substance use which presents on a continuum of severity. The modes of treatment for opioid use disorder and addiction are many and varied, with much discussion as to which approaches are indicated or contraindicated (Amaro et al., 2014).

The term opioid addiction was used in this study to refer to opioid-related bio-psychosocial-spiritual life concerns or impairments, and it represents the severity of disorder of the population being studied.

There are specific barriers that must be considered when treating opioid addiction that are different from other substance addictions. Many clients may not consider treatment due to stigma and misconceptions of what treatment entails (Wakeman, 2018).

There are a wide variety of reasons for treatment initiation including crisis, coercion, fear,

or exhaustion from personal consequences (Damon et al., 2017; Waldorf, 1983). Long- term opioid use alters the body’s neurophysiology for responding to pain and natural rewards in such a way that addicts experience greater pain sensitivity and lack the ability to be satisfied by the body’s natural reward system which leads to increased craving and negative affect (Garland et al., 2017). There are particular dangers of opioid overdose in the present environment of available psychoactive substances wherein many street drugs are often mixed with fentanyl and carfentanil and their potency is unclear. Intravenous

(IV) drug use puts users at risk of multiple chronic diseases such as HIV, Hepatitis-C

(Treloar et al., 2014), and infective endocarditis (Weir et al., 2019). IV drug users also experience social discrimination above other drug users (Crawford et al., 2012).

Treatment for opioid addiction begins with assessment to determine the severity, chronicity of the addiction, likelihood of recidivism, and the level of care appropriate.

Persons may enter treatment either voluntarily or through court-ordered treatment programs. Guidelines for assessment and treatment have been developed by the American

Society of Addiction Medicine (Kampman & Jarvis, 2015) and includes pharmacotherapies and psychosocial approaches, including residential treatment, mutual- help programs (e.g., Narcotics Anonymous and 12-Step programs), and aftercare services. These modalities may be used as stand-alone interventions or in combination with pharmacotherapy. Psychosocial opioid addiction treatment approaches show value and are an important treatment option, however research with greater specificity and consistency is needed to evaluate and achieve better outcomes (Kolodny et al., 2015). At a minimum, psychosocial treatment should include the following: psychosocial needs

assessment, supportive counseling, links to existing family supports, and referrals to community services (Kampman & Jarvis, 2015).

Primary to treatment of opioid addiction includes the use of medically assisted treatments (MAT) to alleviate neurophysiological dependence and withdrawal symptoms in order to allow persons to stabilize and maintain normal function in their daily activities and engage in psychosocial treatment. MAT includes the use of agonist agents

Methadone and Suboxone, and antagonist Vivitrol in combination with development of internal coping skills to adapt to impacted affective-neural circuitry (Garland & Black,

2014; Kelly et al., 2017). Staged psychosocial treatment is often done in phases such as detox, inpatient, intensive outpatient, outpatient, and aftercare or maintenance counseling.

Treatment supplemented by a mutual-help support approach has its place in the treatment continuum and needs to be informed by research to ensure best practices.

Of interest in this study was the aftercare stage of treatment for opioid addiction, which typically follows stabilization and completion of a prescribed (e.g., six-week) intensive outpatient program. Aftercare programs are done as a form of step down from an intensive outpatient (IOP) regimen and promotes maintenance of treatment gains while clients shift to resuming life responsibilities such as return to work, childcare and housing. Aftercare programs are highly varied and little studied. In fact, no research on the efficacy of opioid addiction-specific aftercare programs was found in the literature.

One response to the is need was in 2015, when Summit County Ohio’s Alcohol, Drug and Mental Health Board funded a pilot mindfulness-based relapse prevention (MBRP) aftercare program for opioid addiction with a local private non-profit corrections and treatment organization in Akron, OH. The present study used the archival data to

investigate treatment efficacy of MBRP aftercare for persons with opioid addiction in a court-ordered program.

Mindfulness-Based Relapse Prevention Aftercare

Alan Marlatt and a team from the University of Washington developed a new approach to addiction treatment that combined mindfulness training and relapse prevention after many years of work on cognitive behavioral therapy models and exploration with Vipassana meditation to help people with drug and alcohol problems

(Marlatt et al., 2004). The preliminary data for combined strategies was promising and the approach was manualized as mindfulness-based relapse prevention (MBRP;

Witkiewitz et al., 2005). The MBRP protocol is an eight-week group intervention utilizing mindfulness-based practices to help them engage their awareness and compassion to meet challenges posed by addiction such as toleration of urges or cravings, versus going on “automatic pilot” and giving in (Brown, 2012). The mindfulness practices are integrated with cognitive skills training such as identifying high risk situations and coping skills, approximately 30-40 minutes of mediation practice and open discussion of experiences (Bowen & Vieten, 2012; Witkiewitz & Bowen 2010;

Witkiewitz et al., 2013a). Compared to predominantly CBT treatments, MBRP focuses on clients engaging in an experiential process versus being the recipients of psychoeducation (Bowen & Vieten, 2012).

The first randomized controlled trial of MBRP supported feasibility and acceptance of MBRP as an aftercare program (Bowen et al., 2009). Treatment efficacy was supported by lower substance use rates of those having received MBRP versus treatment as usual (TAU) over at 4-month period. MBRP participants demonstrated

4 greater decreases in craving and increases in acceptance and acting with awareness 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 (Bowen et al., 2009). The largest randomized controlled trial (RCT) done for MBRP and published in the Journal of the

American Medical Association (Bowen et al., 2014) compared relapse prevention (RP),

MBRP and typical 12-step aftercare treatment. Findings indicated that MBRP and RP were beneficial aftercare interventions, and at 12-months follow-up MBRP had significantly less drug use (31%) and a lower probability of heavy drinking. This suggested MBRP may support sustaining treatment gains for longer term.

MBRP is a potentially effective and cost-efficient adjunct to CBT-based treatments (Hendershot et al., 2011). However little is known about which types of individuals would benefit the most from MBRP, therefore there is a need to study individual characteristics associated with positive treatment outcomes. This knowledge would help match clients to treatment (Hsu et al., 2013), and enhance the delivery of

MBRP treatment. (Penberthy et al., 2013). It is theorized the mechanisms of MBRP are increased awareness and acceptance. (Witkiewitz et al., 2013a), and various target neurobiological pathways associated with addiction and relapse have been hypothesized

(Witkiewitz et al., 2013c), but further research is needed to substantiate this hypothesis.

Research is only beginning in testing MBRP with different demographic populations and substances. MBRP results were better than RP for ethnic minority women in a residential correctional facility for substance abuse (Witkiewitz et al.,

2013b). Another MBRP study found racially and ethnically diverse women in a low-

income population satisfaction was high (M = 3.4, SD = .30), but completion rate was modest at 36% (Amaro et al., 2014). Another study was conducted in Iran, whereas much of the mindfulness literature arises from North America and Europe, providing a diverse cultural application to the literature. (Zemestani & Ottaviani, 2016). The present MBRP study considers understudied correctional population of men and women and is the first with all participants having an opioid-specific diagnosis.

In many of the mindfulness studies the facilitator often had extensive training and background in mindfulness practice and the specific intervention. In a study conducted by

Chawla et al. (2010) on the effect of MBRP, there was a mix of 10 therapists with a variety of backgrounds in mindfulness. All had background in CBT interventions. Six had background in mindfulness-based interventions and four had four years’ experience with mindfulness practice. MBRP facilitator training was done through a two-day intensive training followed by additional training and weekly supervision. The five supervisors were experts in mindfulness-based interventions. Demonstrating competence and not simply adherence has been noted as key in delivery of MBRP with an initial effort towards development of an MBRP competency measure (Chawla et al., 2010), but this effort has not been furthered in the research. Gilbert (2014) suggesed two qualities important to delivering help are considered first, the desire and willingness to help, and second having the skills needed to help someone with their problem. Not noted in literature, and of interest to practice, is whether or not therapists without extensive background in mindfulness-based interventions can deliver MBRP effectively with a minimal amount of training and ongoing supervision, as would often occur in a field setting.

It is noted in the MBRP manual that between-session practice is essential to positive change (Bowen et al., 2011a), and 30-45 minutes of practice daily is recommended during the 8-week group. Evidence to support this is mixed, for example a study (Grow et al., 2015) found support for participation in MBRP was associated with a significant increase in home mindfulness practice, and increased involvement in home practice was associated with significantly lower AOD use and craving over the course of the study. These findings suggested that building mindfulness practice into one's daily life, plays a key role in ongoing recovery following MBRP treatment. These findings also suggested that MBRP clinicians should target the post-intervention decline in home practice (e.g., with ongoing mindfulness practice groups) to maximize the benefits of mindfulness meditation in decreasing AOD use and craving (Grow et al., 2015).

But evidence to the contrary has been found. Between-session practice was not predictive of levels of mindfulness at the two-month or four-month follow-up assessments, but primarily to mindfulness immediately at end of the course (Bowen &

Kurz, 2012). Also, another study found that although participation in an MBRP increased mindfulness, flexibility, self-compassion and decrease rumination, these gains were unrelated to amount of practice time outside the MBRP group (Steinman, 2014). This suggested formal practice may not be necessary to bring about changes in mindfulness or its related variables. It is also unclear which mindfulness practices are the most effective active ingredients and how much practice is necessary to achieve successful substance use treatment outcomes. (Witkiewitz & Black, 2014).

Of interest to the present study was a process wherein participants exercise minimal or no practice outside of the MBRP sessions. In this condition, are there still

treatment gains related to MBRP? The standard 8-week format of MBRP used in many of the early studies (Grow et al., 2015) also needs to be studied with adaptations made for the field (Witkiewitz & Black, 2014) based on use of typical treatment counselors and different formats such as a rolling admission to group (Witkiewitz et al., 2014) and specific populations served (Amaro et al., 2014). Retention rates have varied for participants in MBRP from 36% to 61% (Amaro et al., 2014). Reasons for non- completion may be highly varied include non-compliance with program rules, hospitalizations, or clients leaving on their own (Margolin et al., 2007). Understanding of treatment retention and approaches to improve retention are needed.

Mindfulness, Self-Compassion and Impulsivity

Construct of Mindfulness

Mindfulness can be described as focused attention intentionally directed toward experience as it arises in the present moment, characterized by a non-judgmental, open receptivity toward all phenomena (Bishop et al., 2004). Several studies have shown that mindfulness and meditation training can increase an individual's level of mindfulness

(Bowen et al., 2009; Carmody & Baer, 2008). Kabat-Zinn (1994) defines mindfulness as paying attention in a particular way, on purpose. In the last several decades mindfulness based interventions have been a fruitful topic within the mental health practice as a means to reduce the physical and emotional burden related to general life concerns and mental disorders (Chiesa & Serretti, 2014). In spite of growth in research of health benefits of mindfulness, there is not yet a complete consensus as to how the concept of mindfulness should be properly operationalized (Chiesa, 2013). For this study we adopt Baer, Smith,

Hopkins, Krietemeyer, and Toney’s (2006) conceptualization of mindfulness as consisting of five facets: observing, describing, acting with awareness, non-judging of inner experience and non-reactivity to inner experience.

A disposition toward mindfulness may be a protective factor from drug addiction

(Christopher et al., 2013). It is also thought that an increase in mindful awareness may lead an individual to notice mood states including substance-related craving and develop the capacity for non-reactivity to such states leading to greater self-regulation and tolerance of potential triggers for addiction (Staiger et al., 2014).

Construct of Self-Compassion

Research is beginning to link self-compassion and addiction (Graham, 2017). It has been hypothesized that relapse and misuse may be a resultant of negative self-focused emotion including guilt and shame. Self-compassion breaks the cycle of guilt-shame- misuse of substance, allows for reduced self-judgment and enhances a more positive view of oneself and reduces guilt and shame (Rodrigues, 2015). Preliminary findings from

Phelps, Paniagua, Willcockson and Potter (2017) suggested that levels of self-compassion may potentially be predictive of drug risk.

Due to high prevalence of trauma in clients experiencing substance-related addiction, self-compassion is an important treatment factor (Najavits et al., 2012), and one’s level of self-compassion may have protective effect on trauma related symptoms

(Zeller et al., 2015). In two studies, acting with awareness in the presence of symptoms

(versus reacting habitually), and having an accepting/nonjudging stance towards experience, may be critical factors in attenuating the relationship between trauma symptoms and substance dependence (Vujanovic et al., 2009; Bowen et al., 2017).

Theses findings suggested a nonjudgmental acceptance of experience appears to be inversely related to PTSD symptomatology, and may be a means by which treatment efficacy can be increased.

In teaching mindfulness, clients with a history of trauma may have difficulties with feelings of contentment, safeness and compassion (Gilbert et al., 2011). Slowing down and focusing on breathing may trigger aversive reactions related to trauma including hypervigilance, difficulty breathing, and negative physical sensations. Self- compassion approaches may help alleviate these symptoms (Au et al., 2017; Gilbert,

2014). Persons experiencing stigmatization may benefit from a nonjudgmental stance and self-compassionate approach. For example, MBRP was considered to be particularly useful for racial and ethnic minorities who have experienced societal discrimination

(Witkiewitz et al. 2013b). Stigmatization and self-criticism is pervasive among individuals with substance use histories and specifically IV drug users such as heroin

(Crawford et al., 2012). However, research is needed to determine if self-compassion approaches can address this aspect of opioid addiction.

Related to opioid addiction, Gilbert and Proctor (2006) suggested that self- compassion activates emotional and caregiving systems associated with feelings of secure attachment, safety, and the oxytocin-opioid system. Current research supported this hypothesis (Graham, 2017), and it appears opioids and self-compassion interventions target similar neurophysiological systems which justifies further research in approaches that include self-compassion for treatment of opioid addiction.

It has been theorized that self-compassion may help mitigate impulsivity and the temptation to re-use. Basharpoor et al. (2015) demonstrated that cognitive self-control

and self- compassion play a role in predicting treatment motivation and readiness to change in drug-dependent individuals. In another study, it was found that self- compassion is a predictor of reduced impulsivity with prisoners in a correctional institution (Morley et al., 2016). These studies suggest further investigation is warranted to determine the role of self-compassion in lowering impulsivity for persons in substance misuse treatment.

Construct of Impulsivity

Impulsive behaviors are often associated with substance abuse and is considered a risk factor for initiation and maintenance and relapse (Maddox, 2012; Moshier et al.,

2013). Impulsivity is both a reliable predictor and consequence of alcohol and drug addiction (Crews & Boettiger, 2009; Dawe & Loxton, 2004; de Wit, 2009; Verdejo-

Garcia et al., 2008; Heinz et al., 2015). There is also substantial neurophysiological evidence in human and animal models that cognitive function and impulse control is affected by chronic exposure to drugs of abuse (Bankston et al. 2009; Winstanley et al.

2010; de Wit, 2009) and length of treatment (McCown, 1989). Impulsivity is a potential mediator of substance use disorder treatment effectiveness and is related to poorer outcomes (Loree et al., 2014; Stevens et al., 2014). Impulsivity differs for various substances (Beaton et al. 2014; Loree et al., 2015) as well as with the combination of co- occurring mental disorders (Marquez-Arrico & Adan, 2016; Beaton et al, 2014). For all the stated reasons, impulsivity is a potential high impact target for study and treatment intervention (Stevens et al., 2014).

The notion of impulsivity has a powerful impact on the present moment because it shares a person’s emphasis (or overemphasis) on “living in the here and now.” In this

way, impulsivity overlaps with the construct of mindfulness, which relates to a person’s perspective on and experience of the present (Murphy & MacKillop, 2012). It has been hypothesized that mindfulness training may strengthen inhibitory control and decrease impulsive drug seeking (Witkiewitz et al., 2013c), but there is need for research to test this hypothesis. Also, while many treatment programs teach CBT skills, CBT strategies may not consistently work when individuals hastily react before employing alternative courses of action. Individuals may bypass alternative responses when they experience emotional reactions, and it also assumes individuals to be introspective and insightful

(Holt, 2016). Mindfulness-based treatments may decrease emotional reactivity and increase awareness in a way that helps an individual access CBT training that may otherwise be bypassed in an impulsive moment, but further research is needed to substantiate this.

Inter-Relationships of Impulsivity, Mindfulness and Self-Compassion

Contemplative approaches to counseling include both mindfulness and self- compassion. Both address addicition from a different perspective than typical CBT treatments which is consistent with relational-contemplative model (Davis et al., 2017).

The relational-contemplative model of counselor practice emphasizes the integrated roles of self-compassion and mindfulness being core human capacities that are engaged within a therapeutic relationship and developed for treatment (Davis et al. 2017).

Allen and Knight (2005) note possible advantages of explicitly combining mindfulness training and compassion work in treating some depressions and other disorders. Self-compassion can help reduce the sense of threat and create feelings of safeness (Gilbert & Procter, 2006). While a promising approach, few studies have

investigated both mindfulness and self-compassion together (Dahm et al. 2015). Those that researched mindfulness and self-compassion found evidence that self-compassion mediated worry, mindfulness impacted emotional self-regulation, both constructs affected fear and avoidance of emotion (Keng et al., 2012), and clients showed increases in mindfulness, flexibility, self-compassion with consequent decreases in ruminations and cravings/urges (Steinman, 2014).

Statement of the Problem

The current opioid crisis in the United States is of epidemic proportion (Runyan et al., 2017) and there is a need to find better treatments for opioid addiction. As a crucial stage in the opioid addiction recovery process, examining the aftercare component of treatment is needed due to lack of research on evidence-based aftercare programs. One emerging evidenced-based aftercare program is mindfulness-based relapse prevention

(MBRP). Since its inception in 2005 (Witkiewitz et al., 2005), there have been several pilot studies (Bowen et al., 2009; Brewer et al., 2009; Brewer et al., 2010) and one major random controlled trial (Bowen et al., 2014). MBRP studies have also started researching different populations (Amaro et al., 2014; Witkowietz et al., 2013b; Zemestani &

Ottaviani, 2016) and outcome variables (Bowen et al., 2009, Bowen et al., 2012; Bowen et al., 2017, Penberthy et al., 2015).

While evidence for MBRP is promising, there is a need to understand its impact on different populations, and specifically its impact on persons from an opioid-specific treatment population. Presently there are no studies found of MBRP with an opioid- specific population. Since many persons involved with opioid addiction get involved in

the court-ordered programs, there is a related need to better understand the effect of

MBRP on a court-ordered population.

Two major outcomes that are expected from the design of MBRP are increases in mindfulness and self-compassion (Witkiewitz et al., 2013b). With promising but limited research on combined mindfulness and self-compassion interventions for substance addiction (Keng et al., 2012; Steinman, 2014), further study is warranted. Also, not studied to date is the effect of MBRP on reducing impulsivity. Researching the effect of

MBRP on these outcomes could enhance the treatment for opioid addiction.

Finally, given that degree of client and counselor practice may impact results

(Bowen & Kurz, 2012; Chiesa & Serretti, 2014; Grow et al., 2015), further research is needed to understanding real-world situations among those with limited practice experience to define minimum thresholds for benefits of MBRP with opioid addiction.

This study attempted to fill a void in the literature by studying the treatment effects of

MBRP with an opioid specific treatment court-ordered population delivered by typical treatment counselors.

Purpose of the Study

The purpose of this study was to investigate the treatment effect of an opioid addiction-specific MBRP aftercare program on degree of mindfulness, impulsivity and self-compassion with clients in a court-ordered population. Understanding the effect of

MBRP on opioid specific clients in a court-ordered population as delivered by typical treatment counselors has potential for enhancing treatment protocols. This study specifically considered quantitative outcome variables of mindfulness, self-compassion, impulsivity, and qualitative themes that arose from semi-structured interviews with

clients and counselors. The results and findings of outcomes for clients with opioid- specific addiction at a correctional facility were presented and followed by a number of implications for practice and research.

MBRP would have additional support for further research and funding as an evidence-based practice for opioid-specific aftercare treatment. Further research on combining mindfulness and self-compassion in delivery of MBRP and other mindfulness- based interventions could be supported. Clients would have increases in mindfulness and self-compassion which both have been related to positive health outcomes such as reduced depression and anxiety, resiliency for trauma and lower cravings. Clients experiencing reduced effects of impulsivity may experience better treatment outcomes and an improved ability to access skills they have learned in treatment. An understanding of minimum training and practice for effective delivery of MBRP could be gained, which is of practical importance for many treatment centers.

Research Questions

1. Was there a significant difference in participant self-reported mindfulness after

participating in at least six weeks of MBRP opioid addiction aftercare program in

a court-ordered population?

2. Was there a significant difference in participant self-reported self-compassion

after participating in at least six weeks of MBRP opioid addiction aftercare

program in a court-ordered population?

3. Was there a significant difference in participant self-reported impulsivity after

participating in at least six weeks of MBRP opioid addiction aftercare program in

a court-ordered population?

4. How did participants describe their experience of a MBRP opioid addiction

aftercare program in a correctional setting?

5. In what ways did qualitative findings converge with qualitative results?

Definition of Terms

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry with characteristic biological, psychological, social and spiritual manifestations reflected in pathologically pursuing reward and/or relief by substance use and other behaviors (Mee-Lee, et al., 2013).

Aftercare is a step-down phase of treatment (Mee-Lee, et al., 2013) and incorporated to drug treatment court phasing (Hora, 2015) immediately following

Intensive Outpatient Program (IOP) and a transfer down to ASAM Level 1. In the present study, aftercare occurred immediately after IOP and included meeting once or twice per week for 1.5 hours in group for 12 to 16 weeks as needed.

Court-ordered population are the particpants mandated for substance use treatment by a local drug treatment court. For this study the treatment was provided at a local private corrections and substance use treatment center. Participants in this study

may had a variety of living arrangements as dictated by the court such as in a controlled facility or living in the community.

Impulsivity is the inability to wait for reward, and a rapid response style. In the present study impulsivity was measured utilizing the Barrett Impulsiveness Scale-11

(BIS-11; Patton et al., 1995).

Intensive Outpatient Program (IOP) is an ASAM Level 2.1 treatment program that meets at least nine hours per week for six weeks. IOP included six weeks of three sessions per week at three hours per session and uses a CBT curriculum for substance abuse treatment in corrections setting.

Medically Assisted Treatment (MAT) is the use of pharmacological agents including opioid agonist medications such as methadone and buprenorphine, and opioid antagonist medications such as naltrexone as a part of overall treatment for opioid use disorder (Kampman & Jarvis, 2015).

Mindfulness is attending to moment by moment awareness of experience in a nonjudgmental, and nonreactive manner (Bishop et al., 2004; Kabat-Zinn, 1994). In the present study mindfulness was measured utilizing the Five Factor Mindfulness

Questionnaire (FFMQ: Baer et al., 2006).

Mindfulness-based relapse prevention (MBRP) is a manualized (Bowen et al.,

2011a) eight-session aftercare program designed to teach mindfulness skills in conjunction with addiction relapse prevention as developed by Witkiewitz et al. (2005).

Opioid use disorder is a pattern of opioid use leading to clinically significant impairment or distress as defined in the Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition (DSM-5: American Psychiatric Association, 2013).

MBRP aftercare program was a previous program at an Ohio corrections and substance use treatment agency that ran from June 2016 through January 2017, and from which the archival data for this study was obtained.

Self-Compassion is mindful awareness of suffering (vs. overidentification), self- kindness (vs. self-judgment), and a sense of common humanity (Neff, 2003). In the present study self-compassion was measured utilizing the Self-Compassion Scale – Short

Form (SCS-SF: Raes et al., 2011).

Summary of Chapter

Opioid addiction and treatment are critical problems in our nation at the present time. MBRP aftercare is a promising treatment program that may support persons in recovery from opioid addiction, but more research is needed. This study explored client experiences of MBRP aftercare program and measures specific outcomes of mindfulness, self-compassion, and impulsivity specifically for clients in a court-ordered opioid treatment population. This exploration utilized a mixed-methods design analyzing archival data to address five research questions and provide a robust analysis.

CHAPTER II

A REVIEW OF THE LITERATURE

Overview of Opioid Addiction and Treatment

Introduction to Theory of Addiction

The American Society of Addiction Medicine (ASAM) defines addiction as “a primary, chronic disease of brain reward, motivation, memory, and related circuitry.

Dysfunction in the circuits leads to characteristic biological, psychological, social, and spiritual manifestations.” (Mee-Lee et al., 2013, p. 10). Addiction is characterized by inability to abstain, impairment of behavioral control, and dysfunctional responses in emotions and interpersonal relationships. It typically includes periods of remission and relapse and is a progressive chronic disease that without recovery activities can result in disability and premature death (Kampman & Jarvis, 2015; Mee-Lee et al., 2013). This definition parallels the DSM-5 (American Psychiatric Association, 2013) description of substance use disorder which includes a dysfunction in brain circuitry particularly related to the reward system, and therefore, problematic opioid use leads to clinically significant impairment in multiple areas within a 12-month period. The DSM-5 also notes that persons with lower levels of self-control, which reflects impairments of brain inhibitory mechanisms, may make them more vulnerable to developing a substance use disorder

(American Psychiatric Association, 2013).

Treating addiction needs to be viewed as a chronic disease requiring long-term treatment as you would another chronic disease such as hypertension, diabetes, or

asthma. Due to multiple brain circuits involved treatment needs to be multimodal.

Interventions should include strategies that enhance natural reinforcers and strengthen executive function, and decreased drug related condition responses, improve mood, and decreased sensitivity to stress (Volkow & Warren, 2014). As a variety of substances associated with addiction impact various receptors and neurotransmitter systems, medications are used in the treatment of addiction that also demonstrate efficacy based on their molecular structure and affect on particular neurotransmitters (Kampman & Jarvis,

2015; Koob & Volkow, 2016).

ASAM Levels of Care

Due to wide variety of presentation of addiction ASAM has developed a multidimensional assessment and criteria (Mee-Lee et al., 2013) that is the current standard for matching severity of addiction and withdrawal with placement in level of care for treatment. ASAM views addiction treatment as a continuum of care provided by an interdisciplinary team of providers (Kampman & Jarvis, 2015). To provide a complete biopsychosocial assessment including spiritual impact of addiction persons with substance use disorder are assessed across six dimensions from the ASAM Criteria (Mee-

Lee et al., 2013): (1) acute intoxication and withdrawal status; (2) biomedical conditions or complications; (3) emotional and behavioral conditions or complications; (4) readiness to change; (5) relapse, continued use, or continued problem potential; (6) recovery/living environment.

Opioid Addiction and Treatment

Opioids are highly addictive because they induce euphoria (positive reinforcement) and cessation of chronic use produces dysphoria, the symptoms of which

can be alleviated by opioids (negative reinforcement) (Koob & Volkow, 2016). Chronic exposure to opioids results in structural and functional changes in regions of the brain that mediate affect, impulse, reward, and motivation (Upadhyay et al., 2010; Volkow &

Warren, 2014; Younger et al. 2011). The disease of opioid addiction arises from repeated exposure to opioids and can occur in individuals using opioids to relieve pain and in nonmedical users (Koldony et al, 2015).

Treatment options for opioid use disorder include medically assisted treatment and psychosocial treatments. Medically assisted treatment includes detox and use of naltrexone, or induction of methadone or buprenorphine/Suboxone. The methadone patient would have to participate in an opioid treatment program which provides supervised daily dosing at a certified opioid treatment program. Naltrexone or Suboxone treatment may per provided the clinic or in an office-based opioid treatment setting.

Psychosocial treatment is recommended in conjunction with medically assisted treatment for opioid use disorder. (Kampman & Jarvis, 2015). Minimum psychosocial treatments should include: assessment, supportive group and individual counseling, family supports, and referral to community services. Psychosocial treatments can help patients manage cravings and reduce likelihood of relapse and address co-occurring psychosocial and emotional challenges. Determining the level of need in which treatment approach is individualized to each patient. While psychosocial treatment may improve adherence to pharmacologic treatment (Amato et al., 2008a), presently there is not a recommended psychosocial treatment that correlates with specific pharmacological approach (Amato et al., 2008b), and more research is needed to improve specificity, consistency, and evaluate outcomes (Koldony et al., 2015).

Due to high proportion of persons involved the criminal justice system having an opioid use disorder it is important to address their specific needs, and tailor treatment for their situation. While treatment is recommended there currently is a lack of evidence that any specific treatment is superior to another (Kampman & Jarvis, 2015). Also related to persons in the criminal justice system, there is likely a high prevalence of background trauma and resulting resistance to approaches that appear coercive (Damon et al., 2017;

Runyon et al., 2017).

For opioid use disorder there is modest evidence of the benefit of some psychosocial treatments over others, particularly contingency management (CM) and cognitive behavioral therapy (CBT) (Dutra et al., 2008). Overall to date there are very few robust studies of psychosocial treatments for opioid use disorder either as a standalone treatment or in conjunction with pharmacological treatment (Veilleux et al.,

2010). Given the present need for effective evidence based psychosocial treatments for opioid use disorder, promising areas for further research include:

• Identifying the comparative advantages of specific psychosocial treatments.

• Evaluating the effectiveness of psychosocial treatment in combination with

specific pharmacotherapies.

• Determining which concurrent psychosocial treatments are most effective for

different patient populations and treatment settings including primary care.

Aftercare Treatment and Continuing Care

Many terms have been used over the years to describe substance use disorder treatment in defined and time limited phases. The phase after initial treatment has

traditionally been called “aftercare” or “step-down care” to denote a brief time limited program after the initial intensive care (Barthwell & Brown, 2014). It may represent a specific CBT program, follow-up counseling, or referral to mutual help groups like AA.

The literature has begun using the term “continuing care” to refer to any therapeutic contact that is used following initial treatment and is adaptive based on client’s changing needs and implies a long-term treatment (Finney, Moos, & Wilbourne, 2014; Procter &

Herschman, 2014), and the term “continuum of care” for an integrated approach to managing an addiction as a chronic disease (McLellan, 2014). For the this study the term

“aftercare” is used to focus on the specific phase of treatment following an “intensive outpatient program” as was the protocol of the MBRP pilot program from which archival data were obtained.

Research Related to Aftercare

The first year of recovery is one of transition with multiple health and drastic lifestyle changes as one begins introducing healthy behaviors and changing one’s life circumstances. It is also when a person is vulnerable for relapse and possible return to substance abuse (Bottlender & Soyka, 2005; Rahim et al., 2005; Stein, 2015), and some reports show risk of relapse as high as 60-80% within the first 3-4 months following treatment (Brown, Vik, & Creamer, 1989; Marlatt & Donovan, 2005; Sannibale et al.,

2003). For this reason, it has been recommended persons follow initial substance use treatment with some form of aftercare (Arbour et al., 2011; McKay, 2006; McLellan

2014). Due to high rate of recidivism, there is also a need to better understand the non- responders, and what would make treatment more attractive or engaging for them

(McKay, 2009).

Generally, the literature supports aftercare after initial treatment showing low to moderate effectiveness versus no treatment (Blodgett et al., 2013; Ghodse et al., 2003), but there are mixed results and many questions remain as to specifically what is effective in aftercare treatment (McKay, 2009). While aftercare is recommended, there is a call for more research to explore adaptive approaches to continuing care which can adjust frequency, intensity and modalities of treatment based on client need, and to better understand implementation of specific interventions (McKay, 2009; McKay et al., 2009).

Presently there exists a broad agenda for the research related to continuing care and the details of aftercare integration, selection and delivery. In a consensus position paper from the 2008 Betty Ford Institute Consensus Research Conference on Extending the Continuum of Care, participants agreed that research studies have consistently indicated that effective continuing care interventions are likely to include some or all of the following components: extended monitoring; incentives and consequences for performance at the level of the patient, counselor, and program; alternative forms of service delivery; and utilization of community supports (McKay et al., 2009). While evidence-based interventions (EBIs) exist and demonstrate some effectiveness in research studies, little evidence exists on implementing EBIs in aftercare (Lash et al., 2011) and there is a need for further research to guide practitioners on implementing EBIs across different settings, and modalities (Lash et al., 2011).

Research is needed to present the client’s perspective of treatment as demonstrated in an exploratory study (Costello et al., 2018) participants were asked questions about how they personally defined successful recovery. Emergent themes included the following: recovery is a process; abstinence is an important aspect of

recovery, but not sufficient; recovery is multidimensional; and, recovery requires ongoing commitment. These patient driven themes are consistent with findings that effectiveness of aftercare is related to patient perception of care (Hepner et al., 2017).

Drug Treatment Court and Aftercare

Of interest to the proposed study is mandated treatment placement by drug treatment courts (DTC) which rely on the principle that coercive powers of the court system can contribute recovery from addiction to substances. The DTC employ a series of incentives and sanctions to induce compliance and lifestyle changes in criminal defendants. Most drug treatment courts have three phases: first phase an initiation of abstinence, second phase is treatment in which participants meet with the judge twice a month, and third phase of aftercare including relapse prevention, sobriety maintenance planning, and monthly court dates (Hora, 2014).

Court mandated treatment and aftercare faces several challenges including: expectations of criminal justice system, defining a fixed length of stay in a non- individualized program, mandating level of care, decisions made based on resources available versus offenders needs, placing co-occurring needs as secondary, individuals may have different attitudes towards treatment, and imposing sanctions for noncompliance. Staff members need to be cognizant of criminogenic risk, need, responsivity, and trauma informed care (Mee-Lee et al., 2013). Thus, further research of aftercare treatment for persons with substance use disorder in correctional settings is warranted.

Impulsivity in Opioid Addiction

Review of the Empirical Literature

In reviewing the literature, there are many more studies generally addressing the relationship between substance use disorder and impulsivity, and only a few specifically relating opioid use disorder and impulsivity. This review will begin with the general findings of substance use disorder as it relates to impulsivity, then address specifically opioid use disorder, then consider impulsivity and mindfulness and self-compassion, and present needs for further research.

Impulsivity as a risk factor for opioid addiction

Impulsivity has often been associated with substance addiction. It is considered a risk factor for the development and maintenance of substance addiction (Bankston et al.,

2009; Leung et al., 2017; McCown, 1989) and is a strong predictor of substance addiction

(Heinz et al., 2015) and relapse (Evren et al., 2012; Pattij & De Vries, 2013). Persons with a history of substance addiction have exhibited more impulsivity in both behavioral and self-report measures (Allen et al., 1998). Impulsivity is considered a transdiagnostic factor and may partially account for higher rates of substance abuse with co-occurring mental and emotional disorders (Marquez-Arrico & Adan, 2016). Impulsivity may interfere with recovery even with the desire to quit (Moshier et al., 2013). Impulsivity has been associated with poor decision-making in relation to substance use (Tomassini, et al.,

2012).

Some studies have noted transient increases in impulsivity while a person is currently actively using substances with a return to baseline impulsivity, and a difference in predictive use based on drugs used (Pattij & De Vries, 2013). For example, impulsivity

may predict stimulant use, but not heroin, but repeated use of heroin increases impulsivity leading to sustained use. Higher impulsivity scores have been associated with poorer treatment outcomes and dropout rates (Loree et al., 2015; Staiger et al., 2014;

Stevens et al., 2014; Taylor et al., 2013). Impulsivity has been associated with genetic factors as well as chronic exposure to substances (Verdejo-García et al., 2008;

Winstanley et al., 2010).

The construct of impulsivity

Impulsivity has long been a construct of interest, particularly for addiction, but its conceptualization has been difficult to define. Conceptualizations of impulsivity have varied defining it with multiple factors such as disinhibition, inattention, sensation seeking and deficits in decision making (Beaton et al., 2014; Evenden, 1999); rash spontaneous unthoughtful behavior (Dawe & Loxton, 2004), and under broad categories as trait impulsivity (i.e. personality characteristic) (Staiger et al., 2014) or state impulsivity (i.e. “in the moment”) (Beaton et al., 2014).

Trait measurement of impulsivity has historically been done through the use of self-report measures such as the Barratt Impulsivity Scale-11 (BIS-11: Patton et al.,

1995); Esyenck Personality Questionnaire (Eysenck & Eysenck, 1975) or UPPS-P

Impulsive Behavior Scale (Lynam et al., 2006). These measures have been used to make associations with risk factors for substance addiction (Beaton et al., 2014) and as noted above. The measures are unidimensional or may consist of a few factors. And unfortunately, the measurement of this construct has been inconsistent across measures

(de Wit, 2008). State impulsivity has been measured through behavioral tasks and likely captures a distinct aspect of impulsivity not included in trait measures (Griffin et al.,

2017) Work is being done to bridge self-report and behavioral measures of impulsivity

(Gipson et al., 2012). Effort has been made at examining a combination of trait measures

(Stautz et al., 2017).

Traditional conceptualizations of impulsivity have recently come under intense debate (Beaton et al., 2014; Heinz et al., 2015). From a review of multiple studies, the necessity to study impulsivity as a multidimensional construct that does encompass both state and trait factors is clear, as well as neurocognitive processes like attentional bias and urgency (Coskunpinar & Cyders, 2013), reward sensitivity/drive (Dawe & Loxton, 2004), other cognitive biases (Leung et al., 2017), and working memory (Winstanley et al.,

2010). The role of emotion in impulsivity is being considered as negative affect may increase impulsive decisionmaking and behavior (Smith, & Cyders, 2016). Impulsivity is seen as a behavioral manifestation of neurocognitive systems, and an inability to inhibit behavioral responses or regulate urges (overactive reward system “bottom up” processing) is a failure of “top down” executive processes (Tomko et al., 2016).

Impulsivity may be more of an umbrella term that covers multiple processes distributed across different brain regions (Winstanley, et al., 2010).

Impulsiveness may be both a determinant and consequence of substance addiction, with variations in state impulsivity based on situation with underlying trait baseline impulsivity; the direct effect of drug use may allow for an escalation of drug use through disinhibition and long-term sequelae of drug use (de Wit, 2008). Impulsiveness may also vary as a person develops through the lifespan (i.e. rapid change during adolescence), and drug use may impact that development (de Wit, 2008). Understanding neurobiological process related to impulsive behavior is thus important to developing

targeted treatments for substance use disorder (Pattij & De Vries, 2013).

Neurobiology & impulsivity

Frontal regions of the brain are associated with planning and organization, motivation and goal directed activity, weighing consequences and impulse inhibition which are collectively known as executive functions. Addiction is likely due in part to genetic predisposition and loss of inhibition due to substance neurotoxicity (Bankston et al., 2009; Staiger et al., 2014) There is also evidence of neuro-regeneration upon abstinence from substance use (Crews & Boettiger, 2009). Substances may alter dopaminergic receptors and activity in a manner that increases attentional bias and reward sensitivity, while at the same time deactivating executive control (Leung et al.,

2017). In anticipation of reward there is noted increase insula activity, possible lowering of GABA production, and during negative emotion increased amygdala activity (Smith &

Cyders, 2016).

A recent focus has been on behavioral and pharmacological treatments that target these neurobiological systems. (Tomko et al., 2016). There is emerging evidence that mindfulness meditation may target some of these same areas of the brain and nervous system (Tang et al., 2015). Through further study of neurobiology of impulsivity and the impact of substances on this circuitry we can find targets for treatment, biomarkers and treatments to match individuals based on their unique neurobiology (Winstanley et al.,

2010).

Opioid addiction and impulsivity

The results of the few studies specifically relating opioid use disorder and impulsivity are similar but with a few differences from general substance addiction. In

one meta-analysis results indicate chronic opioid exposure is associated with a range of neurocognitive deficits, and primarily in verbal working memory, cognitive impulsivity

(risk taking) and cognitive flexibility (verbal fluency) (Baldacchino et al., 2012). There are differences between illicit heroin users versus those on methadone maintenance treatment (MMT) and non-using controls with illicit heroin users having higher impulsivity and MMT and healthy controls having no differences. This is suggesting a difference that may be important for treatment, and the possible benefit of MMT attenuating impulsive behavior (Baldacchino et al., 2015). Similar findings were found in a neuroimaging study showing opioid use disorder associated with high impulsivity and attenuation with 6 months of abstinence, and some change in brain oscillations, but no change in cognitive function with MMT (Ieong & Yuan, 2017).

Adults with opioid dependence using exclusively prescription opioids had lower delay discounting (impulsivity measure) relative to those who used heroin. This ﬁnding adds to research that heroin use is associated with greater clinical severity among those with opioid use disorder (Karakula et al., 2016). Impulsivity is not a prominent trait observed in pain patients, but findings suggest those with trait impulsivity may be at risk for opioid misuse (Marino et al., 2013; Vest et al., 2016). For opioid use disorder some finding suggest impulsivity may be a predominant factor in initiating and early stage use, but this transitions to compulsivity upon chronic use (Tolomeo et al., 2018).

Impulsivity and mindfulness

Mindfulness may target some of the areas related to impulsivity and addiction in general; and dispositional mindfulness may be a protective factor and facilitate a more deliberate awareness and contemplation of the present moment; which may result in

fewer harmful substance use experiences (Christopher et al., 2013). Mindfulness approaches may also target negative emotional process which in turn can reduce attentional bias and rash action (Leung et al., 2017; Smith & Cyders, 2016). There is a growing body of research on effectiveness of mindfulness with substance use treatment and other disorders (Chiesa & Serretti, 2014). Some findings suggest increases in mindful awareness may lead an individual to notice internal moods states including craving and develop a capacity to be nonreactive to such states. This would result in less impulsive action and warrant further study (Staiger et al., 2014).

Research on impulsivity

Research is needed to further parse out dimensions or forms of impulsivity, refine measures of impulsivity and its related processes, as well as its relationship to drug use initiation and maintenance (de Wit, 2008). There is further need for research is needed for psychosocial treatments and impulsivity to determine targets, dosage, and predictor/moderator of outcome (Bankston et al., 2009; Leung et al., 2017; Loree et al.,

2015). Further research on the malleability of trait impulsivity is warranted to see if treatments can in fact enhance executive control and positive behavioral responses

(Littlefield et al., 2015; Smith & Cyders, 2016). Finally, limited research has been done on gender differences and impulsivity which suggests further study is needed as baseline impulsivity may differ between men and women (Bankston et al., 2009; Lejuez et al.,

2007).

Overview of Self-Compassion in Addiction

In reviewing literature for self-compassion there no studies specifically on self- compassion and opioid addiction, but there were for substance addiction. Therefore, following discussion focuses more broadly on self-compassion and substance addiction as it relates to the proposed study.

The construct of self-compassion

Self-compassion has been described as a stable construct which involves feeling kindness and compassion towards oneself as a person, not due to some achievements or status (Au et al., 2017). Self-compassion includes having a balanced, non-judgmental view of oneself and promotes adaptive function and a reduction in stress, depression, shame, self-criticism, and neurotic perfectionism (Brooks et al., 2012; Gilbert, 2006).

Neff (2003) defines self-compassion as: (1) having kindness towards oneself versus self- judgment, (2) viewing one’s experiences as common to humanity versus isolated or separate, and (3) mindfulness or a balanced-realistic view of negative experiences versus over-identification. Self-compassion can be considered a coping mechanism that promotes a balanced approach to negative emotions and is related to psychological flourishing and reduced psychopathology (Germer & Neff, 2013).

Another view (Gilbert, 2014; Goetz et al., 2010) is that compassion is a human capacity that has developed as part of an evolutionary process involving how humans live and interact in social emotional systems. Older destructive survival behaviors can be organized by newer prosocial behaviors. It is possible to develop these prosocial capacities and in particular compassion in the face of afflictive emotions that might trigger the older brain behavior. Goetz et al. (2010) deﬁned compassion as “a distinct

affective experience whose primary function is to facilitate cooperation and protection of the weak and those who suffer” (p. 351). Compassion is a distinctive affective state that arises when witnessing another’s suffering and consequently motivates one to protect or help (MacBeth & Gumley, 2012). Compassion is an engagement and alleviation/prevention of suffering, and as compassion directed inward towards oneself to organize and balance behavior and motivational systems it is self-compassion.

Neurobiology and self-compassion

It is suggested that self-compassion provides emotional resilience because it deactivates the threat system (associated with autonomic arousal and feelings of insecure attachment and defensiveness) and activates the caregiving system (associated with feelings of secure attachment, safety, and the oxytocin-opiate system) (Gilbert, 2006).

For the proposed study, this oxytocin-opiate system may be particularly relevant to opioid addiction. Studies are just beginning to observe brain and nervous system areas involved in compassion-based responses. Changes have been found in neuroimaging studies of areas related to empathy (Hoffman, 2011), lowering of stress hormone cortisol and heart rate (Germer & Neff, 2013). Further areas of inquiry include areas related to love, distress, sadness, perception of suffering (Goetz et al., 2010).

Compassion-based psychotherapies

Two compassion-based therapies have been recently developed to increase self- compassion: Compassion Focused Therapy (CFT; Gilbert & Procter, 2006) and Mindful

Self-Compassion (MSC; Neff & Germer, 2013). There is considerable overlap between the two including use of practices of loving-kindness meditation, compassionate self-talk and basic mindfulness practice. MSC is rooted in a mindfulness tradition, whereas CFT is

rooted in evolutionary biology, neuroscience and psychology. MSC was developed as an

8-week group-based program for developing self-compassion in both clinical and non- clinical populations. CFT was developed as group-based therapy for populations with chronic and severe mental illness and having specific difficulties with shame and self- criticism (Au et al., 2017). Presently there is no self-compassion treatment that specifically focuses on addiction, but there are mindfulness-based therapies that include self-compassion specially for addiction such as MBRP.

Self-compassion and mindfulness are related but distinct

Mindfulness is required to experience self-compassion, but the mindfulness component of self-compassion is narrower, referring to a balanced awareness of negative thoughts and feelings involved in personal suffering. Self-compassion also focusses on calming and soothing the “self.” Mindfulness in general is a broader awareness or type of attention towards any experience which includes acceptance and equanimity (Neff &

Germer, 2013). Also, mindfulness-based interventions such as MBSR and MBCT while focusing on mindfulness skills inherently include self-compassion through practice of acceptance/non-judgement towards one’s experience and studies have shown increases in self-compassion from these interventions (Germer & Neff, 2013). At the same time, teaching self-compassion as a separate course is not redundant; for example, participants in MSC have had higher self-compassion scores than MBSR or MBCT alone (Neff &

Germer, 2013). Both self-compassion and mindfulness have been found to add resiliency and lower impulsivity in military recruits, and this suggests that self-compassion and mindfulness training may lower impulsivity in military personnel encountering stressful environments (Mantzios 2014). Self-compassion was also found to be related to the

negative relationship between impulsivity and weight loss (Mantzios & Wilson, 2013) and supports supplementing mindfulness training with self-compassion training.

Self-compassion in addiction

Substance addiction has been related to experiential avoidance and lower self- compassion. Substance addiction may attempt to avoid self-criticism or criticism and control unwanted thoughts or feelings (Graham, 2016). A study of persons with alcohol dependence disorder found an overall increase in mindfulness, self-compassion and decreases in self-judgment, isolation and over-identification after a 15-week treatment including self-compassion training. Pretest indicated higher depression, anxiety, alcohol use and lower self-compassion than general population (Brooks et al., 2012). Barriers in early recovery may present issues of stigma, unresolved emotions and difficult relationships, it is thought self-compassion may be a means of enhancing wellbeing in early recovery (Rodrigues, 2015). It is noted that intense emotion either positive or negative can be a precursor to substance use, which in turn undermines rational decisionmaking and leads to impulsive behavior which suggests treatments that focus on emotional regulation may be fruitful. Further treatments that can enhance and maintain positive mood, savor success in an integrated way, and recognize warning signs of impulsive behavior are recommended (Smith & Cyders, 2016; Staiger et al., 2014).

Research on self-compassion and substance addiction

Generally, the research related to self-compassion, psychopathology and substance addiction is limited, but the following provides a summary. Also, as previously noted there are no studies specifically focusing on self-compassion and opioid addiction, so literature reviewed is for the broader substance addiction. In a meta-analysis of 20

studies (MacBeth & Gumley, 2012) a large effect size was found between self- compassion and depression, anxiety and stress supporting self-compassion as a facilitator of resilience. Germer and Neff (2013) noted numerous studies that show self-compassion related to improved psychological adjustment, greater acceptance, increased motivation, and greater emotional connection in relationships. Studies for effectiveness of compassion-based psychotherapies found MSC (Neff & Germer, 2013) resulted in improvements in pre/post gains in mindfulness, self-compassion, wellbeing and compassion for others. Hoffman (2011) also noted positive findings even with interventions, particularly when making associations with traditional Buddhist practices of loving-kindness and compassion meditation of some preliminary studies but cautions that further study and refinement of conceptualization and measurement is needed.

Paniagua et al. (2017) found increased self-compassion to be associated positively with lower drug misuse risk. And a similar study found self-compassion inversely related to alcohol misuse (Phelps et al., 2018). Only a small number of studies of compassion- based interventions have been evaluated for reducing shame in addictions, but results show promise (Au et al., 2017). In a six-week acceptance and commitment therapy

(ACT) random controlled trial (N=20) Graham (2016) found treatment group to have significantly higher self-compassion and psychological flexibility than control group which is suggested to be a factor for relapse prevention in substance misuse. As noted earlier there is a high co-occurrence of PTSD with substance addiction and several studies show promising results. In a study of 210 college students, individuals high in self-compassion may engage in less avoidance strategies following trauma exposure

(Thompson & Waltz, 2008). Another study using loving-kindness meditation found large

increases in self-compassion and decrease in PTSD symptoms (Kearney et al., 2013).

Compassion-based interventions have shown preliminary evidence for facilitating lowering of PTSD symptoms (Au et al., 2017; Hiraoka et al., 2015; Zeller et al., 2015).

Self-compassion in post-traumatic stress disorder (PTSD)

Due to high prevalence of co-occurring substance addiction and PTSD it is important to include consideration of impact and treatment of PTSD in the overall assessment of substance addiction. Self-compassion is seen as a potentially modifiable factor related to the development and maintenance of PTSD (Hiraoka et al., 2015); also, as a protective factor and target for early trauma intervention (Zeller et al., 2015). Some studies have found improvements in PTSD symptom severity with a self-compassion- based intervention (Au et al., 2017; Hiraoka et al., 2015), and self-compassion exercises such as loving-kindness meditation (Kearney et al., 2013). Self-compassion is one of postive factors that increase in the Seeking Safety model (SS: Najavits, 2002; Najavits et al., 2012) of treating co-occuring substance addiction and PTSD.

Overview of Mindfulness and Opioid Addiction

The construct of mindfulness

While there has been rapid growth in research and evidence about health benefits of mindfulness-based interventions, there is not a complete consensus on the definition or conceptualization of mindfulness (Chiesa & Serretti, 2014). Mindfulness has also been viewed as either as a trait or state (Brown & Ryan, 2003; Chiesa, 2013). It has generally been conceptualized in therapeutic literature as a systematic development of attention to present moment experience with an attitude of curiosity, openness and acceptance

(Bishop et al., 2004; Kabat Zinn, 1994). Mindfulness meditation has been best known as a Buddhist spiritual practice (Gunaratana, 2002). In Buddhist tradition it is considered a lucid awareness of what is occurring, and meditation plays a key role in the development of mindfulness. The meditation begins with calming and concentrating, keeping the mind in the present moment with an attitude of acceptance which facilitates the development of both mindfulness and concentration (Chiesa, 2013).

In clinical research, there have been efforts to operationalize mindfulness and to develop psychometric instruments to measure this, one of the first attempts was the mindful attention awareness scale (MAAS: Brown & Ryan, 2003). This measure was designed to measure a person’s attention/awareness, which the authors considered to be the main feature of mindfulness. Others have argued that the traditional Buddhist understanding is much more complex and that it consists of multiple factors. Baer et al.

(2006) combined items from multiple inventories and after performing factor analysis developed the Five Factor Mindfulness Questionnaire (FFMQ) which are: non-reactivity, observing, acting with awareness, describing, and non-judging. Further analysis confirmed four of the factors (all except observing) and found that the factor structure varied with amount of meditation practice. More research studies are needed and perhaps

East-West dialogue to better define mindfulness and how to measure it (Chiesa, 2013).

Neurobiology and mindfulness

Use of opioids and other substances have an impact on a person’s neurobiological system as the body tries to adapt to the chemicals used. An allostatic model of hedonic dysregulation would lead to a lowering of the natural reward system and an increase in drug cue salience which facilitates addictive behavior (Garland et al., 2017). Cognitive

training regimens such as mindfulness training may be able to alter this (Garland et al.,

2015). Recent findings from neuroimaging studies indicate mindfulness practice may be associated with changes in brain structure and activation related to reduced rumination, and reactivity in the face of craving (Chiesa & Serreti, 2014), and improved attention, memory and executive functioning all favorable to improved mental-emotional balance and reduced risk of relapse (Chiesa, 2013; Garland, 2014). Other studies found substance addiction related to alexithymia, frontal lobe executive dysfunction, higher reward salience and inversely related to mindfulness (Lyvers et al., 2014a; Lyvers et al., 2014b).

A possible outcome of mindfulness training is brain activation of these dysfunctional areas, and synaptic training and growth through repeated behaviors, also known as neuroplasticity (Siegel, 2007).

Mindfulness and substance addiction

As noted previously, substance addiction impacts brain circuits and reward and executive functioning. Psychosocial treatments are recommended as part of treatment

(Kampman & Jarvis, 2015; Mee-Lee et al., 2013) including CBT and mindfulness.

Mindfulness is similar to CBT in that they both address the role of observation of thought, mood and behavior, but in the area of substance use disorder mindfulness is unique in also focusing on affective triggers (stress, craving, urges, depression) instead of cues directly related to substances (Breslin et al., 2002). Mindfulness meditation and intervention may be promising in treating substance use disorders by teaching and developing a human capacity for intentional, accepting, and non-judgmental focus of attention on emotions, thoughts and sensations occurring in the present moment. This approach helps a person with substance use disorder be present and attentive to their

experience but not be preoccupied by it, allowing for a more skillful response to situation versus reactive conditioned response (Zgierska et al., 2009). That skillful response may include CBT tools learned but not always accessible in a moment of difficulty.

Mindfulness may also increase tolerance for difﬁcult cognitions, emotions, and craving states through acceptance (Vieten, 2010).

Mindfulness has been proposed as a means to reduce the hypervigilance towards negative symptoms such a chronic pain or opioid withdrawal that provides a powerful cue for use (Garland et al., 2013). Dispositional mindfulness has been related to hedonic capacity (Garland et al., 2017), which suggests for opioid-using persons learning mindfulness skills may be a way to enhance hedonic capacity. One study (Shorey et al.,

2014) of adults with substance use disorder seeking residential treatment found lower levels of mindfulness relative to healthy adults; no differences were found between men and women. Their findings support the use of mindfulness-based interventions for persons with substance addiction. Bayles (2014) reports reduction in substance use was realized with MBRP due to increased awareness leading to increased cognizance of cues that led to substance use. Participants were also accepting of their behavior, non- judgmentally which is necessary in harm reduction approaches. The role of non-judgment and acceptance is also different than 12-step approaches which many judge relapses as failures and focus on grief and loss techniques. Future research needs to clarify the core ingredients of mindfulness-based programs which has implications for training, supervision and implementation. Clarity is needed to ensure MBI teachers are appropriately trained and there is fidelity to the program being delivered (Crane, 2017).

Mindfulness-based interventions for substance addiction

There have been increasing number of studies utilizing mindfulness-based interventions as part of treatment for substance addiction. Some of the initial mindfulness approaches have been studied in conjunction with substance addiction including mindfulness-based stress reduction (MBSR), and mindfulness based cognitive therapy

(MBCT) which has mindfulness practice as primary focus. Other interventions such as dialectical behavior therapy (DBT) and acceptance commitment therapy (ACT) only partially focus on mindfulness and draw from other approaches as well (Chiesa &

Serretti, 2014). At their core they share fundamental features including a state of attention and awareness to internal and external experiences and foster an attitude of non-judgment and acceptance (Bishop et al., 2004).

MBIs may be helpful for substance addiction in developing a non-judgmental attitude toward distressing phenomenon (Kabat Zinn, 1982), lead to adaptive changes in one’s thought patterns (Teasdale et al., 1995), and allow for enhanced ability to work with unpleasant emotional experiences (Linehan, 1993). Mindfulness-based relapse prevention (MBRP: Bowen et al., 2011a) was built upon a combination of relapse prevention (Marlatt & Donovan, 2005) and MBSR and MBCT. In the next section we will present an in-depth review of the literature related to MBRP. But as an example, one small study of an 8-week MBRP group for (N=71) adults with substance addiction findings included increase mindfulness, cognitive-behavioral flexibility, and self- compassion and decreased rumination and a decrease in cravings/urges (Steinman, 2013).

Another mindfulness-based intervention tailored for substance addiction, Spiritual Self-

Schema Therapy (Margolin et al., 2007) found in a preliminary study with HIV patients a

reduction in impulsivity and substance use and increases in spiritual practices, motivation for abstinence, and medication adherence. This program also demonstrated the feasibility of a manualized self-help manual approach for this treatment population.

Mindfulness-Oriented Recovery Enhancement (MORE) was developed to specifically help patients with chronic pain and prescription opioid addiction.

Randomized control trial (Garland & Howard, 2013) demonstrated MORE may attenuate pain attentional bias, decrease emotional reactivity, and further study (Garland et al.,

2014b) found MORE may significantly reduce pain severity and functional interference while decreasing opioid misuse and craving. Generally, mindfulness-based interventions can be embedded in harm reduction approaches to help bring greater awareness to their immediate desire and use of substances. Mindfulness maintains a non-judgmental stance that can provide a compassionate and helpful alternative to 12-step approaches which require abstinence when that does not work for some and may better meet people where they are at (Bayles, 2014).

Research on mindfulness and substance addiction

Mindfulness research related to substance addiction has focused on characteristics of persons with addiction and effectiveness of interventions. There have been several meta-analyses and reviews of the literature. Chiesa and Serretti (2014) reviewed 24 studies and found evidence suggests MBIs can reduce consumption of several substances including alcohol, cocaine, amphetamines, marijuana, cigarettes and opiates. MBIs may reduce craving and increase mindfulness. A significant finding was that MBRP outperformed 12-step facilitation at 6-months post intervention (Bowen et al., 2009), and also outperformed relapse prevention at 12-months (Bowen et al., 2014). There were

some other studies that showed MBIs performing the same or less than a CBT program for substance use disorder (Alterman et al., 2004; Brewer et al., 2009; Smout et al.,

2010). It is difficult to generalize the studies as they have methodological limitations including lack of randomized controlled studies, small sample sizes, and objective measures of drug use which makes them open to possible bias. These findings of an earlier review of 25 studies are like an earlier systematic review (Zgierska et al., 2009) of mindfulness-based treatments for substance addiction. Generally, the studies show promise but are inconclusive for treatment for substance addiction due to methodological concerns.

In a more recent systematic review of 42 pertinent studies evaluating mindfulness treatments for substance use disorders (Li et al., 2017) findings indicated small to large effect sizes for mindfulness in reducing frequency and severity of substance misuse, intensity of craving, and severity of stress. A majority of these studies reported effectiveness in reducing substance misuse, psychological, relationship and legal problems in follow-ups up ranging 2 weeks to 12 months. Some of the studies included

Vipassana meditation outperforming TAU (Bowen et al., 2006), MORE outperforming the Matrix model CBT treatment (Garland et al., 2010, 2014b, 2016), and MBRP outperforming 12-step facilitation and relapse prevention (Bowen et al., 2014).

Methodological concerns again were small sample sizes, lack of randomization, variation in treatment dosage or practice time (Brewer et al., 2011; de Dios et al., 2012). Beyond needing studies with more methodological rigor, unresolved issues were outlined by

Witkiewitz and Black (2014) including: (1) refining operational definitions of mindfulness, (2) clarifying practice targets (dosages) for different populations, (3)

understanding mechanisms of change and determining which interventions are most effective and for whom, and (4) dissemination and implementation issues which bridge research to clinical gap (i.e. teacher preparation and fidelity or adaptation of delivery in different clinical settings).

Regarding future research on practice time, some of the current MBIs such as

MBSR, MBCT, ACT and MBRP follow traditional meditation training guidelines requiring formal daily practice ranging from 15-45 minutes. In a few studies amount of practice time was related to improvements in mindfulness, decrease in symptoms, and improvements in wellbeing (Carmody et al., 2008). The practice time develops experiential familiarity with the body and mind, and an appreciation that attention and awareness can be regulated, fine-tuned and optimized through training (Crane et al.,

2017). Fidelity to practice is also then important for the quality of experiential learning.

Regarding implementation and also related to practice and quality of experience is the competence of the teacher. One of the MBIs, MBSR has a teacher training curriculum and certification where most others do not. In MBSR and the MBIs more closely aligned to it there is an expectation to commitment to ongoing practice and cultivation of mindfulness in one’s life to be able to embody mindfulness practice when facilitating training of others. Teacher training then is not only content oriented but integrative with experience of personally developing qualities that are desired for participants to learn

(Crane et al., 2017).

Mindfulness and substance addiction in special populations

In a systemic review of studies (Katz & Toner, 2013) considering gender in mindfulness-based interventions for substance addiction, only six studies met the criteria;

the two RCTs found no differences, and the other four found women may have gravitated and benefitted more, but further research is needed. It was also recommended that studies consider combining mindfulness-based interventions with trauma focused treatment as the rate of PTSD is higher with population with substance use disorder, and particularly women. A small pilot study of a brief intervention including a combination of mindfulness and motivational interviewing was found to be feasible and effective for young adult women marijuana users (de Dios, 2012).

Early studies on mindfulness-based interventions with incarcerated individuals included a pilot program using Vipassana, a traditional mindfulness approach, that was found to be helpful in reducing substance use and symptoms of psychiatric disorders

(Marlatt et al., 2004). Lyons and Cantrell (2016) similarly found MBIs helpful, but also add they may benefit both the prisoners and correctional staff in promoting a sense of non-duality and community. In work with incarcerated adolescents, it was found that mindfulness-based intervention can feasibly be implemented (Himelstein et al., 2012). A systematic review of the use of mindfulness or other Buddhist-derived interventions for correctional populations by Shonin et al. (2013) initially found 85 papers but only eight were included in study. Interventions included four vipassana meditation treatments, two mindfulness treatments and two other Buddhist-derived interventions. Findings found significant improvements in five criminogenic areas: negative affect, substance use (and attitudes), anger, relaxation, and self-esteem/optimism. Quality issues were noted for methodology and a call for stronger research is warranted for mindfulness interventions for persons with substance use disorders in correctional settings.

Overview of MBRP for Substance Addiction

Review of MBRP Theory and Practice

MBRP Theory

Developed at the Addictive Behaviors Research Center at the University of

Washington in Seattle, MBRP was the convergence of the work of Alan Marlatt combining his research in cognitive behavioral relapse prevention (RP: Marlatt &

Donovan, 2005) with mindfulness meditation practice as a compassionate approach to help people skillfully work with the symptoms and experiences of addiction. It aligns with his previous work in harm reduction as a non-judgmental, client-centered program to help decrease and reduce severity of relapse (Bowen & Vieten, 2012). As a harm reduction approach, it may provide benefits over traditional abstinence-based programs by offering a low stigma, flexible goals, and tolerance of a variety of religious beliefs

(Bowen et al., 2011b).

RP is a cognitive behavioral treatment that sees substance addiction as a learned behavior with biopsychosocial determinants and consequences. As such, it teaches the identification of high risk situations and then provides coping strategies for recognizing and responding to environmental risks, cognitive therapy for risky thoughts and moods, and lifestyle changes to address each step of the relapse process (Bowen et al., 2011b).

While effective as a treatment for addiction, some limitations include: (1) it is an avoidance versus approach strategy, and has (2) a focus on controlling causes of negative affect and craving versus being able to tolerate negative affective states, and (3) less emphasis on individual differences versus identifying and developing tailored skills

(Witkiewitz et al., 2014).

Present mindfulness based therapeutic approaches in the West, including MBRP have their roots in Buddhist tradition. From a Buddhist perspective, craving and attachment are primary parts of human existence and viewed as a root cause of suffering.

Addiction then may be seen as an effort to hold on to or avoid certain experiences in an effort to avoid suffering and hold onto postive states (craving the next high). The intention of mindfulness practice is to bring awareness to this experience and learn to observe it without reacting or judging it (Witkiewitz et al., 2013a). Acceptance of negative physical and affective states as they are in the present moment is viewed as counter to craving (Breslin, Zack, & McMain, 2002).

Alan Marlatt had done research on transcendental meditation and Buddhist

Vipassana meditation as an alternative approach to the treatment of substance addiction

(Bowen & Vieten, 2012; Marlatt et al., 2005). The early Vipassana research was based on a 10-day retreat format and showed promising results, but widespread use has potential barriers of lengthy time, silence, and association with Eastern religion (Bowen et al.,

2006). He was also familiar with different the therapeutic interventions of MBSR and

MBCT which delivers mindfulness training in a less intensive and secular format.

Combining these approaches with his work in RP his team developed MBRP as an economical approach for aftercare treatment that could be potentially used in a wide variety of settings.

In MBRP, two core intentions of the mindfulness practice are first to cultivate awareness of internal and external process (e.g. cues, craving, urges, thoughts) that trigger conditioned using behavior (“automatic pilot”) providing an opportunity to respond in postive ways versus react. The second is to practice acceptance/non-judgment

and learn to be with triggering negative affect or experiences without having to react to escape them; thus, developing skill and self-efficacy in responding to substance use cues and craving (Bowen et al., 2011a; Witkiewitz et al., 2014).

Different than cognitive behavioral approaches that emphasize disputation of thoughts or thought suppression, mindfulness approaches utilize acceptance non- judgment, and non-reaction to difficult thoughts and associated emotions. Focus on acceptance of internal experience versus external cues may increase tolerance of distress and subjective urgency to alleviate discomfort via substance use and decouple habitual response to use substances when experiencing negative affect (Bowen et al., 2007).

Modern approaches to substance addiction treatment recognize the problem as a bio-psycho-social-spiritual problem that needs a comprehensive response. MBRP was proposed as a holistic approach to be used in conjunction with other treatments (Bowen et al., 2011a; Witkiewitz et al., 2014) which is dynamic and phasic. MBRP recognizes tonic processes (e.g., negative affect, craving, self-efficacy) within the context of high risk situations and targets both in its interventions.

It is not clear how MBRP and similar mindfulness approaches work and is a needed area of ongoing research. One idea is that it is not acceptance alone, but acceptance allowing a decentered perspective on thoughts, beliefs and emotions related to substance addiction (Ostafin & Marlatt, 2008). There are beginning to be neurological studies to associate mindfulness training and cognitive and affective functioning. It its theorized that mindfulness training may help with attentional, executive and memory functions as well as affective regulation. It may be a way of intervening in neural reinforcement loops (rumination and stress abated by substance use) that perpetuate

addiction (Brewer et al., 2010; Brewer et al., 2011) MBRP is a compassionate approach allowing for acceptance or self-compassion reducing shame, guilt and stigma often associated with addiction, and increasing self-efficacy (Ostafin, et al., 2006; Penberthy et al., 2015).

MBRP and neurobiology

The literature proposes many potential neurobiological targets for MBRP. One of the targets of MBRP in the research is craving. Different neurobiological and affective models suggest craving may arise due changes in neurotransmitters such as dopamine, serotonin, and GABA, and activation/deactivation of different brain regions such as the dorsal striatum due to substance use or interoceptive dysregulation during physical withdrawal (Witkiewitz et al., 2013a). Craving can be both a result and precipitant of stress. Cognitive process such as memory, expectancies, and higher order information processing (Witkiewitz et al., 2014). Mindfulness meditation practice has been shown to reduce neural aspects of craving including the subgenual anterior cingulate cortex, and reduced connectivity with the ventral striatum and bilateral insula, all associated with craving (Westbrook et al., 2011).

In a review article (Witkiewitz et al., 2013), authors further hypothesize the neural targets and mechanisms related to MBRP training including: (1) top down processes of executive control, attention and self-regulation involving the prefrontal cortex (PFC), medial cortex, orbitofrontal and ventromedial PFC, anterior cingulate cortex, dorsal striatum and amygdala, and (2) bottom-up processing of salient stimuli and reactivity involving the dorsolateral PFC, anterior cingulate cortex, ventral striatum, insula and amygdala. Additional targets include neural circuits known to be disrupted by substance

use such as reward circuitry, executive processing, learning and memory. All are potential targets for MBRP, but further research is needed to establish actual brain responses to MBRP intervention.

MBRP Intervention

MBRP (Bowen et al., 2011a; Witkiewitz et al., 2005) is an 8-week manualized aftercare treatment, with 2-hour weekly sessions integrating formal and informal mindfulness meditation practice, cognitive behavioral RP skills and psychoeducation. It is primarily an experiential approach with each week building on the following week’s exercises and skills. Initial sessions focus on mediation practices and increasing awareness of physical, emotional and cognitive experiences, triggers and reactions. Later sessions focus on integrating awareness and acceptance practices into daily life and coping skills for urges, craving and high-risk situations. Focus of latter sessions in on developing a lifestyle that will support and maintain recovery and mindfulness practice.

An outline of the 8 MBRP session content (Bowen et al., 2011a) is found in Table 1.

Table 1

Outline of MBRP Session Content

Session MBRP session content

1 Automatic Pilot and Relapse - Introduce concept of "automatic pilot" and how often we are unaware of our behavior. Introduce mindfulness and MBRP as means to becoming aware. Teach and practice Body Scan & mindfulness of daily activity.

2 Awareness of Triggers and Craving - Continue practice of body awareness; introduce awareness of physical, emotional and cognitive reactions to triggers. Teach and practice Urge Surfing & Mountain Meditation.

3 Mindfulness in Daily Life - Introduce formal sitting practice and SOBER breathing space. Continue practices and discussion of integrating mindfulness into everyday life.

4 Mindfulness in High Risk Situations - Increase awareness of high risk situations; practice staying with uncomfortable sensation or emotions rather than avoiding them. Learn skills to stay present and not automatically lapse. Teach and practice Mindful Walking.

5 Acceptance and Skillful Action - Introduce and cultivate a different relationship to challenging experiences. Discuss role of acceptance in change process. Teach and practice Mindful Movement and False Refuges Exercise (see Appendix J).

6 Seeing Thoughts as Thoughts - Reduce identification with thoughts. Discuss relapse cycle and role of thoughts in perpetuating cycle.

7 Self-Care and Lifestyle Balance - Discuss lifestyle balance and self-care for reducing vulnerability to relapse. Discuss regular mindfulness practice to maintain balance. Use Reminder Card for future high-risk situations.

8 Social Support and Continuing Practice - Highlight importance of social support networks for recovery. Find ways to overcome barriers to seeking help. Reflect on Course and reasons for continuing practice.

MBRP meditation practices teach and foster an attitude of friendly curiosity towards one’s experiences rather than aversion. In this manner a person engages in an imaginal exposure to triggers and cues and the opportunity to respond in a non-using manner and de-escalating associated emotions thus building self-efficacy for coping with high-risk conditions (Witkiewitz et al., 2013). After each guided practice the therapist leads the group in an “inquiry” which is a form of discussion focusing on present moment experiences of the participants. Mirroring the mindfulness meditation inquiry helps them notice and focus on what is actually arising in their present moment experience versus getting mentally caught up in the story or conditioned interpretation (Bowen, et al.,

2011b). Continued practice is encouraged to build increased capacity for awareness, nonreactivity and skillful response to the discomfort of craving and triggers of substance related cues.

Research Leading to Development of MBRP

In beginning mindfulness research with substance addiction comparisons of spirituality and mindfulness were investigated to see if they are similar constructs. In a study (Leigh et al., 2005) with undergraduate college students (N=196) found that spirituality was inversely related to decreases in alcohol and tobacco use which is consistent with many 12-step programs. Another finding was that using a new inventory, mindfulness and spirituality were likely different constructs. Lastly, a positive relationship between alcohol and tobacco use was uncovered and attributed to possible higher body sensitivity. This early study shows some of conceptualizing process for defining mindfulness and at times unexpected findings.

Prior to the development of MBRP, Marlatt’s research team investigated the use 52

of 10-day Vipassana meditation retreat (Bowen et al., 2006) as an intervention with an incarcerated population with substance addiction. Findings showed reduction in use of alcohol and other substances and psychiatric symptoms. It was noted that the 10-day intensive format may limit the use of this type of intervention, but this laid the groundwork for a different 8-week format of MBRP which was recommended.

Additional analysis (Bowen et al., 2007) of incarcerated participants in 10-day Vipassana meditation course found greater decreases in attempts to avoid unwanted thoughts that individuals who did not take the course. The decrease in thought suppression (avoidance) partially mediated effects of the course on post-release alcohol use and consequences.

Another study (Ostafin et al., 2006) of a 10-day Vipassana course on psychological symptoms of (N=53) participants at retreat centers utilizing repeated measures ANOVA found reductions in psychological distress from pre-course to 3-month follow-up.

Correlation analysis indicated results were not influenced by social desirability bias, nor dependent on daily meditation practice between course completion and follow-up.

One of common exercises in MBRP is “urge surfing” where one allows experience of craving to be present without acting on it as a form of exposure. In order to parse out how mindfulness may help address substance use disorders Ostafin and Marlatt

(2008) studied in undergraduate drinkers (N=50) and found that mindfulness, and specifically acceptance, may moderate the automatic alcohol-approach associations and hazardous drinking. “Surfing the urge” is the practice of experiential acceptance in the face of substance related stimuli. In another study (Bowen & Marlatt, 2009) “urge surfing” was developed as a brief mindfulness intervention and using a randomized control design with undergraduate smokers (N=129) found both groups did not differ on

urges, but those in mindfulness group smoked significantly fewer cigarettes over a 7-day follow-up. Study supports future study of mechanisms and effectiveness of mindfulness- based interventions for smoking cessation.

MBRP Empirical Studies

The first article describing mindfulness-based relapse prevention was written by

Witkiewitz, Marlatt, and Walker in 2005. It referenced data from previous studies in relapse prevention and vipassana and other mindfulness approaches and specifically proposed MBRP as a new approach to addiction treatment which should be researched.

The first feasibility pilot study of the MBRP protocol was conducted by Zgierska et al

(2008) to analyze the effect of MBRP on alcohol relapse with a small group (N=19).

Participants were allowed to continue other treatments they may be engaged in such as

12-step or RP groups. 15 completed the study, there was no comparison group, but results indicated a significant lower number of heavy drinking days, and due to small sample results should be used with caution.

The first randomized control trial (RCT) of MBRP (Bowen et al., 2009) compared to TAU (12-step based aftercare) for 168 adults with substance use disorders found participants who received MBRP had greater decreases in craving and increases in acting with awareness (but not other factors of mindfulness). Feasibility was established as evidenced by homework completion, attendance and participant satisfaction. Return to same substance use as TAU at 4 months post intervention is suggested to be related to lack of continued practice after program ended. Several studies doing secondary analysis of this data follow.

Further analysis (Witkiewitz & Bowen, 2010) of study results of adults with

substance addiction (N=168) in RCT of MBRP versus TAU found MBRP influencing a reduction in depressive symptoms, related craving, and post intervention substance use.

These results support the use of MBRP as part of substance addiction treatment. Another secondary analysis of data (Witkiewitz et al., 2013a) from the Bowen and colleagues

(2009) RCT of MBRP as an aftercare treatment to examine the effect of MBRP on craving. The primary analysis from original study found a decrease in craving. The findings from the secondary analysis indicate a latent factor of an increase in acceptance, awareness and non-judgment mediating lower levels of craving. The findings are consistent with the goals of MBRP. Attending to awareness, acceptance and nonjudgement need to be done together as individually they did not mediate lower levels of craving.

Another secondary analysis (Hsu et al., 2013) of data from MBRP randomized control trial (Bowen et al., 2009) found that participants with lower distress tolerance who received MBRP experienced a greater decrease in alcohol or drug use days over time than those in TAU group. These effects were not maintained at 4-month follow-up.

Findings suggest distress tolerance is clinically relevant factor which MBRP may be helpful. Further study is needed to examine maintaining long term gains.

In a pilot RCT study (Brewer et al., 2009) comparing mindfulness training (MT) adapted from MBRP and CBT for substance addiction in an outpatient setting (N=36 started; N=14 completed) found equal satisfaction with programs but reduced psychological and physiological stress in MT group. Study suggests MT may be efficacious in targeting stress in persons with SUDs. Limitations include small sample size and large dropout rate. In another RCT study (Brewer et al., 2011) for 88 treatment

seeking adults comparing mindfulness training (MT) with the American Lung

Associations freedom from smoking treatment (FFS) findings were that MT showed greater reduction in cigarette use and abstinence rate. Results support MT as a more efficacious smoking cessation treatment than a current standard treatment. Further studies are encouraged with larger samples and investigating mechanisms and possible enhanced effectiveness with pharmacotherapy.

In a review of data from a separate large RCT study combining pharmacotherapy with a behavioral intervention for alcohol addiction, Witkiewitz, Bowen, and Donovan

(2011) found that the craving module of combined behavioral intervention may weaken the relation between negative affect and heavy drinking by fostering greater decreases in craving during treatment; the implications set the stage for MBRP targeting craving as a mechanism of change.

A second larger RCT (Bowen et al., 2014) was conducted between 2009-2012 (N

= 286) of adults completed initial treatment for substance use disorders at a private non- profit treatment facility. Participants were randomized to MBRP, RP or 12-step program

(TAU) aftercare and followed for 12 months. Findings were that MBRP and RP had significantly lower risk for relapse, and for those who did use substance fewer use days at

6-month follow-up. At 12-month follow-up MBRP participants reported fewer substance use days than RP and TAU. Results suggest MBRP aftercare has added benefit over RP and TAU on reducing substance use and supporting long-term outcomes.

Understanding unique ingredients of mindfulness-based treatments and who will benefit is important. To help parse this out, a study (Bowen & Enkema, 2014) examined mindfulness and its relationship of non-clinical college students and substance use

treatment seeking adults (N=281) to examine differences related to severity of substance addiction. It was found that there are differences in mindfulness based on severity of substance addiction indicating the need to take into consideration the differences between individuals in their relationship to substances and its potential influence on mindfulness.

One of the few qualitative studies found (Harris, 2015) was done to understand the use and feasibility of MBRP in a therapeutic community (TC) 21 participants coming from day program and residential program. General feedback included most had a relatively positive experience, there were conflicting perceptions regarding “urge surfing” exercise, and most perceived MBRP as valuable. Implementation issues may account for some of the differences in reception as it was found inpatient and detoxification patients were more receptive than outpatient day program, as MBRP was designed as an outpatient aftercare program. Data from this study indicates MBRP may help with treatment retention. The study also suggests MBRP may help clients verbalize their thoughts and emotions. In this study it was found that understanding of how MBRP can help them with recovery came at different points, and that the closed group format was preferred as it seemed those entering midcourse did not benefit as much.

MBRP and PTSD and other co-occurring disorders

Due to high rate of comorbidity of PTSD and substance use disorder it is of interest determine if mindfulness is a mediator between symptoms of PTSD and substance addiction. In a study (Bowen et al., 2017) using data from a parent study having 286 participants (Bowen et al., 2014) findings indicated that higher levels of

PTSD symptoms are associated with lower levels of mindfulness, and subsequently more severe substance dependence. Specifically acting with awareness and non-judging

emerged as significant factors. This study supports the use of mindfulness interventions such as MBRP for intervention with persons having cooccurring PTSD symptoms and substance addiction. In a study (Amaro et al., 2014) for women with ethnic and socioeconomic diversity it was found necessary to make adaptations to the mindfulness intervention format to account for PTSD.

Related to MBRP’s impact on negative affect, a small RCT study (Zemestani &

Ottaviani, 2016) of Iranian adults with substance use disorder (N=74) comparing MBRP to TAU. Findings were supporting the effectiveness of MBRP for significantly lower post-intervention rates of depression, anxiety and craving. These effects were stable at a

2-month follow-up. A pilot randomized control trial (Glasner et al., 2017) evaluated the effects of MBRP relative to a health education control condition among stimulant dependent adults (N=63 started; N=45 completed) receiving contingency management.

Primary outcomes found MBRP had lower post course depression (p = 0.03; effect size =

0.58) and psychiatric severity (p =0.01; effect size = 0.61 at follow-up), and lower odds of stimulant use for those with depressive or anxiety disorders than those in control condition (odds ratio (OR) = 0.78, p =0.03 and OR = 0.68, p = 0.04). Limitations of study include small sample size, dropout rate, possible ceiling effect related to CM treatment, and need for stronger study to examine group differences between specific diagnoses.

MBRP implementation

An ongoing question for MBRP and MBIs in general is what is the necessary amount of practice is (or dosage) needed to gain and maintain benefits of mindfulness training? Brewer et al. (2011) found strong correlations between home practice and outcomes related to smoking cessation. These outcomes may suggest benefits including

learning to “sit” through difficult mind states (negative affect and craving) which parallel the situation when one is faced with the occaision to smoke. They also suggest it may be that those regularly practicing MT may more readily be able to access mindfulness and thus smoking cessation skills.

To better understand factors that lead to increased mindfulness, a secondary analysis of 93 adults in outpatient treatment for substance abuse utilizing MBRP was conducted (Bowen & Kurz, 2012). Findings found between session practice predictive of mindfulness at post-course, but not at 2-month or 4-month follow-up assessments. Client rated therapeutic alliance was a significant predictor at 2-month follow-up, but not at 4- month. Results suggest client between session practice and therapeutic alliance may be important factors for initial increases in mindfulness, but that factors shift with time.

Another secondary analysis (Grow et al., 2015) of the same data (Bowen et al., 2009) found that MBRP participants (N=93) significantly increased participation in amount of time in home mindfulness practice. It was also found that amount of home practice was associated with less alcohol or drug use and craving at the 2-month and 4-month follow- ups. Also noted were fading of treatment gains at 2 and 4-month follow-ups as participants returned to standard aftercare which did not involve mindfulness practice.

Results suggest that building mindfulness practice into one’s life has a key role in ongoing recovery from addiction and has potential to boost MBRP treatment effects.

A corollary to personal practice is the quality and practice of the MBRP teachers.

In the MBRP manual it is recommended MBRP teachers have training and regular mindfulness practice (Bowen et al., 2011b). In other MBIs there is an emphasis on the teacher having been trained well and having an ongoing mindfulness so as to embody

what they are trying to convey and to be able to speak from their own experiences. There is only one study (Grepmair et al., 2007) related to mindfulness teacher training in general, and there are no studies specifically related to teacher training in substance use disorders. Grepmair et al (2007) conducted an RCT (N=124) comparing Zen trained psychotherapists in training (PiTs) versus non-meditation trained PiTs, and found patients rated Zen trained PiTs with higher evaluations of their therapy and demonstrated greater improvement on measures of psychopathology. One study (Bowen, et al., 2009) identifies MBRP groups being led by therapists with master’s degrees in psychology or social work who underwent several weeks of intensive training, engaged in daily practice, and had weekly supervision throughout the trial. Some of the teachers had extensive experience in mindfulness meditation. Another study (Bowen & Kurz, 2012) emphasized importance of therapeutic alliance with client gains in mindfulness.

To measure of treatment integrity and therapist competence, the Mindfulness-

Based Relapse Prevention Adherence and Competence Scale (MBRP-AC) was developed

(Chawla, et al., 2010) during a RCT of MBRP efficacy. It includes two components of

Adherence (to MBRP components and discussion of key concepts) and Competence

(ratings of therapist style, approach and performance). Findings included high interrater reliability for all adherence and competence ratings and adequate internal consistency for therapist ratings. Adherence ratings were positively related to changes in mindfulness over course of MBRP program. To date this measure has had limited use, and the authors note limitations in being able to measure nuanced aspects of teacher delivery of MBRP.

There is some evidence (Grow, 2013) that utilizing a brief pretreatment interview may enhance treatment outcomes and retention. N=286 were randomized to receive or

not receive a brief pretreatment interview as part of a larger study. Logistic, Poisson, and zero-inflated negative binomial analysis revealed that those participants who received the brief pretreatment interview were more likely to attend the first aftercare class, stay in aftercare treatment. There were no differences in substance use outcomes.

Many mindfulness-based interventions are designed as closed group formats with sessions building upon one another (Witkiewitz et al., 2014). The reality of treatment programs is high dropout and turnover rates. Given the reality in the field or financial needs of situation, researchers have begun to test more flexible approaches such as having “block” entries at session 1 or 5 (Brewer et al., 2009), with a separate introduction session, or as a rolling group format (Witkiewitz, Warner, et al., 2014).

Multicultural research for MBRP

It has been noted there is a gap in the overall literature addressing mindfulness- based interventions for SUDs for diverse populations specifically in consideration of gender, ethnicity and economic status (Katz & Toner, 2012). Two areas needed for further research are well powered studies addressing gender, ethnicity and socioeconomic status, and attention to these factors in tailoring the MBIs to be culturally appropriate and under different conditions than original research samples (Amaro, 2014). For example, after an initial rejection of a standard MBSR program by a group of African American and Latina women participating in a substance addiction treatment program, Amaro

(2014) addressed lack of fit by modifying and simplifying language, shortening initial mindfulness practices, and modifying practices to reduce potential for triggering trauma.

Another change was allowing more time for group discussion. Finally, it was important to have an addictions counselor as a cofacilitator to address addiction related concerns

and treatment issues. This study underlined the need to tailor mindfulness-based intervention to specific population being served.

In the follow-up study (Amaro et al., 2014) adapted MBRP for a racially and ethnically diverse sample of 318 low-income women in substance use disorder treatment.

Using a single group, repeated measures design had findings of high satisfaction (M =3.4,

SD =.3), modest completion rate (36%), Using linear regression found reduced alcohol addiction severity (β = −.07, p < .05), drug addiction severity (β = −.04, p<.05), and perceived stress (β = −2.29, p < .05) at 12 months. Finding support further research for

MBRP-W as an adapted approach. Adaptations included language, consideration for

PTSD and common stressors for this population. In another RCT study (Witkiewitz,

Warner et al, 2014) found modest support for MBRP as an efficacious intervention

(N=105) compared to an active treatement for women in a residential based substance abuse program for female criminal offenders. At 15-week post treatment follow-up, regression analysis found MBRP participants reported fewer substance use days, and less legal and medical problems. MBRP has also been found acceptable and effective in other countries such as Taiwan (Lee, et al., 2011) and Iran (Zemestani & Ottaviani, 2016).

MBRP and corrections populations

A limited number of studies have been done with corrections populations utilizing

MBRP treatment program. Several studies were already mentioned with favorable results and encouraging further research. Amaro et al. (2014) worked with women court-ordered to drug treatment having 73.9% in residential facilities and 26.1% as outpatient, and

Witkiewitz et al. (2014) worked with women all in residential corrections setting. A small

RCT study (Lee, et al., 2011) with incarcerated adult men with substance addiction

(N=24) compared MBRP with TAU utilized MANOVA and repeated measures ANOVA for several psychosocial outcomes. Findings between pretest and posttest measures show

MBRP trending to lower depressive mood and higher negative expectancy for use. A small mixed-methods study (Holt, 2016) with six incarcerated men found participants gained some benefits from MBRP related to anger management, empathy and mindfulness.

MBRP and impulsivity

One study considered automatic appetitive responses and hazardous drinking with mindfulness (Ostafin & Marlatt, 2008). In a sample of undergraduate drinkers (N=50) it was found that greater mindful acceptance of current experiences weakens the automatic alcohol approach associations and hazardous drinking. The results suggest automatic mental processes and behavior may be moderated by mindfulness training. Only one small dissertation study (Maddox, 2011) was found specifically investigating MBRP and its effect on cultivating mindfulness and reducing impulsivity as measured by the

UPPS+P. A small sample (N=14) using a single group pretest-posttest correlational design found no decrease in scores of impulsivity but did find significant increases in mindfulness scores.

Mindfulness, Self-Compassion, Impulsivity and Opioid Addiction

Advantages of explicitly combining mindfulness and compassion for the treatment of psychopathology (Allen & Knight, 2005; Dahm et al., 2015; Davis et al.,

2017) have been proposed but to date there are few empirical studies (Keng et al., 2012) and only one related to substance addiction (Steinman, 2014). MBRP was originally

designed as a compassionate approach that combines mindfulness training and relapse prevention (Bowen & Vieten, 2012). Mindfulness is a form of metacognition and attention regulation associated with increased activity in the middle prefrontal cortex

(Siegel, 2007). Compassion is linked to older caregiving systems, which involve oxytocin and other hormones related to attachment (Goetz et al., 2010; Dahm et al., 2015). Further study of the neurobiology of substance use and impulsivity may help identify targets of treatment, and biomarkers for vulnerability and matching treatments for individuals

(Winstanley et al., 2010).

Mindfulness and self-compassion approaches may target negative emotional processes which in turn can reduce attentional bias and rash action (Leung et al., 2017;

Smith & Cyders, 2016) which may be useful to decrease impulsivity and opioid use disorder. Increases in mindful awareness may lead an individual to notice internal moods states including craving and develop a capacity to be nonreactive to such states. This would result in less impulsive action and warrants further study (Staiger et al., 2014).

Intense emotion either positive or negative can undermine rational decisionmaking and can lead to impulsive substance use which suggests treatments that can enhance and maintain positive mood, savor success in an integrated way, and recognize warning signs of impulsive behavior would be useful. (Smith & Cyders, 2016; Staiger et al., 2014).

Neurobiological connections

Executive functioning includes planning and organization, motivation and goal directed activity, weighing consequences and impulse inhibition are associated with the frontal lobes of the brain. Differences in executive functioning and impulsivity can be considered as variable human trait which may fluctuate in state behavior depending on

momentary conditions. Substance addiction may alter dopaminergic receptors and activity in a manner that increases attentional bias and reward sensitivity, while at the same time deactivating executive control (Leung et al., 2017). With substance cues

(triggers) and use reward circuitry is activated and there is increased insula activity, possible lowering of GABA production, and during negative emotion increased amygdala activity (Smith & Cyders, 2016). In a study specifically relating opioid addiction and impulsivity results indicate chronic opioid exposure is associated with a range of neurocognitive deficits primarily in verbal working memory, cognitive impulsivity (risk taking) and cognitive flexibility (verbal fluency) (Baldacchino et al., 2012).

For opioid addiction a proposed allostatic model of hedonic dysregulation would lead to a lowering of the natural reward system and an increase in drug cue salience which facilitates addictive behavior (Garland et al., 2017). Recent findings from neuroimaging studies indicate mindfulness practice may be associated with changes in brain structure and activation related to reduced rumination, and reactivity in the face of craving (Chiesa & Serreti, 2014), and improved attention, memory and executive functioning all favorable to improved mental-emotional balance and reduced risk of relapse (Chiesa, 2013, Garland, 2014). Other studies found substance misuse related to alexithymia, frontal lobe executive dysfunction, higher reward salience and inversely related to mindfulness (Lyvers et al., 2014a; Lyvers et al., 2014b).

Self-compassion may enhance emotional resilience because it deactivates the threat system (associated with autonomic arousal and feelings of insecure attachment and defensiveness) and activates the caregiving system (associated with feelings of secure attachment, safety, and the oxytocin-opiate system) (Gilbert, 2006). This oxytocin-opiate

system may be particularly relevant to the of opioid addiction. Changes have been found in neuroimaging studies of areas related to empathy (Hoffman, 2011), lowering of stress hormone cortisol and heart rate (Germer & Neff, 2013). Mindfulness and self- compassion training may activate dysfunctional brain areas and foster neuroplastic growth through repeated practice.

Given the above research, the combination of mindfulness and self-compassion training presents a potentially effective intervention targeting “bottom up processes” and facilitate the ability to access the higher level skills that may be otherwise disrupted due to momentary negative affect, cognitive disruption/distortion and impulsive action. Table

2 summarizes the targets and components of MBRP treatment for impulsivity, mindfulness and self-compassion in treating opioid use disorders.

Table 2

Impulsivity and MBRP Components

Treatment MBRP Components

Targets Impulsivity Self-Compassion Mindfulness Relapse Prevention

General Automatic - Affective Systems - Cognitive Systems - Learned Skills - SUD Affective Response Calming Attention/Awareness Higher Level "Mindlessness" Cognitive Processing

Executive Function Enhance emotional Exercises executive Skill focus on Deficits - Frontal resilience functions observing, region of brain assessing and responding to high risk situations & relapse situations

Increased Insula & Deactivate Threat Developing Cognitive Amygdala activity System increased attention reappraisal of (Threat System) and awareness and situations non-reactivity Motivational Interviewing

Decreased GABA Focuses on stepping Cognitive (calming & out of "automatic" Behavioral Therapy emotional mental processes & Decisionmaking regulation) Skills

Teacher Modeling Teacher Modeling Teacher Instructing

Opioid Working memory Activates Focus on Working "Urge surfing" Exposure impairment caregiving-safety Memory tolerating difficult system (oxytocin- emotions opiate)

Increased cognitive Enhances natural Calming & impulsivity (risk rewards processing Concentrating; taking) Settling the Mind

Decreased Decrease isolation, Opening awareness Reframes cognitive flexibility rigidity & self- "Abstinence criticism Violation Effect" (AVE) as part of process

Decreased hedonic Enhances natural Noticing & Savoring Consideration of capacity (natural rewards processing alternative positive rewards) rewards and activities

Decreased Distress tolerance Awareness of interoception with compassion internal sensations (bodily signals; with non-judgement pain) and acceptance.

Neurotoxicity Foster postive Neuronal emotional state Regeneration needed for neuronal regeneration

PTSD & Intense PTSD Approach therapy - Awareness and Harm reduction Co- response - Acceptance and Acceptance of approach that occuring Avoidance Self Compassion negative affect & emphasises Disorders thoughts learning over failure

Depression Acceptance in the Evidenced based Psychoeducation face of negative approach for Identification of affect; savoring and depression and Irrational or fostoring postive anxiety disorders Unbalaced affect Thoughts and Beliefs

Anxiety Directly addresses A form of exposure self-criticism, therapy shame and guilt

Summary of Related Research Literature

Opioid addiction and treatment

Opioid addiction has been defined as a primary, chronic disease of brain reward, motivation, memory and related circuitry with characteristic biological, psychological, social and spiritual manifestations reflected in pathologically pursuing reward and/or relief by opioid use (Mee-Lee, et al., 2013; Kampman & Jarvis, 2015).

Opioids are highly addictive (Koob & Volkow, 2016), and chronic exposure results in structural and functional changes in regions of the brain (Upadhyay et al., 2010;

Volkow & Warren, 2014; Younger et al. 2011). Treating opioid addiction needs to be viewed as a chronic disease requiring long-term multimodal treatment including strategies that enhance natural reinforcers, strengthen executive function, decrease drug related conditioned responses, improve mood, and decrease sensitivity to stress (Volkow

& Warren, 2014).

While the research supports psychosocial treatment for opioid addiction, and has recognized the need for personalized aftercare, continued research is needed to improve specificity, consistency, evaluate outcomes (Koldony et al., 2015), and to understand

non-responders (McKay, 2009). Needs include determining which interventions and approaches will extend engagement for successful treatment (McKay et al., 2009), how to effectively implement evidence-based interventions (Lash et al., 2011), and better incorporate the client’s perception of care (Costello et al., 2018; Hepner et al., 2017). Of specific interest to this study are finding effective aftercare approaches when working with criminal justice population (Hora, 2014), and meeting the challenges that arise with this population (Mee-Lee et al., 2013).

Impulsivity

Impulsivity is considered a risk factor for the development and maintenance of substance addiction (Bankston et al., 2009; Leung et al., 2017; McCown, 1989) and is a strong predictor of abuse (Heinz et al., 2015) and relapse (Evren et al., 2012; Pattij & De

Vries, 2013). Differences in impulsivity occur based on drugs used (Pattij & De Vries,

2013), for example, impulsivity may predict stimulant use, but not heroin, but repeated use of heroin increases impulsivity leading to sustained use. There presently is little research connecting impulsivity and opioid addiction, so further research is warranted.

Conceptualizations of impulsivity vary (Evenden, 1999; Beaton et al., 2014, but it has been described as rash spontaneous unthoughtful behavior (Dawe & Loxton, 2004), and as both a trait (Staiger et al., 2014) and state (Beaton et al., 2014). Negative affect may increase impulsive decisionmaking and behavior (Smith, & Cyders, 2016). And the inability to inhibit behavioral responses or regulate urges (overactive reward system

“bottom up” processing) is hypothesized as a failure of “top down” executive processes

(Tomko et al., 2016) which may reflect underlying neurocognitive systems. Impulsivity may be considered an umbrella term that covers multiple processes distributed across

different brain regions (Winstanley, et al., 2010).

Addiction is likely due in part to genetic predisposition and loss of inhibition due to substance neurotoxicity (Bankston et al., 2009; Staiger et al., 2014) There is also evidence of neuro-regeneration upon abstinence from substance use (Crews & Boettiger,

2009). However conceptualized, the direct effect of drug use may allow for an escalation of drug use through disinhibition and long-term sequelae of drug use (de Wit, 2008).

Understanding neurobiological process related to impulsive behavior is thus important to developing targeted treatments for substance use disorder (Pattij & De Vries, 2013).

Therefore, further research is needed for impulsivity and psychosocial treatments to determine targets, dosage, and predictors/moderators of outcome (Bankston et al.,

2009; Leung et al., 2017; Loree et al., 2015). Further research on the malleability of trait impulsivity is warranted to see if treatments can in fact enhance executive control and positive behavioral responses (Littlefield et al., 2015; Smith & Cyders, 2016). There is emerging evidence that mindfulness meditation may target some of these same areas of the brain and nervous system (Tang et al., 2015). Questions specific to our proposed study are raised: can mindfulness interventions improve impulsivity? (Staiger et al.,

2014). Can we better match treatments to individual needs and differences for a more personalized approach, particularly with individuals with high impulsivity? (Tomko et al., 2016). Finally, to date only two small studies utilize MBRP and impulsivity (Maddox,

2011; Ostafin & Marlatt, 2008).

Self-compassion

Substance addiction has also been related to experiential avoidance and lower self-compassion; persons with SUD may attempt to avoid self-criticism or criticism and

control unwanted thoughts or feelings. (Graham, 2016). It is noted that intense emotion either positive or negative can be a precursor to substance use, which in turn undermines rational decisionmaking and leads to impulsive behavior which suggests treatments that focus on emotional regulation may be fruitful. Research to find treatments that can enhance and maintain positive mood, savor success in an integrated way, and recognize warning signs of impulsive behavior is recommended. (Smith & Cyders, 2016; Staiger et al., 2014).

Self-compassion includes having a balanced, non-judgmental view of oneself and promotes adaptive function and a reduction in stress, depression, shame, self-criticism, and neurotic perfectionism (Brooks et al., 2012; Gilbert, 2006). Self-compassion can be considered a coping mechanism that promotes a balanced approach to negative emotions and is related to psychological flourishing and reduced psychopathology (Germer & Neff,

2013). It is suggested that self-compassion provides emotional resilience because it deactivates the threat system (associated with autonomic arousal and feelings of insecure attachment and defensiveness) and activates the caregiving system (associated with feelings of secure attachment, safety, and the oxytocin-opiate system) (Gilbert, 2006) which for the proposed study on addiction is highly relevant.

Generally, research related to self-compassion, psychopathology and substance addiction is limited, and there are no studies specifically focusing on self-compassion and opioid addiction. In one meta-analysis of 20 studies (MacBeth & Gumley, 2012) a large effect size was found between self-compassion and depression, anxiety and stress supporting self-compassion as a facilitator of resilience. While there are promising findings relating increased self-compassion to lower drug use (Paniagua et al., 2017), and

inversely related to alcohol misuse (Phelps et al., 2018); only a small number of studies of compassion-based interventions have been evaluated for reducing shame in addictions

(Au et al., 2017; Graham, 2016).

Two compassion-based therapies have been recently developed (CFT; Gilbert &

Procter, 2006; MSC; Neff & Germer, 2013), but presently there is no self-compassion treatment that specifically focuses on addiction. Mindfulness-based therapies for addiction (MBRP & MORE) include self-compassion as a component of an overall program. With a high prevalence of co-occurring PTSD and substance use disorder it is necessary to include treatment of PTSD in the overall assessment of substance use disorder. Self-compassion is a potentially modifiable factor related to the development and maintenance of PTSD (Hiraoka et al., 2015), a protective factor (Zeller et al., 2015), and a target for intervention (Au et al., 2017; Hiraoka et al., 2015; Kearney et al., 2013

SS: Najavits, 2002; Najavits et al., 2012).

Mindfulness

While, there is not a complete consensus on the definition or conceptualization of mindfulness (Chiesa & Serretti, 2014) it has been viewed as a trait or state (Brown &

Ryan, 2003; Chiesa, 2013), and a systematic development of attention to present moment experience with an attitude of curiosity, openness and acceptance (Bishop et al., 2004;

Kabat Zinn, 1994). Mindfulness meditation and intervention may help a person with addiction be present and attentive to their experience but not be preoccupied by it, allowing for a more skillful response to situation versus reactive conditioned response

(Zgierska et al., 2009). That skillful response may include CBT tools learned but not always accessible in a moment of difficulty.

Chiesa and Serretti (2014) in a review of 24 studies found evidence that suggests

MBIs can reduce consumption of several substances including alcohol, cocaine, amphetamines, marijuana, cigarettes and opiates; reduce craving and increase mindfulness; findings are consistent with an earlier systematic review of 25 studies

(Zgierska et al., 2009 which show promise but inconclusive for treatment for substance addiction due to methodological concerns. Li, Howard et al (2017) reviewed 42 studies and found small to large effect sizes for mindfulness in reducing frequency and severity of substance misuse, intensity of craving, and severity of stress. A majority of these studies reported effectiveness in reducing substance misuse, psychological, relationship and legal problems in follow-ups up ranging 2 weeks to 12 months.

Unresolved MBI research issues were outlined by Witkiewitz & Black (2014) including: (1) refining operational definitions of mindfulness, (2) clarifying practice targets (dosages) for different populations, (3) understanding mechanisms of change and determining which interventions are most effective and for whom, and (4) dissemination and implementation issues which bridge research to clinical gap. Research concerns for implementation include practice time for efficacy (Carmody et al., 2008; Crane et al.,

2017); teacher training and practice (Crane et al., 2017), and adaptations for different multicultural populations (Katz & Toner, 2013). With many involved with correctional system having co-occurring substance addiction surprisingly there are only a few studies addressing this population (Lyons & Cantrell, 2016; Himelstein et al., 2012; Marlatt et al., 2004; Shonin et al., 2103). Findings with correctional studies to date have been promising, including significant improvements in negative affect, substance use (and attitudes), anger, relaxation, and self-esteem/optimism, but methodological quality issues

warrants a call for stronger research with mindfulness interventions for persons with substance addiction in correctional settings.

MBRP

MBRP is a harm reduction approach that combines cognitive behavioral relapse prevention with mindfulness meditation practice as a compassionate approach to help people skillfully work with the symptoms and experiences of addiction and may provide benefits over traditional abstinence-based programs by offering a low stigma, flexible goals, and tolerance of a variety of religious beliefs (Bowen et al., 2011b). MBRP is a compassionate approach fostering acceptance and self-compassion to reduce shame, guilt and stigma often associated with substance misuse.

Two core intentions of MBRP are first to cultivate mindful awareness of internal and external process (e.g. cues, craving, urges, thoughts) that trigger conditioned using behavior (“automatic pilot”) providing an opportunity to respond in postive ways versus react. The second is the self-compassionate practice of acceptance/non-judgment with triggering negative affect or experiences without having to react to escape them; thus, developing skill and self-efficacy in responding to substance use cues and craving

(Bowen et al., 2011a; Witkiewitz, et al., 2014). The focus on acceptance of internal experience versus external cues may increase tolerance of distress and subjective urgency to alleviate discomfort via substance use and decouple habitual response to use substances when experiencing negative affect (Bowen et al., 2007), or facing shame, guilt or the stigma of addiction, and increasing self-efficacy (Ostafin, et al., 2006; Penberthy et al., 2015).

Empirical research for MBRP began when it was introduced conceptually by

Witkiewitz, Marlatt, and Walker in 2005, mindfulness-based relapse prevention has had a number of pilot or small RCT studies (Brewer et al., 2009, Brewer et al., 2011; Zemestani

& Ottaviani, 2016, Zgierska et al., 2008), two qualitative studies (Harris, 2015; Holt,

2016) most supporting the feasibility and benefit of MBRP with different populations; due to typical small sample sizes results must be used with caution and it is recommended that future studies with greater power and rigor be conducted. Three larger randomized controlled trials (Bowen et al., 2009; Bowen et al., 2014; Witkiewitz et al.,

2014) were found in the literature as well as related studies conducting secondary analysis of data.

The first randomized control trial RCT of MBRP (Bowen et al., 2009) compared to TAU (N=168) found participants who received MBRP had decreases in craving, increases in acting with awareness, and feasibility was established as evidenced by homework completion, attendance and participant satisfaction. Several studies doing secondary analysis found MBRP influencing a reduction in depressive symptoms, related craving, and post intervention substance use (Witkiewitz & Bowen, 2010); a latent factor of an increase in acceptance, awareness and non-judgment (all together) mediating lower levels of craving (Witkiewitz et al., 2013a); participants with lower distress tolerance experienced a greater decrease in alcohol or drug use days over time than those in TAU group, but effects were not maintained at 4-month follow-up and further study is needed to examine maintaining long term gains (Hsu et al., 2013).

A second larger RCT (Bowen et al., 2014) was conducted between 2009-2012 of adults completing initial treatment for substance addiction, Findings were that MBRP and

RP had significantly lower risk for relapse, and for those who did use substance fewer use

days at 6-month follow-up. At 12-month follow-up MBRP participants reported fewer substance use days than RP and TAU. Results suggest MBRP aftercare has added benefit over RP and TAU on reducing substance use and supporting long-term outcomes.

Additional studies doing secondary analysis included: (Bowen et al., 2014) findings indicated that higher levels of PTSD symptoms are associated with lower levels of mindfulness, and subsequently more severe substance addiction. This study supports the use of mindfulness interventions such as MBRP for intervention with persons having cooccurring PTSD symptoms and opioid addiction.

To better understand factors that lead to increased mindfulness, two secondary analyses of Bowen et al. (2009) considered adults randomized to MBRP (N=93) and found between session practice predictive of mindfulness at post-course, and client rated therapeutic alliance was a significant predictor (Bowen & Kurz, 2012). Similarly, MBRP participants significantly increased participation in amount of time in home mindfulness practice. It was also found that amount of home practice was associated with less alcohol or drug use and craving (Grow et al., 2015). In a separate study Brewer et al. (2011) found strong correlations between home practice and outcomes related to smoking.

Results suggest client between session practice and therapeutic alliance may be important factors for initial increases in mindfulness, but that factors shift with time. Results suggest that building mindfulness practice into one’s life has a key role in ongoing recovery and has potential to boost MBRP treatment effects.

It is recommended MBRP teachers have training and regular mindfulness practice

(Bowen et al., 2011a), but there is little research done to date (Bowen & Kurz, 2012;

Grepmair, 2007). Assessing teacher’s competence and program fidelity also has research

limited to the development of the MBRP-AC adherence ratings (Chawla et al., 2010).

Other areas of implementation research with MBRP include utilizing a brief pretreatment interview to enhance engagement (Grow, 2013), delivering MBRP in block (Brewer et al., 2009) or rolling group formats (Witkiewitz et al., 2014).

There is a gap in the overall literature addressing mindfulness-based interventions for addiction for diverse populations (Katz & Toner, 2012). Only a few studies were found for MBRP and diverse populations including corrections (Amaro et al., 2014; Holt,

2016; Lee, et al., 2011; Witkiewitz et al, 2014; Zemestani & Ottaviani, 2016). All show promising findings, but further research is needed to understand and improve outcomes.

Finally, the combination of mindfulness and self-compassion training presents a potentially powerful intervention targeting affective and cognitive “bottom up processes” and may be necessary to facilitate the ability to access the higher-level skills during physical and mental states of disruption due to momentary negative affect, cognitive disruption/distortion and impulsive action. The proposed study will examine this yet unstudied area for treatment of opioid addiction.

Rationale for Study

Opioid addiction is a chronic disease for which better psychosocial evidence- based treatments are needed at every stage (McKay, et al., 2009) and understanding specifics with respect to population and treatment implementation may improve outcomes (Koldony et al., 2015; Lash et al., 2011; McKay et al., 2009) while simultaneously helping clinicians understand the client’s perception of best practices

(Costello et al., 2018; Hepner et al., 2017). MBRP is an aftercare program combines

cognitive behavioral relapse prevention with mindfulness meditation practice as a compassionate approach to help people skillfully work with the symptoms and experiences of addiction. While it has a growing body of research evidence, there is still a need to further establish its benefit for specific populations. To date there is limited research on the use of MBRP with correctional populations and no research found for persons with opioid addiction or the important construct of impulsivity. Also, although mindfulness and self-compassion both have some evidence for benefitting persons with substance addiction, both have not been studied together. This study was needed to address these gaps in the research. This study addressed further research needs on implementing MBRP in the field with typical treatment counselors. Finally, a mixed- methods approach helped understand clients’ subjective experiences of MBRP as well as more concrete reported changes in quantitative outcomes.

CHAPTER III

METHODOLOGY

The purpose of this study was to investigate the treatment effect of MBRP aftercare program on degree of mindfulness, impulsivity and self-compassion with a group of participants in a court-ordered population with opiod use disorder. To answer the research questions and to provide a holistic interpretation it was necessary to draw from several data sets. In this study qualitative data were needed to enhance quantitative data and further express clients’ experience of MBRP aftercare program (Teddlie &

Tashakkori, 2009).

The present study used a mixed-methods ex post facto single group pre-test posttest research design (Creswell & Plano Clark, 2018). This mixed-methods study considered quantitative outcome variables and qualitative themes that arose from interviews. Quantitative and qualitative data were analyzed and interpreted to explain treatment effects on the clients. This study investigated the following research questions:

1. Was there a significant difference in participant self-reported mindfulness after

participating in at least six weeks of a mindfulness-based relapse prevention

(MBRP) opioid addiction aftercare program in a court-ordered population?

2. Was there a significant difference in participant self-reported self-compassion

after participating in at least six weeks of a MBRP opioid addiction aftercare

program in a court-ordered population?

3. Was there a significant difference in participant self-reported impulsivity after

participating in at least six weeks of a MBRP opioid addiction aftercare program

in a court-ordered population?

4. How did participants describe their experience of a MBRP opioid addiction

aftercare program in a correctional setting?

5. In what ways did qualitative findings converge with qualitative results?

Hypotheses

Null hypothesis 1: Self-reported mindfulness (as measured by the Five Facet

Mindfulness Questionnaire [FFMQ] and subscales) will not statistically significantly change from before (pre-test) to after (post-test) a MBRP aftercare program for clients with opioid addiction in a correctional setting.

Directional hypothesis 1: Self-reported mindfulness (as measured by the FFMQ and subscales) will statistically significantly increase from before (pre-test) to after (posttest) a MBRP aftercare program for participants with opioid addiction in a court-ordered population.

Null hypothesis 2: Self-reported self-compassion (as measured by the Self

Compassion Scale-Short Form [SCS-SF]) will not statistically significantly change from before (pre-test) to after (post-test) a MBRP aftercare program for participants with opioid addiction in a court-ordered population.

Directional hypothesis 2: Self-reported self-compassion (as measured by the SCS-

SF) will statistically significantly increase from before (pre-test) to after (post-test) a

MBRP aftercare program for participants with opioid addiction in a court-ordered population.

Null hypothesis 3: Self-reported impulsivity (as measured by the Barratt

Impulsivity Scale-11 [BIS-11]) will not statistically significantly change from before

(pre-test) to after (post-test) a MBRP aftercare program for participants with opioid addiction in a court-ordered population.

Directional hypothesis 3: Self-reported impulsivity (as measured by the BIS-11) will statistically significantly decrease from before (pre-test) to after (post-test) a MBRP aftercare program for participants with opioid addiction in a court-ordered population.

Qualitative research question 4: Participants with opioid addiction in a court- ordered population will describe their experiences of a MBRP aftercare program.

Qualitative research question 5: Results on the outcome measures will be converged with qualitative findings from interviews of participants with opioid addiction in a court-ordered population.

Description of Independent and Dependent Variables

Specific to the quantitative analyses used in the present study, two independent and eight dependent variables were included. The independent variables were time, and counselor. Eight dependent variables were utilized: one mindfulness full score utilizing the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006), the five FFMQ subscales of observing, describing, acting, nonjudging and nonreacting, one self- compassion full score utilizing the Self-Compassion Scale – Short Form (SCS-SF; Raes

et al., 2011), and one Barratt Impulsivity Scale – 11(BIS-11; Patton et al., 1995) impulsivity full score.

Research Design

This study used a mixed-methods ex post facto single group pre-test post-test intervention design (Creswell & Plano Clark, 2018) utilizing archival data (Teddlie &

Tashakkori, 2009) from a previous sponsored aftercare treatment program. The present study was a hybrid or advanced mixed-methods design as it incorporates several more phases and procedures than core designs (Plano Clark & Ivankova, 2016).

A mixed-methods case study was used for integration across the quantitative and qualitative data within and across cases to demonstrate points of convergence. The mixed-methods study utilized a convergent design combined the two independently obtained study components and through merging analysis develops a more holistic interpretation of the results and findings (Plano Clark, 2019; Usher et al., 2019).

Integration strategies included: asking mixed method research questions, aligning qualitative and quantitative data sources, and finding points of integration to develop a joint display (Plano Clark, 2019). The data included results from 24 participants and findings from a subsample of nine participants, each case includes all archival data for participants including inclusion in one of four counselor groups. The merging and integration of quantitative results and qualitative findings generated meta-inferences for answering the research questions and to better understand clients’ experiences and outcomes.

Because mixed-methods design can often be difficult to follow it is recommended to provide diagrams to describe the research design (Creswell & Plano Clark, 2018).

Utilizing Morse (1991) notation data collection was depicted as quantitative using

“QUAN” or “quan” with uppercase lettering indictating greater importance and lowercase lettering indicating less importance. Similarly qualitative data was represented by either “QUAL” or “qual”. In this study both QUAN and QUAL are used to indicate equal importance of the data obtained. The Morse notation also used the “+” sign to indicate simultaneous data collection or analysis, and the “→” arrow sign indicated sequential data collection or analysis. Figure 1 and Figure 2 diagram this study in its two phases.

Figure 1 Phase 1 MBRP Pilot Program Intervention and Archival Data Collection

Figure 1 depicts the data collection and intervention process for the initial MBRP pilot program which resulted in archival data used in the present study. QUAN pre-test data was collected prior to the MBRP intervention. At completion of the MBRP intervention

QUAN post-test data was collected and immediately followed by QUAL interviews of participants and counselors.

Figure 2

Phase 2 Analysis of Archival Data from Phase 1

Figure 2 represents the present study which utilized the archival data from Phase

1. This diagram shows the data analysis process. QUAN pre-test and post-test data were statistically analyzed and concurrently QUAL interview data was coded and themed.

Following this, within case QUAL and QUAN data were analyzed together for convergence and divergence to address research question four explaining client experiences, and comparative case analysis of QUAL and QUAN data are done for convergence and divergence to address research question five to explain outcome results.

Ex post facto studies make use of data that has already been collected from a previous study (Heppner et al., 2008). Both quantitative and qualitative archival data were available for the present study from the MBRP aftercare program that ran between

June 2016 and January 2017, as well as documentation related to the process in how they were attained. While much of evidence-based practice emerges from well-controlled experimental studies, it has been argued that complimentary practice-based evidence

(Barkham & Mellor-Clark, 2003; Holmqvist et al., 2015; Margison et al., 2000) is needed to provide greater external validity of treatment. These types of studies are conducted in

day to day therapeutic practice and can help inform the implementation of evidence- based practice to specific populations or conditions. This study used archival data from the MBRP intervention to develop practice-based evidence for implementation of MBRP in the field.

A mixed-methods approach allowed for qualitative data to be collected during and after quantitative phases. Qualitative interviews of participants observations described how outcomes occurred (Teddlie & Tashakkori, 2009), checked fidelity or other factors that influenced intervention (Creswell & Plano-Clark, 2018), and gave voice to participants’ perspectives and experiences (Teddlie & Tasshakori, 2009) of the MBRP aftercare program that could not be captured with a quantitative measure. This study was necessary due to very limited literature on aftercare programs in general, and the lack of a mixed-method design approach in the study of MBRP.

To answer or research questions 4 and 5 this study employed a multiple case study and cross case study analysis as outlined in Table 3.

Table 3

Summary of Data Analysis

Research Questions Analysis Method Data Sources

1, 2, 3 Single Group Pre-Test Post-Test QUAN: Pre-Test & Post-Test Scores

4 Coding & Themes QUAL: Participant Interviews Individual Cases

5 Quantitizing Coded References QUAN: Pre-Test & Post-Test Scores Cross-case analysis & QUAL: Coded References from Joint Displays Participant Interviews

This case study approach was oriented to answering how and why questions, used multiple sources of data, and focused on contemporary events (Yin, 2014). This study focused in on multiple cases that are similar in nature to understand the concepts that are common across cases and moved toward generalization of interpretation across the collection of all the cases, or quintain (Stake, 2006). Cases in the study centered on individual participants and four counselor groups. Cross case analysis used results from cases to provide a merged analysis and examined convergence within and across the quintain (Stake, 2006).

A mixed-methods ex post facto single group pre-test post-test intervention design was appropriate for a study intended as a small feasibility or dissertation study when available data of one type was limited, data could not be changed, and used multiple data types to strengthen the findings. This methodology was also fitting when only one researcher was available to collect data (Creswell & Plano Clark, 2018; Stake, 2006;

Teddlie & Tashakkori, 2009). While this approach limited generalizability, it was economical and provided practical information for those implementing MBRP programs and added to needed field research for treating persons with addiction to opioids.

Participants and Delimitations

Data from a total of 24 adult participants from a local court-ordered drug treatment program in northeastern Ohio was included in the present study of the effects of a MBRP aftercare program on clients with opioid addiction. For inclusion in this study, all participants met the American Psychiatric Association (2013) criteria for an opioid use disorder diagnosis at the time of the MBRP aftercare program and completed six to eight

sessions of MBRP aftercare program. The participants were divided between four different treatment counselor groups and experienced the same MBRP aftercare curriculum. Participant demographics are reported in Table 4.

Table 4

Participant Demographics

Characteristic Participants (N = 24) M SD Age in years 32.0 9.1 n % Gender Women 15 62.5 Men 9 37.5 Ethnicity White 20 83.3 African American/Black 1 4.2 Asian 1 4.2 Not Reported 2 8.3 Work Status Unemployed 14 58.3 Employed 8 33.3 Not Reported 2 8.3 Education High School or GED 8 33.3 Some College 8 33.3 4-year College 3 12.5 Did not complete high school 3 12.5 Not Reported 2 8.3

Has Opioid Use Disorder Diagnosis 24 100

In this sample there were more women (62.5%) than men (37.5%), the ethnicity of the majority of participants was White (83.3%), most participants were unemployed (58.3%) and had at least a high school education or GED (33.3%) or some college (33.3%).

For quantitative sampling, power analysis utilized G*Power 3.1.3 statistical power analysis program (Faul et al., 2007) and showed that with one independent variable (time), an α = 0.05 and a hypothesized medium effect size, a given sample size of N=25 for each dependent variable a post hoc sensitivity analysis showed a power level of 0.78 and a Critical t of 1.71 was required to reject the null hypothesis that no meaningful changes occurred before and after the MBRP aftercare program. Due to small size of each of the four counselor groups only descriptive statistics were reported for the counselor groups.

For qualitative data collection, two client interviews were completed for three the counselor groups, and three client interviews were completed for one counselor group.

The clients were selected on a convenience and self-selection basis due to limited resources and availability of participants. Nine interviews were obtained from the total sample of 24 participants which provided a 37.5% representation of sample.

The counselor groups were segregated by gender due to treatment program’s protocol, an not this study’s design. The four treatment counselors who participated in the program were White and comprised of two female and two male counselors. Table 5 provides counselor demographics.

Table 5

Counselor Demographics

Counselor Sex Race Education Licensure

A Female White Bachelors CDCA II

B Male White Masters LPC

C Male White High School CDCA II

D Female White Bachelors CDCA

Note. CDCA is chemical dependency counselor assistant and LPC is licensed professional counselor.

The four treatment counselors facilitating the MBRP aftercare program were employed full time by pilot program site and had experience with conducting CBT-based

IOP and aftercare programs. None had previous experience with MBRP, three had no training or experience with mindfulness practice, and one had exposure to Mindfulness

Based Stress Reduction (Kabat-Zinn, 1982) and had practiced minimally for a couple of years.

All counselors participated in a two-day training program facilitated by the researcher and joined via Skype by an expert MBRP supervisor. As part of training each of the group counselors co-lead with researcher their first MBRP groups. The second and third MBRP groups were facilitated by the counselors on their own, and data was only used from the second and third groups. Biweekly team meetings were held throughout the delivery of MBRP aftercare with the counselors, researcher, and an MBRP expert to answer questions, practice facilitation skills, and troubleshoot difficulties that arose.

The author of this study trained and supervised the treatment counselors who facilitated the MBRP aftercare groups. His experience included a background of teaching and utilizing MBCT for ten years prior to the MBRP aftercare program and had

completed advanced training in MBCT. Prior to the present study, in 2015 he obtained a small Summit County ADM grant to support the MBRP aftercare program including an additional weeklong MBRP training with Neha Chawla, PhD one of the authors of the

MBRP manual, and engaged in supervision and consultation services with Joel Grow,

PhD, an MBRP expert and part of original MBRP research group. Consultation and supervision sessions with Dr. Grow were conducted weekly or bi-weekly throughout the period of the study for a total of 16 sessions.

Procedures

Archival data

Archival data was available for the present study from the previous sponsored

MBRP aftercare pilot study at a local mental health agency in Akron, Ohio. First, the researcher obtained written permission to obtain and use archival data for this study. The raw data available for this study had not yet been entered or statistically or qualitatively analyzed. After permission was granted and pre-approval from the researcher’s dissertation committee and the Institutional Review Board at the University of Akron obtained, quantitative and qualitative data was entered and coded for analysis.

During the previous MBRP aftercare program and upon informed consent, pretests using the instruments summarized in this chapter were completed by participants.

Following the MBRP aftercare program, participants who completed a minimum of six of eight sessions completed the post-test questionnaires. The post-tests were administered by the treatment counselors. All pretests and posttests were deidentified prior to use as archival data to maintain participant confidentiality. Identification of counselor group assignment was maintained.

Also upon completion of MBRP aftercare program, the treatment counselors solicited for volunteers willing to do interviews. The researcher scheduled with treatment counselor the time to meet with participants to conduct the semi-structured interview. At time of interview, interviewer explained process and gave a new informed consent for each participant to sign. Interviews were recorded, and later transcribed utilizing an online transcription service, transcriptions were deidentified prior to use as archival data.

Finally, deidentified demographics data were collected by the treatment counselors from client records post MBRP sessions.

Intervention from MBRP aftercare program

MBRP aftercare program was reviewed and approved by research coordinator and clinical director. Clients diagnosed with an opioid dependence disorder at site were assigned to MBRP aftercare as a normal progression through the treatment. Prior to

MBRP aftercare clients completed a 6-week CBT based intensive outpatient treatment program, and during this time their treatment counselor began to introduce the MBRP aftercare program. The four treatment counselors leading the aftercare groups would explain to clients the MBRP aftercare and study, and those willing to participate in the study portion completed an informed consent form and pre-test questionnaires. All clients in groups did MBRP aftercare as part of mandatory programming, whether or not they signed up for the study. No rewards were given for participation.

The eight sessions were delivered as per the MBRP manual (Bowen et al., 2011a) and described previously in Table 1 with the following modifications: (1) sessions lasted

1.5 hours, (2) groups were open and rolling to accommodate treatment agency, (3) an

additional 10 minute exercise was inserted into session 5 to enhance self-compassion (see

Appendix J, for “False Refuges” exercise). Each session generally included time for a check-in with participants, practice of specified mindfulness exercise, inquiry to review meditation experiences, and time for psychoeducation integrating relapse prevention concepts and skills.

Instruments

Demographic Information

As part of the previous MBRP aftercare study, demographic characteristics for participants were collected by the treatment counselors from client records, de-identified and compiled into a separate spreadsheet specifically for the MBRP aftercare study. The spreadsheet did not include identifying information but did report anonymous participant number, gender, race, birthdate, diagnosis codes (up to five), employment status, education level attained, number of prior treatments, medically assisted treatment (MAT)

Status, Ohio Risk Assessment System (ORAS) score (Low, Medium, High, & N/A), and reason for discharge.

Five Facet Mindfulness Questionnaire

As research in mindfulness developed, a review of five of the available questionnaires were studied for psychometric properties, factor analysis and then a confirmatory factor analysis of five components from earlier studies that comprise the 39- item Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006). The FFMQ requires a response on a 5-point Likert-scale ranging from “never or very rarely true”

(scored 1) to “very often or always true” (scored 5). Intermediate scores include “rarely

true” (2), “sometimes true” (3), and “often true” (4). Results are reported on the five facet subscales as well as a total score.

In the same report additional studies were conducted to further discriminant and predictive validity of the new measure. The five facets demonstrated adequate to good internal consistencies with alpha coefficients ranging from .75 to .91. The five facets or scales of the FFMQ are: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. The observing component has been found to act differently than the others (Baer et al., 2008; Lilja et al., 2013) and may require observing of emotions component to develop it (Rudkin et al., 2018) Comparing meditating and non-meditating groups found expected differences observing and psychological symptoms (Baer et al., 2008).

In a follow-up validation study using item level indicators, confirmatory factor analysis provided a good fit for the FFMQ model. The reliability and validity of each of the five facets of the FFMQ was acceptable (Christopher et al., 2012). Another confirmatory factor analysis study with a heterogeneous clinical sample of individuals with anxiety and mood disorders found similar supportive evidence for a 4-factor model of FFMQ and cross validation with other measures in appropriate direction (Curtiss &

Klemanski, 2014). Addressing concerns of understanding of mindfulness by different populations, further research found show no differential item functioning between meditators and non-meditators (Baer et al., 2011). A confirmatory factor analysis study with a community sample found support for a 4-factor model with non-meditators and a

5-factor model with meditators (Williams et al., 2014) indicating the importance of possible difference between meditating and non-meditating groups.

Several studies provided psychometric data relating the FFMQ to substance abuse. A pilot study (Brewer et al., 2009) comparing MBRP treatment versus CBT for substance abuse found increases in mindfulness for both groups, and greater increases in

FFMQ for MBRP group, but not at a level reaching statistical significance (N=36 started study; CBT completers=5; MBRP completers=9). In examining how some of subscales interact together, Eisenlohr-Moul et al. (2012) found substance use was negatively associated with observing scale at higher non-reactivity, but positively associated at lower non-reactivity scores. Comparing persons with past history of SUD to those without, those with a history of SUD had greater deficits in acting with awareness and nonjudgmental. Interestingly no differences were found on observing (Levin et al., 2014).

Self-Compassion Scale – Short Form

The 12-item Self Compassion Scale-Short Form (SCS-SF) is an economical alternative to the long Self-Compassion Scale (SCS) to measure self-compassion. The

SCS-SF requires a response on a 5-point Likert-scale ranging from “Almost never”

(scored 1) to “Almost always” (scored 5). Intermediate scores are given as 2, 3, and 4 with no label. Results are reported as a total score. Even though the SCS-SF has half the items, it is reliable and has same factorial structure as the SCS (Raes et al., 2011). Self- compassion is the ability to hold one’s feelings of suffering with a sense of warmth, connection and concern, and it has three components: (1) self-kindness, (2) common humanity, and (3) mindfulness of one’s experience. A short form of the SCS may be useful in research or clinical practice where time is a constraint (Neff, 2003).

Items for the SCS-SF were drawn from the longer SCS. The SCS items were developed through an iterative process of focus groups and pilot testing items related to

Neff’s (2003) conceptualization of self-compassion. A large pool of potential items was generated. Items were further tested through larger scale studies and analysis of items reliability and factor loadings on intended subscale scores. Validity was established through comparison with other more established measures (Neff, 2003).

While subscales are used with the longer SCS, it is directed to use only the full- scale score when utilizing the SCS-SF (Neff, 2016; Raes et al., 2011). The six SCS subscales which the Short Form draws from are: self-kindness versus self-judgment, a sense of common humanity versus isolation, and mindfulness versus over-identification; taken together the subscales comprise a compassionate frame of mind (Neff, 2016).

The internal consistency of the SCS-SF was high (alpha = 0.86). Cronbach alphas for subscales were much more variable between 0.54 and 0.75. The total score of the

SCS-SF showed a near perfect correlation of r = 0.98 with the longer SCS version.

Correlations between subscales on long and short form SCS were also excellent (r = 0.89 to 0.93). Due to low internal consistencies it is recommended to only use the full-scale score of the SCS-SF in practice and use the longer version when wanting to monitor and analyze subscale components (Raes et al., 2011).

Additional study found confirmatory factor analysis support for six-factor model for both SCS and SCS-SF. The SCS-SF showed good psychometric properties and is a reliable instrument to assess self-compassion in practice and research (Castilho et al.,

2015). While pretest and posttest data for interventions is limited some data are reported.

During a reanalysis of data (Neff, 2016) from randomized control trial (Neff & Germer,

2013) of a self-compassion focused intervention, Mindful Self Compassion (MSC), found a pretest and posttest full score difference of 38%.

Most of research has been focused on the longer SCS and analysis of the factors of self-compassion. The SCS-SF has been supported in its use of single factor as a measurement of a multidimensional construct so studies on SCS do inform use of SCS-

SF. One recent study with 1609 college students at 10 college counseling centers, examined factor structure and construct validity found the SCS-SF did not support the three-factor model, but rather revealed two factors: Self Care and Self Disparagement.

Evidence of construct validity was found with expected relationships to measures of depression, anxiety, hostility, academic distress, eating concerns, family distress, perfectionism, suicidality, self-injurious behavior and social support, but SCS-SF scores were unrelated to various measures of substance abuse (Hayes et al., 2016).

In a recent meta-analysis of the SCS and SCS-SF considering the positively and negatively worded items it was found that the positively worded items did relate inversely to psychopathology and may indicate a protective factor. It was found that the negatively worded items had a significantly stronger relationship with psychopathology which may inflate scores in this direction, potentially introducing negative bias to the instruments (Muris & Petrocchi, 2017). Therefore, use of the total score for either the

SCS or SCS-SF must be used with caution not to overestimate psychopathology. In contrast, Cleare et al. (2018) found support for the use of the original scoring method of a

6-factor model and one overarching factor for self-compassion. This study also gave strong support for a bi-factorial model. It also provided evidence contrary to support for

Muris & Petrocchi’s (2017) concern for two factor bias but does recommend further

study of the factors. Neff et al. (2017) furthered the bi-factorial model for self- compassion and also provided further evidence justifying continued use of SCS full scale score for self-compassion.

Barratt Impulsivity Scale - 11

The Barratt Impulsivity Scale –11 is one of the most widely used self-report instruments for impulsivity (Stanford et al., 2009). The original form was developed 61 years ago (Barratt, 1959), it is currently in its eleventh revision (Patton et al., 1995). It is a 30 item self-report measure designed to assess the personality/behavioral construct of impulsiveness. The BIS-11 requires a response on a 4-point Likert-scale ranging from

“Rarely/Never” (scored 1) to “Almost Always/Always” (scored 4). Intermediate scores include “Occaisionaly” (2), and “Often” (3). Results are reported as a total score.

One of the definitions of impulsiveness is “a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to the impulsive individual or others.” (Moeller et al.,

2001, p. 1784). Over time it was theorized that impulsiveness was multi-dimensional, and

Barratt redesigned the instrument around three theoretical subtraits of Attentional

Impulsiveness, Motor Impulsiveness and Non-Planning Impulsiveness. Earlier research has supported this factor structure (Gerbing et al., 1987; Miller et al., 2004; Patton et al.,

1995) although more recent studies have challenged this theory (Reise et al., 2013;

Vasconcelos et al., 2012). Many researchers support the theory of a multifactor structure for impulsiveness, but typically only report a full-scale score (Stanford et al., 2009). A full scale of 72 or greater is considered highly impulsive; 52 to 71 is considered normal

impulsiveness; and 51 and below is considered over-controlled or has not honestly answered the questionnaire (Stanford et al., 2009).

The Barratt Impulsiveness Scale (BIS; Barratt, 1959) has been revised repeatedly to identify a set of impulsiveness items that are orthogonal to anxiety items, and to fit within structure of related personality traits. The most recent revision (Patton et al., 1995) has 30 items, kept in mind a three-factor structure and the scale was normed using 412 college undergraduates, 248 psychiatric inpatients, and 73 male prison inmates. Prison inmates were hypothesized to score higher than other groups, and psychiatry patients and those with substance abuse disorder were hypothesized to score higher than normal.

College undergraduates scored lower than the other two groups. The study results suggested the BIS-11 was an internally consistent measure of impulsiveness and may have clinical utility for measurement with different clinical and inmate populations

(Patton et al., 1995). Additional psychometric data was presented supporting full scale and three subscales (Stanford et al., 2009).

Three second-order subscales are considered subtraits of impulsiveness based on an original six first order factors. Attentional Impulsiveness involves the inability to focus attention or concentrate, Motor Impulsiveness involves acting without thinking, and

Non-Planning Impulsiveness involves a lack of future orientation or forethought. Recent research utilizing exploratory and confirmatory factor analysis for a community sample does not find empirical support for Barratt’s 3-factor model of impulsivity, and the use of the BIS-11 total score as reflecting individual differences presents challenges for interpretation. (Reise et al., 2013; Vasconcelos et al., 2012). For this reason, this study will only utilize full score impulsivity for analysis and interpretation. In a review of 21

studies it was found BIS-11 has both reliability and criterion related validity

(Vasconcelos et al., 2012).

A number of studies have correlated substance users to high impulsiveness scores on the BIS-11. Higher scores were found with cocaine dependent adults (Lane et al.,

2007); ecstasy users (Bond et al., 2004); alcohol misuse (Dom et al., 2006) and predictive of crack cocaine use (Lejuez et al., 2007).

Interviews

One of the most common mixed-method strategies is to follow the quantitative closed ended questionnaires with qualitative interviews in a manner that compliments both data sets (Teddlie & Tashakkori, 2009). Interviews were conducted with participants from each MBRP conducted by the four treatment counselors upon completion of the eighth session. Each interview was held at the MBRP aftercare program facility between interviewer and interviewee. An interview guide (Appendix G) was developed for previous study, and the format was a semi-structured interview which was designed to last no more than 30 minutes. Sessions were recorded on a handheld recorder and transcribed by a professional transcription service; no personal identifying information was provided to transcription service. For this study, archival transcripts of eight client interviews and four treatment counselor interviews were obtained for analysis.

Client Interview Questions

As part of archival data set and during the MBRP aftercare program, semi- structured interviews were conducted to collect clients’ attitude and content of interest and allow for probing by interviewer to provide in depth information (Teddlie &

Tashakkori, 2009). Interview questions were developed to solicit information on each

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participant’s experience of the MBRP aftercare program, how they saw changes occurring in their thinking, feeling behavior, and perception of self, and their explanation for how this occurred. Additional questions focused on what parts of aftercare they intended to continue and what was important for their recovery. All questions were left open ended, and no questions specifically used the words “mindfulness, self-compassion or impulsivity” so as not to lead or bias the responses of the participants. During MBRP aftercare pilot program. interview questions were developed and reviewed with an expert in qualitative methods and an expert in MBRP prior to interviews. Expert reviewers helped ensure interview questions had clarity and were non-leading; interview protocol was revised accordingly. A copy of the final client interview protocol and questions are provided in Appendix G.

Data Analyses

Quantitative Analyses

Descriptive statistics were obtained for all variables. Descriptive statistics included the means, standard deviations, and ranges of the independent and dependent variables. The researcher used the IBM Statistical Package for Social Sciences (SPSS) software for data entry and statistical analysis.

In order to test the null hypotheses one, two and three, a paired samples t-test was conducted. This approach was appropriate as there is one categorical independent variable, time between pretest and posttest after completion of MBRP aftercare, and we measured group differences for a single continuous dependent variable (Gravetter &

Wallnau, 2013). Prior to conducting analysis, the data was screened for missing data,

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extreme values and basic assumptions of normality, linearity and homoscedasticity. None of the basic assumptions were violated, and statistical procedures were not employed in order to transform data. (Mertler & Vanetta, 2010). An alpha level of p < .05 was used to determine statistical significance in data analysis.

In testing hypothesis one, the independent variable was completion of the MBRP aftercare program. The dependent variable was mindfulness as measured by the Five

Facet Mindfulness Questionnaire (Baer et al., 2006) full-scale score, and its five subscales of observing, describing, acting, nonjudging and nonreacting. To test if MBRP was effective on clients’ mindfulness, a dependent samples t-test was conducted to test the null hypothesis that there is no statistically significant mean difference in clients’ average mindfulness scores from pre-to-post MBRP intervention. When conducting multiple t-tests the probability of a Type I error increases and a Bonferroni-type adjustment was used (Mertler & Vannatta, 2010). This type of adjustment set the alpha level higher than the common alpha level of p < .05.

In order to test hypothesis two, the independent variable was completion of the

MBRP aftercare program. The dependent variable was self-compassion as measured by the Self-Compassion Scale-Short Form (Raes et al., 2011) using its full-scale score. To test if MBRP was effective on clients’ self-compassion, a dependent samples t-test was conducted to test the null hypothesis that there is no statistically significant mean difference in clients’ average self-compassion scores from pre-to-post MBRP intervention. Due to multiple t-tests, a Bonferroni-type adjustment was made to prevent

Type I error.

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In order to test hypothesis three, the independent variable was completion of the

MBRP aftercare program. The dependent variable was impulsivity as measured by the

Barratt Impulsivity Scale-11 (Patton et al., 1995) including its full-scale . To test if

MBRP was effective on clients’ impulsivity, a dependent samples t-test was conducted to test the null hypothesis that there is no statistically significant mean difference in clients’ average impulsivity scores from pre-to-post MBRP intervention. Due to multiple t-tests, a

Bonferroni-type adjustment was made to prevent Type I error.

Qualitative Analyses

Verbatim transcriptions from a subsample of nine participant interviews

(designated P1 – P9) were inputted into the NVivo software program (Leech &

Onwuegbuzie, 2011) to assist with analysis. NVivo allowed for an efficient and flexible coding and thematic analysis of material. Use of qualitative data analysis software has advantages and disadvantages (Leech & Onwuegbuzie, 2007). The qualitative data analysis process is summarized in Table 6.

Table 6

Data Analysis for Qualitative Data

Cases QUAL Data Analysis Methods

Participant Interviews Cycled Coding Theming

P1 - P9 • Initial Codes • Types of Experiences

• Invivo Codes • Outcomes

• Hypothetical • Other Recovery Experiences Codes • Process Codes

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Coding was done by researcher alone in consultation with methodologist.

Analysis was conducted on two levels: within each case and across cases. A single case included all data related to each individual participant. Steps in the analysis (Saldaña,

2013) included: preliminary reading of the data, first cycle coding using initial codes to breakdown data into discrete parts, in vivo coding drawing from words in the data and process coding describing action in the data, creating analysis memos, and development of code book; then proceeding with second cycle coding consisting of focused (thematic), axial and theoretical coding. After coding was completed then analysis proceeded to examine codes and themes and theorize (Saldaña, 2013) within cases and then across cases to answer research question four.

Mixed-Method Analysis

Mixed-method analysis considered how qualitative data augments quantitative results converge through integration of quantitative and qualitative data (Creswell &

Plano Clark, 2018) to answer research question five. Additional analysis considered differences between counselor groups to determine differences between groups. The mixed-method process for integration is summarized in Table 7.

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Table 7

Mixed-Method Analysis

Integrated Data Analysis Methods

Cases QUAN QUAL

Participant Interviews Statisical Results Quotes

P1 - P9 FFMQ & Subscales Quantitized Coded References

SCS-SF Ranked Participants

BIS-11

QUAN & QUAL Data Merged in Tables and Joint Display

Counselor Groups Compared Results & Findings Across Counselor Groups

A, B, C, D

Statistical results for all scales were merged with exemplar quotations from participant interviews. Findings from qualitative themes of types of experience and outcomes were quantitized (Sandelowski et al, 2009) to allow for participant ranking by number of coded refererences (Teddlie & Tashakkori, 2009). The analysis of results and findings were formatted into tables and a joint display depicting visual summaries and integration (Creswell & Plano Clark, 2018; Guetterman et al, 2015). Descriptive differences between counselor groups were noted in both quantitative and integration results sections.

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Validity and Credibility

The credibility of qualitative research can be enhanced through analysis and procedures of researcher, review of process of engaging participants, and from external reviewers (Creswell & Plano Clark, 2018). For this study several qualitative procedures were employed including: member-checking, triangulation, reporting disconfirming evidence, participation in-peer review (Creswell & Plano Clark, 2018), and providing thick descriptions from interview quotes and researcher observations (Creswell, 2014). In addition, researcher reflexivity was conducted as the researcher reported his own personal biases, assumptions, beliefs that influence the interpretation of the data (Creswell, 2014).

Member-checking was attempted with treatment counselors during data analysis and interpretation but cannot be done with client participants due to transient nature of this population. Triangulation of multiple sources included interviews of clients, quantitative data, and external literature. Participation in peer review included review by dissertation methodologist, MBRP consultant, or one external reviewer with background of MBRP to provide critical feedback, challenge assumptions, and provide methodological guidance on process and interpretations. Peer reviewer(s) were provided with copies of research questions, transcribed interviews, coding books, and outlines of thematic analysis. Peer debriefing included having a person review study to ask questions about the qualitative study to verify the study will resonate with people other than the researcher (Creswell, 2014). Thick descriptions included quotes from interviews and field notes.

Since the data was coded only by the researcher, the reliability of qualitative data was addressed by a process of the researcher seeking assessment and evaluation of initial

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coding by another researcher competent in qualitative methods through peer debriefing sessions. Also, as with only a single coder, intrarater reliability analysis was conducted as a reflective exercise (Joffe & Yardley, 2003; O’Connor & Joffe, 2020) and percentage agreement was calculated (Shweta et al., 2015). Finally, documentation of process of data collection, coding and analysis was done by researcher to further enhance credibility of the proposed study. This step-by-step approach is illustrated in Figure 3.

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Figure 3

Coding & Analysis Process Coding Process Analysis Process Read texts and became familiar with data Started Coding and Analysis Log

Preliminary jottings of words and phrases for Used Research Questions and Interview Pre-Coding codes Questions as main guide for a priori list of codes, and remained open to emergent coding in process

Used a priori codes begin coding data in Nvivo Broke data down into smallest units.

Added emergent codes Wrote memos for codes, and analytic memos 1st Cycle while reflecting on data

Coding Broke down data into smaller units Did Epoche exercise 81 codes generated

Reviewed code list and data Began organizing codes into categories

Organized codes; split and lumped data Began mapping data relationships Debrief Identified 22 main codes Mtg. #1 Refined code descriptions Considered 2 major themes of Client Experiences and Client Outcomes

Reviewed data with updated coding Reviewed code mapping 2nd Cycle Recoded and consolidated to 22 main codes Wrote analytic memos including theorizing on Coding relationship between qualitative and quantitative data

Agreed on main themes from coding 3 Major Themes & 15 Main Categories 15 Main codes 3 Types of Client Experiences Began discussion of integration of qualitative & 5 Facets of Experience Debrief quantitative strands Mtg. #2 3 Oucomes related to mindfulness, selfcompassion and impulsivity

4 Emergent Outcomes

Coded a sample of the qualitative data twice & Reported percentage of agreement Intrarater caculated Intrarater Reliability Reliabity Check

Wrote narrative descriptions of main themes Development of joint displays Writing Integrated Qualitative findings and Quantitative Synthesized analytic memos in to narratives results

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Researcher Subjectivity

As a researcher and counseling professional for over twenty years my professional background has been in mental health and cognitive therapy. Eleven years ago, I received basic and advanced training in mindfulness-based cognitive therapy

(MBCT) with Zindel Segal, PhD and Susan Woods, MSW. I have incorporated mindfulness-based practices in my counseling work since that time and have benefited personally from mindfulness practice. Throughout my doctoral program I have taken the opportunity to research and write regarding mindfulness as a therapeutic intervention.

More recently I have been studying and practicing compassion-based approaches. During my doctoral internship at the study correctional setting I gained expertise in substance use disorder treatment and had the opportunity to try out MBRP for substance use treatment and subsequently proposed the MBRP pilot program utilizing regular treatment counselors from this correctional setting. I obtained a small grant from the Summit

County Alcohol, Drug and Mental Health Board to support the program and obtain training from Neha Chawla, PhD, and program supervision from Joel Grow, PhD, both from the original research team with Alan Marlatt, PhD.

During the time of the MBRP pilot program, Summit County, OH experienced its peak period for opioid-related deaths due to the influx of fentanyl. The pilot program was a direct response to the opioid epidemic, and it took unique significance as reports of persons dying from overdose occurred on a tragically frequent basis which added a sense of gravity to the work being done at MBRP pilot program. Throughout my career I have tended toward trying to solve complex problems and finding resources to do creative projects that benefit our community. My basic disposition to love others, show

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compassion and be of service, which is personally expressed through the profession of counseling.

Summary of Methodology

The purpose of this study was to examine the treatment effect of an MBRP aftercare program on degree of mindfulness, impulsivity and self-compassion, while providing services to clients having a primary diagnosis of opioid use disorder in a correctional setting. Archival data was used and included participants from an MBRP aftercare program that was conducted between June 2016 and January 2017. Using an ex post facto single group pre-test post-test intervention mixed-method design and multiple case study analysis, this study specifically considered quantitative outcome variables of mindfulness, self-compassion, impulsivity, and qualitative themes that arose from semi- structured interviews with clients. Quantitative measures included the Five Facet

Mindfulness Questionnaire (FFMQ), Self-Compassion Scale-Short Form (SCS-SF), and the Barratt Impulsivity Scale-11 (BIS-11). Demographic data included: gender, race, birthdate, diagnosis codes, employment status, education level attained, number of prior treatments, MAT Status, ORAS, and reason for discharge.

Quantitative data analysis included presentation of descriptive statistics and null hypothesis testing included repeated measures dependent t-tests with Bonferroni-type adjustment for the dependent variables. Qualitative analysis included coding and thematic analysis of interviews. Mixed-methods analysis included multiple case study and cross case analysis, and produced a joint displays of findings.

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CHAPTER IV

RESULTS

The purpose of this study was to investigate the treatment effect of MBRP aftercare program on degree of mindfulness, impulsivity, and self-compassion among a group of clients in a court-ordered treatment program with opioid use disorder. The following research questions were addressed:

1. Was there a significant difference in client self-reported mindfulness after

participating in at least six weeks of MBRP opioid addiction aftercare program in

a court-ordered treatment program?

2. Was there a significant difference in client self-reported self-compassion after

participating in at least six weeks of MBRP opioid addiction aftercare program in

a court-ordered treatment program?

3. Was there a significant difference in client self-reported impulsivity after

participating in at least six weeks of MBRP opioid addiction aftercare program in

a court-ordered treatment program?

4. How did clients describe their experience of a MBRP opioid addiction aftercare

program in a court-ordered treatment program?

5. In what ways did qualitative findings converge with quantitative results?

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Quantitative Results

The mean pretest and posttest scores and descriptive statistics for all scales are listed in Table 8. Prior to analysis, all data were screened and no data was missing. All scales were checked for the assumption of normality of the dependent variables, and most of the results for skewness and kurtosis values were within the acceptable range of -1.0 to

1.0 (Meyers et al., 2006) with three values that were slightly larger than 1.0. The data presented was considered normally distributed within an acceptable range and used for further data analysis. A dependent samples t-test was conducted to test the null hypothesis that there were no statistically significant mean differences in participants’ average scores for mindfulness, self-compassion, and impulsivity. For significant results,

Cohen’s d effect size was calculated and interpreted using guidelines suggested by Cohen

(1988): small (d ≥ .20), medium (d ≥ .50), and large (d ≥ .80).

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Table 8

Descriptive statistics for Pretest and Posttest FFMQ, SCS-SF and BIS-11 Scores

(N = 24)

Scales M SD SE Skewness Kurtosis

Observing - Pretest 27.38 5.93 1.210 0.262 −0.822

Observing − Posttest 28.92 6.20 1.265 −0.544 −0.085

Describing − Pretest 26.96 5.76 1.176 0.238 −0.216

Describing − Posttest 28.00 6.26 1.277 −0.023 −0.976

Acting − Pretest 26.54 4.81 0.982 0.303 −0.505

Acting − Posttest 27.67 5.71 1.165 −0.245 −0.523

Nonjudging − Pretest 26.38 5.07 1.035 −0.357 −0.747

Nonjudging − Posttest 26.79 5.79 1.183 −0.813 1.047*

Nonreacting − Pretest 21.13 3.75 0.765 1.248* 1.899*

Nonreacting − Posttest 23.46 4.30 0.878 0.299 −0.870

FFMQ − Pretest 128.38 18.22 3.720 −0.095 0.302

FFMQ − Posttest 134.83 20.47 4.178 0.097 −0.372

SCS-SF − Pretest 37.79 9.33 1.904 −0.355 −0.536

SCS-SF − Posttest 39.96 9.34 1.907 −0.115 −0.546

BIS-11 − Pretest 73.00 15.34 3.131 −0.123 −0.219

BIS-11 Posttest 70.38 13.30 2.714 −0.484 0.013

Note. * p < .05 with Bonferroni adjustment.

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A series of dependent samples t-tests using Bonferonni adjusted p-values of

0.00625 showed that there was a statistically significant increase in participants’ average nonreactivity to inner experience score from pretest to posttest, t(24) = 2.99, p < 0.006 and d = .61 (−2.33/3.82, medium effect size). No other t-tests were found to be statistically significant. Figure 4 illustrates the difference in effect size between pretest and posttest scores for nonreacting.

Figure 4

Nonreacting Effect Size (Cohen’s d) between Pretest and Posttest Scores

While the change in nonreacting was found to be statistically significant, the effect size of d = .61 suggests a moderate practical significance of MBRP aftercare on the change in nonreacting.

There was no statistically significant difference in clients’ scores on the mindfulness, self-compassion and impulsivity scales (see Table 9). Inspection of the mean scores for each the full scales indicated change in direction: FFMQ (mindfulness)

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increased 6.46 points, the SCS-SF (self-compassion) increased by 2.17 points, and the

BIS-11 (impulsivity) decreased by 2.63 points.

Table 9 Participants’ Difference Between Pretest and Posttest Mindfulness, Self-Compassion and Impulsivity

95% CI of the Difference p- Outcome Mean Change SD SE Lower Upper t(24) value Observing 1.54 4.39 0.90 −0.31 3.40 1.72 0.099

Describing 1.04 5.08 1.04 −1.10 3.19 1.01 0.325

Acting 1.13 4.88 1.00 −0.93 3.18 1.13 0.270

Nonjudging 0.42 5.85 1.19 −2.05 2.89 0.35 0.730

Nonreacting 2.33 3.82 0.78 0.72 3.95 2.99 0.006*

FFMQ 6.46 16.35 3.34 −0.44 13.36 1.94 0.065

SCS-SF 2.17 6.92 1.41 −0.76 5.09 1.53 0.139

BIS-11 −2.63 8.69 1.77 −6.30 1.05 −1.48 0.153

Note. * p < .05 with Bonferroni adjustment. Increase indicates improvement on Mindfulness and Self-

Compassion scales. Decrease indicates improvement on Impulsivity scale.

Participant scores indicated a variety of results from pretest to posttest. To illustrate the overall direction of change of mindfulness, self-compassion and impulsivity scores are summarized in Table 10 as increasing, decreasing, or no change.

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Table 10

Frequency of Participants’ Scores Increasing, Decreasing, or No Change (n = 24)

FFMQ (%) SCS-SF (%) BIS11 (%)

Increasing 15 63% 11 46% 10 42%

Decreasing 8 33% 9 38% 12 50%

No change 1 4% 4 17% 2 8%

Table 9 shows mindfulness (FFMQ) scores increased for most of the participants

(63%); self-compassion (SCS-SF) increased for slightly less than half of participants

(46%), and impulsivity decreased for half (50%) the participants. The participants’ average change scores across the four counselor groups are reported in Table 11.

Table 11

Comparison of Differences in Mean Group Scores by Counselor Group

Counselor FFMQ FFMQ Δ SCS- SCS- ΔSCS- BIS11- BIS11- Δ Group 1 2 FFMQ SF-1 SF-2 SF 1 2 BIS11

A 117 125 8 32 35 3 83 75 −9

B 128 139 11 37 44 7 66 69 4

C 137 140 3 45 44 −1 63 67 4

D 138 143 5 40 41 1 71 67 −4

Note. Pretest score is designated by “Scale-1” and posttest score is designated by “Scale-2,” and difference between pretest and posttest scores is designated by “ΔScale.”

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Table 11 shows that Group B had most improvement in mindfulness (ΔFFMQ =

11), and most improvement in self-compassion (ΔSCS-SF = 7). Counselor Group B had the most improvement on impulsivity (ΔBIS-11 = -9), and the second highest score for mindfulness (ΔFFMQ = 8). Counselor Groups C and D had lower scores on all three measures. For a list of individual participant scores see Appendix I.

To examine change by cases within the four Counselor Groups, the difference between participant pretest and post scores for FFMQ, SCS-SF and BIS-11 are shown in the following figures. In all the figures we see differing results in mindfulness, self- compassion and impulsivity. Across all groups most participants had increased in mindfulness, and participants with the greatest increase in mindfulness also had the highest increase of self-compassion. Impulsivity increased or decreased irrespective of change in mindfulness or self-compassion.

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There were nine participants in Counselor Group A and score differences are shown in Figure 5.

Figure 5 Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group A

Counselor Group A 40 ΔFFMQ ΔSCS-SF ΔBIS11 30 20 10 0 -10 -20 Difference Pretest to Posttest to Pretest Difference -30 A01 A02 A03 A04 A05 A06 A07 A08 A09 Participants Group A

Note. This figure shows the difference (Δ = Posttest - Pretest) between scores for the FFMQ, SCS-SF, and

BIS-11 for participants in Counselor A’s group.

Of the participants in Counselor Group A, six showed increase in mindfulness, two showed increase in self-compassion and eight showed decrease in impulsivity. The two participants with largest increase in mindfulness also had largest increase in self- compassion. Impulsivity decreased regardless of direction of mindfulness except for one participant who had no change in mindfulness and an increase in impulsivity.

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There were four participants in Counselor Group B and score differences are shown in Figure 6.

Figure 6

Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group B

Counselor Group B

40 ΔFFMQ ΔSCS-SF ΔBIS11 30 20 10 0 -10 -20 -30 B10 B11 B12 B13

Participants Group B Difference Pretest to Posttestto Pretest Difference

Note. This figure shows the difference (Δ = Posttest - Pretest) between scores for the FFMQ, SCS-SF, and

BIS-11 for participants in Counselor B’s group.

Of the participants in Counselor Group B, all four showed increase in mindfulness, three showed increase in self-compassion and only one showed decrease in impulsivity. The one participant with largest increase in mindfulness also had largest increase in self-compassion. Impulsivity varied regardless of direction of mindfulness with two increasing, one decreasing and one no change.

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There were five participants in Counselor Group C and score differences are shown in Figure 7.

Figure 7

Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group C

Counselor Group C 40 ΔFFMQ ΔSCS-SF ΔBIS11 30 20 10 0 -10 -20 -30 Difference Pretest to Posttestto Pretest Difference C14 C15 C16 C17 C18 Participants Group C

Note. This figure shows the difference (Δ = Posttest - Pretest) between scores for the FFMQ, SCS-SF, and

BIS-11 for participants in Counselor C’s group.

Of the participants in Counselor Group C, three showed increase in mindfulness, one showed increase in self-compassion and none showed decrease in impulsivity. The participant with largest increase in mindfulness also had largest increase in self- compassion. Impulsivity increased for all participants regardless of direction of mindfulness.

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There were six participants in Counselor Group D and score differences are shown in Figure 8.

Figure 8

Difference in FFMQ, SCS-SF, & BIS-11 Scores by Participants in Counselor Group D

Counselor Group D 40 30 ΔFFMQ ΔSCS-SF ΔBIS11 20 10 0 -10

-20 Difference Pretest to Posttestto PretestDifference -30 D19 D20 D21 D22 D23 D24 Participants Group D

Note. This figure shows the difference (Δ = Posttest - Pretest) between scores for the FFMQ, SCS-SF, and

BIS-11 for participants in Counselor D’s group.

Of the participants in Counselor Group D, only two showed increase in mindfulness, three showed increase in self-compassion and three showed decrease in impulsivity. The participant with largest increase in mindfulness also had largest increase in self-compassion. Impulsivity changed in both directions regardless of direction of mindfulness.

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Summary of Quantitative Results

Data indicated a significant difference with medium effect size on Nonreacting subscale of the FFMQ from pretest to posttest for participants completing six to eight sessions of MBRP aftercare. No other statistically significant results were found for mindfulness, self-compassion and impulsivity utilizing dependent sample t-test analysis.

Reviewing the descriptive statistics showed that there were increases in mean mindfulness and self-compassion, and a decrease in mean impulsivity. The participants were divided among four counselor groups. Counselor groups had different levels of improvement for mean mindfulness, self-compassion, and impulsivity scores.

Qualitative Findings

To address the fourth and fifth research questions, transcripts from nine participant interviews were coded and analyzed. Three themes emerged from the qualitative data: (1) varying participant experiences of MBRP aftercare, (2) participant change in mindfulness, self-compassion, and impulsivity, and (3) recovery of mind, feelings, responsibility, and future. Each of these themes gave voice to the participants’ experiences and outcomes from MBRP aftercare. The nine participants included five women (P1, P2, P3, P8, P9) and four men (P4, P5, P6, P7). The following describes each of the emerging themes in detail and supports them by citing quotes from the participants.

Theme One: Varying Participant Experiences of MBRP Aftercare

One of three types of experiences emerged from each participant’s reflection on the MBRP aftercare program: engaged, transitional, or disengaged. Five facets were described within each type of experience: sentiment, attitude, motivation, learning, and

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relationships. Each facet was described differently across the three types of experiences, as summarized in Table 12.

Participants with typical engaged experience described positive sentiment toward the MBRP aftercare program, they were open to learning, had high internal motivation and were practicing the skills learned. They valued and engaged in recovery relationships and positive family/friend relationships. Participants with the typical transitional experience described changes during the course of the MBRP aftercare program from negative to positive sentiment, shifting positively their attitude and motivation and eventually learning and practicing MBRP skills. They reported support in groups but may or may not have had outside support. Participants with the typical disengaged experience displayed negative sentiment and attitude towards the program, and they described external motivations for complying such as avoiding consequences and having concern for how others see them. These participants also spoke of little or no supportive recovery relationships and portrayed a more individualistic approach to treatment.

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Table 12

Summary of Three Types of Participants’ Experiences & Related Facets in MBRP

Type of Participant Experience

Facet Engaged Transitional Disengaged Sentiment Overall Positive Shifted from Negative to Overall Negative

Range of expressed Positive

opinion or feeling toward

MBRP aftercare.

Attitude Open & Engaged Shifted from Closed to Closed & Resistant

Open & Engaged vs Open

Closed & Resistant to

MBRP aftercare.

Motivation Internally Motivated Began External & Externally

Underlying reason/goal Becoming Internal Motivated

for participant behavior

during MBRP aftercare.

Learning Active in Session & Became Active in Session Passive in Session;

Extent of Activity in Knows Skills; Practices & Learning Skills; No No Outside Practice

sessions, skills learned Outside Sessions Outside Practice

and practiced.

Relationships Has Recovery Network; Building Recovery Little or No

Extent of Supportive Has Family & Friends Network; Limited Family Recovery Network

recovery relationships. Support & Friends Support

Facet labels were not derived from an existing theory, but as names designated by researcher based on emergent open coding; operational definitions are as follows.

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Sentiment was the range of expressed opinion or feeling toward MBRP aftercare. Attitude was participant openness and engagement in MBRP versus closedness and resistance.

Motivation was the underlying reason or goal driving participant behavior during MBRP aftercare; motivation was contrasted as external versus internal. Learning described the participant’s extent of activity in MBRP sessions, skills learned, and practice of skills learned. Relationships described the extent a participant reported having a network of supportive recovery relationships. Drawing on quotes from the participants’ interviews, the five facets of sentiment, attitude, motivation, practice and relationships are presented in detail in the context of the three types of experience.

Engaged experience

Sentiment. Many participants expressed overall positive sentiment toward the

MBRP aftercare and often mentioning specific aspects of it that they liked. For example, one participant found the MBRP curriculum helpful:

For overall, I personally thought it was helpful for mindfulness, some of the steps, and some of the stuff that we learned I do use. A lot of times if I'm getting frustrated or irritated, whatever, I'll take the time to stop, think about it. I definitely use the breathing technique. Yeah, I mean overall I liked it, honestly. I think it definitely helped, new steps that I didn't know before. (P4)

This person stated he learned something new that he could practice when feeling frustrated or irritated. Another participant found the MBRP aftercare interesting and enjoyable: “I just felt like I got more out of it. Maybe it was my time to go into, it's still, but into aftercare or IOP. It was just interesting.…I enjoyed it.” (P1) Two participants specifically noted having a caring counselor was a positive part of their experience:

I think it's been positive. I think learned a lot of tools in the classes. I think [Counselor] does and did, does a wonderful job. I think he truly cares. I think that comes out in the classroom or the group setting. I would highly recommend

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it.…He's just a good guy and it comes out in the classroom as somebody who actually gives a shit. (P7)

And, “I totally loved her [Counselor] style. The way she led the group. It was like a soft lead. My group was really cohesive.” (P9) For another participant it was important for structure and interaction with others: “It's fine. I like it, I mean it keeps me on the schedule and I get to interact with other people going through the same thing” (P2). One participant gave the MBRP aftercare high praise, “Oh my god, did it. Life changing. I just said in after care just now, it was the hand of God. I truly believe it.” (P9)

Attitude. Some participants were open and engaged from the beginning of MBRP aftercare. For example, this participant’s “surrender” was the necessary action that lead to change in her life:

When I turned myself in, I feel like I surrendered because I've had periods of sobriety before; not very long. This is the longest one. But I had to get sober and knew there was a better way to live. So, by surrendering and kind of ... I feel like that was kind of my way of saying, "I can't do this anymore. I'm giving up. I have to give up that whole way of life." So, I became willing to do whatever it took. I sat in jail for a little bit, and then went to another treatment center. Basically, this whole year, I've been in an institution more than I've been home. But now, looking back, I'm grateful for it because I wouldn't be where I'm at today if it wasn't for all that…. When I surrendered, I think that was when it [change] happened…that was the day I got arrested in May; May 16th. So, it actually ... I was always scared to go to jail prior to that, …. and when the handcuffs actually got put on me, I felt relieved. (P3)

After repeated periods of sobriety and relapse she felt ready and relieved. Similarly, another participant acknowledges going through the addiction cycle too many times, and she was ready to “do everything” to improve:

For me, it's improved. It hasn't really changed a whole lot, just because I came into this with a very good attitude. I came into it like I'm going to take everything that I can from this experience to better myself. I'm not taking no for an answer type thing. I'm going to get this this time. I'm getting older and I've done this too many times. I've been to prison three times. I've used drugs for 15 years. It's just

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ridiculous. I came into it with a full I'm going to be doing everything I'm supposed to be doing. I would say that it's improved. (P8)

Internal motivation as engaged experience. The desire for a better life motivates to recovery as one participant described:

I don't want to be 35 years old and sitting on a couch all day. Some of the girls that I was in treatment with are 30ish and you know there's still going through with this and they have children. I don't want to be that mom because I know I could be a really good mom. It's just other people's experiences and seeing something in myself that I'm just tired of it. (P1)

Most participants have tried treatment more than once, and two participants give examples of how internal motivation makes this time in treatment different:

I got a lot out of it more this time because I wanted it more than the last time I came through here, so I think that has a lot to do with it is if you feel like you're done and you're ready. I think you take in a lot more than if you are just doing it because the court says you have to do it and get this over with….This is the longest that I've ever been sober, so I mean, it feels great. I mean, I got my life back, family. Trust is the biggest thing. The good girl. It feels good. (P6)

That's the part that I didn't get. I've been in treatment before. I do well in it. But I would listen, but I didn't actually apply the stuff in my life. This time I took every little teeny tiny suggestion and I actually applied it in my everyday life. Now my entire quality of life has just ... It's just improved. (P8)

These participants shared that they learned from the past and know they cannot simply attend the program to comply with court. Similarly, another participant realized, “I had to get sober and knew there was a better way to live,” she was, “getting sick and tired” of the lifestyle of addiction (P3). Another participant said that he needed to protect his sobriety, making it “front and center” of his life:

I'm an addict. I've had some success in life, but I'm an addict, so I have to be cognizant of this every day, and I have to use the tools every day…Remembering the tools, utilizing the tools, and just keeping this thing front and center. Protecting my sobriety…. And how good it is now. I'm not going to sabotage that. Like I said, protect my sobriety. (P7)

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Internal motivation helped another participant set boundaries, even with her husband if he jeopardizes her sobriety and freedom:

I used to say that no matter, with my husband still being incarcerated, that whatever he wanted to do when he came home was what it was going to be. Now I'm no longer willing for that to happen. If he doesn't want to do what I want to do, then he's gone. He knows this. Again, with the boundaries. Boundaries were key for me. I wasn't good with that. I've been with my husband for 12 years and he's a big part of my life, but I'm not willing to go back to drugs. I'm not willing to go back to prison. I'm not willing to do any of this anymore. (P8)

Engaged experience of learning. While there was a variety of attitude and motivation towards MBRP most participants had an engaged experience of learning during the sessions. Several participants described their overall experience with MBRP aftercare as less “intense” than IOP, as illustrated in this reflection:

I guess the aftercare to me was, after the intense IOP, it was nice to just kind of gradually, not so intense but still get some good information and some more tools, just to kind of downgrade to out the door as far as completion. IOP was intense with a lot of paperwork and then aftercare was, you have to be kind of more relaxed but still take in information and new information. (P6)

This participant saw it as still learning even though he was nearing completion of his

[court mandated] program. Another participant found it relaxing and enjoyable, learning new skills different from IOP:

I mean I honestly did enjoy it [aftercare] because it was relaxing. It was relaxing and it was relaxing, you only had to come one time a week. It was nice honestly. The thing is, like I said, there is stuff that you can use in aftercare that you don't learn how to use in the IOP course. (P4)

And for another it was practicing skills learned in IOP and communication while getting some time in their week to relax:

Just the different techniques in IOP. Communication skills and whatnot because I'm terrible at communicating and getting ideas out of my head and out of my mouth. It's very hard for me. In aftercare, it was just relaxing. I looked forward to it because I could go and know for at least 10 minutes I'd be just carefree. It was nice. (P1) 128

These three participants found it a valuable time in their week, to relax and to learn and practice new things before they leave the program.

Engaged experience of knowledge and skills. Learning mindfulness meditation practices is at the core of MBRP aftercare and was new for most participants, “Good because I never knew. I always heard about meditation ...” (P2). Participant 4 shared how he learned it and found it helpful in stressful situations:

She also recalled “examining my body, deep breathing” was helpful and was able to stop and examine her thoughts differently for a court appearance:

Not too long ago I had to go to court for a checkup thing and I was a little nervous about it. I stopped and I thought about it, "I'm not here for anything bad." I told myself too, "I'm not here for anything bad. I'm here pretty much because I'm doing good." It's just more the fact that I was nervous though because I don't like going in front of a judge…. Yeah, everything that I learned from those, from the beginning to the end, for sure different steps.

Meditation practice learned in MBRP aftercare included a variety of practices including deep breathing, awareness of mind and body, yoga, which participants began to use in their daily life. Below participants described their positive meditation experiences:

I guess I like the mindfulness where you just close your eyes and picture everything, see things in a different perspective if you really just stop and think about what's going on with your mind and your body. It's something I never really did, but…deep breathing, effective communication with others. That's a big one. (P6)

Meditation practice helped get a “different perspective” and improved communication. It helped the following participant with a neighboring barking dog while she tried to sleep:

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I try to breathe in and just try to picture everything leaving my body, all the negative and the dog barking [next door at night], trying to have it leave my body…It helps somewhat with the dog. Sometimes it doesn't help, because it's there. But sometimes I can get myself to sleep at least a little bit or at least in a resting state. (P8)

Meditations did not necessarily have to be long, as one participant found a short eight minute meditation helped her feel better and “got her out of that dark place”:

I read that eight-minute meditation, and it definitely worked. It might have only been eight minutes, but it was eight minutes that I felt lighter. I felt better. Then I started going to groups in prison that were geared towards meditation and mindfulness, and yoga. That kind of stuff. It just made me feel so much better. It got me out of that dark place of just no control. (P9)

Engaged participants had a generally positive opinion regarding meditation. “I would have to say the meditation. I like that probably the best.” (P6) And another who had previous experience with meditation stated, “I like meditation to begin with. I was already into meditating.” (P9).

The structure of the MBRP aftercare sessions had time up front for check-ins which included lapse reviews, CBT skills and problem solving. Most participants engaged in this part of the sessions. One participant described her experience of getting support during check-in with handing people from the past coming into her work:

Talking about the different kinds of situations and stuff like that really helped me to deal with situations that I've encountered, like different people from my past coming into my work. I work in downtown Akron. I've encountered people coming there to purchase food and had to deal with that. (P8)

Her situation was like others that are getting back to life after intensive treatment and experiencing some challenges. Another participant described learning about lapses, and recognizing them:

I mean, I learned what a lapse was. I didn't know what that was before…So, it’s like before a total relapse like before Aftercare I thought relapse was relapse, you

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know. I didn't know that your thoughts actually had something to do with relapsing. So, that was one thing I learned. (P2)

Using CBT tools was reinforced as this participant described, “I couldn't believe how many times I sat back and played the tape through…. I think now before I do something.” (P9) and also she said, “It is real important for me to have positive affirmations. To try to see the positive. Maximize the positive.” Another participant utilized the skill of “self-talk”:

I'd say the self-talk and stuff helps a lot too. I do that a lot. Probably the best part where I do the most. Talking to myself like, "You really don't want to do this again."….You gotta talk yourself out of it. It's crazy. (P2)

And using a combination of CBT skills this participant described, “I do a lot of self- talk…. I do a lot of play the tape, and I pray a lot.” (P7)

Through both meditation and CBT practice participants learned to “just slow down and take things in, process them before reacting” (P6) and then act with awareness as the following participants explained:

It teaches you to stop and think. That's what I've learned. To stop and think. A lot is in your head and a lot is really in your head when you're becoming sober. So, you have to stop and take a step back instead of just jumping forward. (P2)

She had learned skills to not just jump into something without thinking. Another participant used all the tools to better relate to other people and have a more positive way to approach them:

I mean, I would say yeah only because, with all the tools that we've used, the effective communication, stop and thinking before you say something or react, so I guess just the proper way to come across and to talk to people. I notice that a lot, even at work, just talking to my boss even. Tell him how you feel, but in a nice way or something that you disagree with but not just saying, "I don't like the way you do this." (P6)

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This participant made the CBT connection of thinking, feeling and behaving. Then she used the skills and new awareness to help her:

It was learning that our thinking errors, and how our thoughts effect our feelings to our behaviors and naming them…. Just learning to be honest with your feelings. Knowing your feelings. Naming your feelings and realizing how everything effects everything. Your thoughts, your feelings, your behavior. Now that I am aware of my own it helps me to be more aware of others around me. (P9)

Only a couple of participants practiced skills outside sessions which also indicated engaged experience of learning. Participant 6 gave an example of regular simple informal practice:

I meditate in the morning when I'm just relaxing, just I feel that a good 5 minutes is better for me than a half hour or 20-minute one because [inaudible], and then my mind just starts racing, and now I'm not meditating. Now I'm thinking of what's going to happen or what my day is going bring, that first few minutes or five minutes is more peaceful to me than a longer meditation. Only one participant described having a regular formal meditation practice:

Because I like meditation to begin with. I was already into meditating. I just did two years. Without I would have never made it through. Deep breathing. Focusing on the moment. Being in the moment. Not worrying about the past or the future…. Yeah. At night I have access to the lounge where I am all by myself. It is hard to be alone, and it is hard to be quiet. I have been able to learn to block that out, and just stay in the moment. I am able to go down there and meditate, and be grateful, use visualization. She read us one about the mountain. Being a mountain, and since she read us that I use that a lot. (P9) Engaged experience of relationships. Most participants in this study expressed the value of having a regular opportunity to share experiences with peers, “It's fine. I like it, I mean it keeps me on the schedule and I get to interact with other people going through the same thing. I've been with the same people the same time so that's kind of a cool feel.” (P2) And “I think the aftercare just kept me connected.” (P7) Another

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participant connected with her sponsor and sober support, and hoped one day to help others:

Just staying honest. Continue to reach out to my sponsor and sober support. Continue to go to meetings because I've kind of been sliding the meetings, so I need to get back into it. I want to continue to work on my step work and then hopefully sponsor girls someday, and I'll share what my experience was like with them. Just kind of stay active in the program pretty much. (P3)

She knew when she is “sliding” and knew to get back to it with hopes of sponsoring others in the future. The following participant structured her life around recovery relationships:

I keep my conscious contact with God. That's who I have as my higher power. I continue to work the 12 Steps with my sponsor. I have daily contact with her. That hasn't stopped. Since I got her, I talk to her on a daily basis. I have home group. I go to my meetings. I have a huge support group, even if it's just shooting a text daily or whatever. I talk to at least five people throughout the day, even though when I'm really busy I still make time just to make sure that they know I'm okay and then we all do the same for each other. Somebody doesn't hear from somebody, somebody says, "Hey. I haven't heard from you. What's going on?" It's a good checks and balances system. (P8)

This regular contact with multiple people was her checks and balances system. Recovery supportive relationships were described as more than just treatment or addiction self-help groups, for example:

Friends, family. I go to at least a meeting a week. I found that, for me, CrossFit is kind of like a meeting for me. It just lets me focus on myself and gets me in a better mood like meetings used to do, and just continuing to find something that works for me right now. (P1)

For some, recovery relationships may become part of their new lifestyle, not just for treatment. “So, I just really loved them, and I just got really close with them. I made some wonderful lifelong friends, I hope.” (P9)

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Transitional experience

Sentiment. Starting with negative sentiment but later changing to positive sentiment over the course of the MBRP aftercare was a common experience shared by most participants. For example, two participants expressed dislike for meditation, but later saw the benefits:

I'm not going to lie, at the beginning I thought it was going to be kind of stupid…The thing is though, when time went on though ... Like I said, I never liked meditation, I never really liked just sitting there with my eyes closed thinking about things. After time went on though, I did realize though, it was helpful. (P4)

Lapse reviews, yes. That was really helpful. Then we moved into the mindfulness part. At first, I wasn't very ... I don't want to say I wasn't willing, but it was very hard for me to get into the actual meditation itself. As I went on, the last, I don't know, the last couple of weeks it's been easier for me, but I've been trying to clear my mind more before I got here and stuff like that to try to get the best out of it. (P8)

Both participants overcame initial difficulty with meditation to later realize it became easier and was helpful.

Attitude. Many participants described a shift of moving from being closed and resistant to becoming open and engaged with the MBRP aftercare. Coming from prison and being forced into treatment one participant felt she had no choice and was resistant to treatment, but later she realized she did have a choice between remaining resistant or to listen and engage:

When I first started, like I said, I was real resistant. I was forced to come here. It wasn't my choice but coming to aftercare I learned I did have a choice. I do have a choice. I can choose to be resistant. I can choose to stay where I am at or I can choose to listen and put into action all these wonderful things that they are telling me. I am also able to see the change in my peers. The girls that are hungry for it. That want to be there. Just how their whole demeanor changed, and it just seemed happier…. I noticed that when I started participating. I started absorbing. I started listening and applying it. I just felt like the weight of the world had been lifted off me. (P9)

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Her openness to engage in treatment allowed her to experience change and happiness, and she saw it happen in the other women who did the same. Similarly, Participant 1 recalled her initial attitude, “You know before I entered into to do IOP and aftercare over again, I was like, ‘All right, well I'm going to go and do this and start drinking occasionally.’” However, as she opened up to IOP and MBRP aftercare, she started experiencing changes that helped her find “a purpose” for her life as she states:

Yeah. IOP and aftercare filled my tag. It gave me coping skills. I found things that I like to do, and I have money to afford. I have a clear mind, well not a clear mind, yeah. I just felt a hundred times better than I did before I started and it's refreshing. I can wake up in the morning and not be so exhausted and sleep until 1:00, 2:00 and then go to work. It feels like I have a purpose, or I found a purpose.

One participant recognized this initial resistance as an addict’s perspective that presumed no one understands their situation, but through an act of faith in others he made a choice to commit to change:

Taking the suggestions and doing what I'm told. That's often I feel like for me, as an addict, it's hard to do. "You don't know me. You don't know my life. You don't know what I've been through. Why are you telling me how to do this?" I just go into it. It's sort of faith. You guys are here for a reason. You guys are telling us this for a reason. This has been around for a long time…. Yeah. My sponsor says, "There's one thing you have to change, and that's everything." That's absolutely what I did this time. (P8)

Motivation and transitional experience. Motivation shifted at some point from fear of consequences to an internal conversion that using substances is no longer desirable, and that living a sober life is satisfying and beneficial. Participant 2 started to feel internal positivity as a result of positive external actions, and recognition by others.

She noted, “I think it's just kind of ... I don't know. Maybe just natural. You want to change because of other people. My case worker, [Counselor], my PO.” The external action began to translate to internal satisfaction.

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Another example of external motivation shifting to internal motivation is “doing the right things” for court which lead to feeling good as this participant described:

I've had two court hearings since I've been in here, … I feel like they see the change in me, and it makes me feel good that I'm doing the right things. Then the last court hearing before that, I got my six-month sobriety award and got to read a poem that I wrote. So, it felt good on myself, even though there was a couple hundred people in there. It felt good to be able to actually read it and get applauded instead of getting in trouble. (P3)

Participant 9 recalled her beginnings, before she had a shift from external to internal motivation, “It was forced on me. Period. I felt that way. You know.” Then, as she participated in group, a shift in motivation occurred:

Before my goals were just to get through this. Get out of here. Do what these people want. Now my goal is to listen, to learn, because I have learned that I can apply these things and it works. I get better results. Do you know what I mean? …I noticed that when I started participating. I started absorbing. I started listening and applying it. I just felt like the weight of the world had been lifted off me.

It definitely saved my life. I was angry when I was forced to come here. I just wanted to stay in prison and do my thing. Now I am so grateful that I was forced to come here, because it did change the way I think and most importantly it changed the way I view myself.

She shared that she was angry at first but then felt that it “saved [her] life”: “I was so angry when this whole thing started, but I realize now that it is probably the best thing that ever happened. It saved my life. You know.” Similarly, others described that they

“got their life back” (P2 and P6), and it changed their “quality of life” for the better (P8).

Learning and transitional experience. Some participants described a transition in their learning experience. One initially resistant participant was “wowed” when she realized she could use what she was learning in daily life:

They actually teach you like stop and think, ask them questions so you'll know all that and it's like wow. Then you use this stuff in daily life and you think back to IOP/Aftercare and you actually do use that stuff. It's crazy because when you're

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learning about it you're like, "I'm never gonna do this, like this is stupid." You know. (P2)

At first she thought that “this was stupid,” but with time and use it changed. Similarly, another participant had a negative attitude toward mediation:

The thing is though, when time went on though ... Like I said, I never liked meditation, I never really liked just sitting there with my eyes closed thinking about things. After time went on though, I did realize though, it was helpful….I would say like the first week I was kind of iffy still about it, but I think maybe the second week, somewhere second, third week, it started clicking to me like, "Oh, I can actually use this." (P4)

But after a couple of weeks, it started making sense and he could see how he could use meditation.

Practice and transitional experience. In MBRP aftercare there is encouragement to practice outside of the program to develop mindfulness, and most participants indicated some informal practice using skills outside, but few did formal regular meditation practice outside of the program. These participants fit the transitional experience of practice, for example, Participant 2 acknowledged that meditation helped, but it was hard for her to do on her own:

It was good. It was relaxing. It was nice to ... I don't know, I struggle doing it by myself at home. I try it all the time but it's so much easier when someone else is talking to you. So maybe I should get a tape or something.

Similarly, Participant 4 described doing informal practice as he needs it; and it is easier to do at home:

I just feel like when I'm at home, I'm sitting down on the couch, I'm comfy, no TV on, there's completely silence, I don't hear nothing. Like I said, especially at nighttime, like before I go to bed if I feel like I need to use the skill because I'm stressed or irritated or whatever, I just feel like it's more useful.

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Relationships in transitional experience. For most participants it took time to develop trust and vulnerability needed to build a network of supportive relationships. One participant shared that she felt like she had no help in the beginning, but changed her view after she got into the program:

Before I just had no help. None. I was like I'm not gonna change, there's no way and then, you get into this program and then [inaudible] especially. They just uplift you; you know. They make you feel like you're worth something and you can do something. It might take time but one step a day, you know. (P2)

The group gave her encouragement, and confidence that she can do something. Also, this participant described becoming honest, vulnerable and opening up to the group:

Do you have what I need, and you move on. So, that was a really hard thing for me to adjust to was being honest, opening up and sharing with the group. Being judged, being vulnerable, being perceived as weak. That kind of stuff, but Ms. [Counselor] really made the experience relaxed. You know confidential. You had that trust, and the girls did. I said it more than once, "Of all the things that I have been through the whole program of [Women’s Corrections Facility]. Aftercare and IOP was life changing." (P9)

It was not easy, and she recounted feeling alone and lost in feelings until she was in group:

You feel alone and lost in your feelings. But then when you are in that group, and there is somebody that says, "Hey, I feel that way too or I did exactly that." It alleviates that shame, that guilt, that isolation. It gives you a way to deal with it. To deal with the things that you used drugs to help you deal with. I think I am saying it right. (P9)

Together with the group, she found connection with others that felt like her, shameful, guilty and isolated, and began a new way of dealing with it. She continued to describe being part of the group helped her to change her goals in relationships:

To be honest with myself as well as others which is hard. It is hard to tell on yourself. I think I am more transparent. I am not as guarded. You know. I am more compassionate towards people in that I can see their pain. Recognize it, and ... Once again, my goals aren't the same. I am not manipulating. I don't want what

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you have. I want to give you what I got. You know what I am saying. Yeah. I just can't say enough about aftercare. It is just pulls it all together, and it makes it to where it comes natural instead of having to work for it. (P9)

She contrasted a change in her relationships from caring only for herself to caring for others:

I think that was like the most important thing is to learn to care about somebody else. When you are in addiction you don't even care about yourself. You know what I mean. All you care about is obtaining. (P9)

This new attitude found in her recovery relationships then extended to healing her family relationships:

I truly felt that my actions only hurt myself. I wasn't hurting anybody else. We learned about the ripple effect. How that one thing ripples out. Being in the group helped me open up to my family I have adult daughters, and they were aware of my addiction. I would be honest with them in that. My daughter told me ... She was like, "Mom, I always thought I was going to get the call that you were gone." (P9)

Another participant also found this healing in family relationships:

Yes. Just going again, [from] being a bump on a log to actually doing things and communicating with my parents. I talk to my mom on a daily basis now and she doesn’t drive me nuts, which is a first. (P1)

Of the interviewees, the men shared less comments on relationships than the women, yet some evidence was given for the value of recovery relationships. For example, this participant shared initial difficulty sharing in group which later gave way to openness:

Yeah, I mean when I started, I wasn't exactly nervous, but I didn't feel as comfortable. As time went on, I don't know if it's because I got to know people more or whatever, my feelings, how I felt like I wasn't as nervous anymore, or uncomfortable. I don't know if that was really to do with that or if it was just to do with me, I'm not exactly sure. (P4)

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Another participant acknowledged the benefit of friendship in recovery as one of the factors in continuing through treatment:

I think it helps being in a room with guys that are in the same situation you are. Eric started with me on day one. He and I become somewhat friends. Just good to see him succeed. (P7)

Disengaged experience

Sentiment. Of the interviewees, only one participant (P5) expressed overall dislike of the aftercare meditation and IOP treatment. He demonstrated this several ways, one of which was though an inability to recall details:

I don't really remember a lot of it. I don't know, just like emphasizing being aware of your surroundings. Recognizing how you're feeling, stuff like that and the only thing I didn't like is just how we do the meditation.

He also doubted treatment effectiveness based on past failed attempts at treatment, “Yeah because sometimes it doesn't work. The only way to stop feeling like that is to get high or drink some beer or something...” He was tired of being forced to listen repetitively to others, “I just listen to people talk just hearing the same thing over and over and just having to sit through it all the time. I'm just tired of it.” Also, he believed his negative opinion of meditation is shared by most, “I don't think a lot of people really like the meditation part, but some people get into it. It's not like it's a, like a game changer whatever, like a game. You know what I mean?”

Attitude and disengaged experience. Not every participant had a positive attitude towards MBRP aftercare, as Participant 7 said, “I’m not a meditation guy,” and

Participant 5 stated:

The only thing I didn't like is just how we do the meditation…It was just, I don't know would just get kind of antsy. Couldn't really get into it too much. I just, it was kind of foreign to me, never had that in many of my treatments.

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Trying to meditate made him uncomfortable and felt foreign which disengaged him, as he candidly noted, “I just never really participated in that exercise. I just kind of sat there.”

External motivation as disengaged experience. Everyone in this program did not choose to be here, they were here because of consequences of their behavior that resulted in court mandated treatment. Most participants had some degree external motivation, or the intention to do what you had to do to get through the punishment and stay out of trouble. A couple of participants described their disengaged experiences as primarily external motivated.

Yeah and I've been going nowhere since I was fourteen when I started getting high. Tired of going to treatment too so I might probably try and stop so I don't have to keep doing IOP over again. I was just in treatment at [treatment facility] for like six months and now I have to do IOP all again at this place. It's kind of pissed me off…. I'm going to just not get high just so I don't have to keep doing this, it's so annoying. IOP doesn't help me, tired of it. (P5)

He continued, “You know IOP never stopped me from getting high. What's stopping me now is getting drug tested here and being trapped here. What's stopping me now.” The possibility of further punishment kept him participating, “I have like two or three years of prison over my head, I'm not getting kicked out of this place.” Participant 5 was also concerned about how he looked and felt physically, “Yeah I don't want to get high because I don't want to mess this program up. I want to start doing things again like running on the trails again.” And, “I feel like that plays a big role and I'm just hoping that

I'll feel better when I get out and won't want to get high since I feel good. That's the whole reason I was getting high.”

For Participant 2, aversion to further external consequences was also significant motivator, “Yeah. I'm doing it like ... I'm in drug court but I have three felony cases, four

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felonies total so, I mean, I have a lot of time over my head.” She also gave an example of keeping score of external goals and a concern of how she was viewed by others:

Things are looking great right now. I have no negatives. I'm doing everything I'm supposed to. So, it’s good and it’s good to know that people actually see it. That makes you feel so much better too. You know what you’re doing but for other people to realize it, it's like, a big deal.

Disengaged experience of learning. The participants with disengaged experience of learning described not learning anything in MBRP aftercare. One stated, “I've definitely learned a lot more in IOP than Aftercare. Definitely, like a lot more. Aftercare, we just talk about what we've been doing, and you don't really learn anything. In my opinion.” (P2) and similarly for this participant:

For me, I just kind of feel like it was more just talking about how we feel, to be honest. I don't really feel like I learned much of anything new…. It was nice to meet the new people and tell someone about my feelings because it helps get me out of myself, but I didn't really learn anything new. (P3)

She described benefitting from talking and meeting people but did not believe she learned anything new. Participant 5 also acknowledged learning some things in aftercare and IOP such as, “Just to recognize when you're feeling something and don't act on it I guess. Just to be aware of everything around you and what your consequences will be and stuff like that.” But he also noted difficulty in application: “I guess some of the management skills they taught me in IOP would help if I could use it every time.”

Participants who described experiences indicating disengagement were not into meditation and admitted to not practicing. Participant 5 did not engage at the class, “I just never really participated in that exercise. I just kind of sat there,” and Participant 8 stated regarding outside practice, “Not so much for the meditation.” Another described himself as “I'm not a meditation guy.” (P7). One participant found meditation was unfamiliar

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treatment, “Yeah, I mean, I've never really did that in any other type of treatment programs that I've been in.” (P6)

Disengaged experience of relationships. Two participants with disengaged experience of MBRP aftercare gave no direct comments on relationships as a recovery support. One participant conveyed a sense of an individual responsibility to choose recovery:

There ain't going back. I mean, especially today, everyone's dying from what's out there, and I mean, I've lost everything three times, and it only got worse every time. I mean, I'm at that age where it's either, I'm going to live that lifestyle the rest of my life, or I've got to change and live a new life because there's no medium. There's a left or a right. There ain't no going both ways or recreational. (P6)

The most description Participant 6 had of relationships was his own description of how he related to others at this time:

I'm more trustworthy, just the way I act around people that before, I was either a smart ass or tell you how it is or tell you what you want to know. Today, I have more respect for people just the proper way to talk to them or even come across dependable.

He did attribute change in his life to treatment, but it was from an individualistic versus relational perspective:

I think it was the repetitious practice every Monday, Wednesday, every three days a week, and then carrying it back over into aftercare two days a week, so I think it was just reprogramming your brain. I mean, you learn something one day in school. I mean, it's just one day, and you wind up forgetting it. We went over it and over it and over it and use them throughout the whole IOP and aftercare, so it kind of, not brainwashed, but just kind of pounding it to you. You got do it in role plays, and then you got to use it when you're out on your own or out at work or in public. (P6)

Participant 5 also had no positive comments about recovery relationships in his interview, and for the most part he stated his frustration at having to be in treatment:

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Yeah, it makes me angry, I'm tired of doing it. I've been doing these groups for like over a year. I did a bunch of groups for two months straight last summer and then I got out of bed rehab and then they sent me right to IOP. I got kicked out of that IOP in the after care and then I went to another place. I went to like two more places and then I did [different treatment program] and then now I got to do this IOP. I'm just tired of all this treatment crap.

He recognized family as important for recovery, but his overall outlook was pessimistic and impoverished at the time:

I've stolen a lot of stuff from my family. Probably another go around they probably would not want me around anymore. It's my future I guess, I'm in my twenties still and everybody that I was in [residential treatment] with are in their forties and fifties and they all told me they wish they had it now. Got out of there when they were my age. I would just be taking it for granted if I were to just, I mean just because since I was fourteen, I started using drugs and I haven't really accomplished really anything notable. I don't really have any useful work skills, trades. (P5)

Theme Two: Participant Change in Mindfulness, Self-Compassion, and Impulsivity

The quantitative dependent variables for this study were mindfulness, self- compassion and impulsivity. Qualitative findings showed some evidence that supports change in mindfulness, self-compassion, and impulsivity for some of the participants.

The most frequent references by participants were for mindfulness factor of nonreacting to inner experience and acting with awareness. There were some participants indicating change in self-compassion, but very little data on impulsivity.

Mindfulness

The five factors of the FFMQ represent mindfulness and are: acting with awareness, observing, describing, nonjudging of inner experience and nonreacting to inner experience. Seven of the nine participants experienced some of the factors of mindfulness, and often the factors worked together in practice. Most participants had

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something to say regarding nonreacting to inner experience and acting with awareness.

Fewer participants gave evidence regarding observing, describing and non-judging inner experience.

Nonreacting to inner experience

A majority of participants described a change in how learning mindfulness helped them not to react but respond to their inner experiences. This participant recounted learning new mindfulness steps and skills he did not know before:

He used the breathing technique when frustrated to help him to “stop and think” about his situation; at least the ability to “stop” would be non-reacting to the inner experience of frustration. Another participant also could “stop” and “live in that moment” or take a non-reactive stance while the “mind goes…”

I think just stopping my mind and focusing on what was being said and what the directive was to do. It's so easy when you close your eyes, your mind goes to the different things that you have to do, the things you haven't done, planning. I'm always busy, so usually when I come here I'm either ... Usually I'm going to work. It's hard to stop and live in that moment and focus just on the things that are being told to you to focus on. (P8)

Another participant began to realize an increased ability to not react to feelings and his environment, but simply be aware of them which led to consideration of consequences:

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Just to recognize when you're feeling something and don't act on it I guess. Just to be aware of everything around you and what your consequences will be and stuff like that. (P5)

This participant described that there can be a lot of difficult emotions and stress in recovery. She stated her meditation kept her “centered” and “in tune” in spite of what the emotions or mind may be doing:

That is a lot of anxiety, and a lot of stress. Oh. Am I going to do it? Just so many things come into your mind. The meditation definitely helped me, and staying centered and knowing who I am. What my goals are. Just being in tune with my physical, my mental, and my spiritual. That was important to me. You know. (P9)

She was very clear her meditation practice, “helps me to stay centered, and in the moment…. I am the mountain, and I am grounded in my recovery.” (P9)

Another participant described the mindfulness practice of grounding in the body helped his “thinking”:

I don't exactly know how to say it, there are things that did help. Especially for examining my body, that for some reason, when I do that, a lot of things go off my mind. My thinking helps when I do use that step. For the most part though I think it's me too because now since I've been clean for how long? My mind is clear. (P4)

He also recognized part of his improvement may be related to time being “clean”, so there may be a combination of mindfulness practice and time that helped him.

Mindfulness practice enabled another participant to “stop” and be aware of “what is going on with your mind and your body,” which gave him a new ability to process situation before reacting:

I guess I like the mindfulness where you just close your eyes and picture everything, see things in a different perspective if you really just stop and think about what's going on with your mind and your body. It's something I never really did, but…Thinking, maybe just slow down and take things in, process them before reacting. (P6)

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He described a new ability to not react to the inner experiences which supports self- awareness and time to process the experience before reacting. Similarly, another participant recognized staying in the moment, and awareness of feelings and physical reactions helped her to use skills learned in IOP:

I don't know that I can say since I started the aftercare program, but since I've started IOP. To me, this is all one big bundle. I try and stay in the moment. I try to be cognizant of not only my feelings, but my physical reaction to situations. That's when the self-talk and the play the tape and remove myself from a situation or whatever. Those things all come into play. (P7)

Her experience highlighted the connection of mindfulness skills helping a person access and use other recovery skills they may have learned. The ability to not react to inner experience gave her and the other participants the capacity to consider their circumstances and then act with awareness.

Acting with awareness

In MBRP, acting with awareness is the opposite of reacting without awareness or conditioned behavior (automatic pilot). One participant described coming out of the usual reactive mode of mind to focus on one thing:

He described his experience of “stopping my mind” which is more like ceasing unfocused mental activity versus non-reactivity to inner experience, in order to focus on one thing, the guided meditation in MBRP session. Similarly, another participant

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described his usual reaction to situations, but was able to act with awareness for a different approach to relating with others:

Yeah, it was new. I think would help in situations when you might make that split decision of doing something and just sit back and think about the consequences and think about the turnout…I mean, I would say yeah only because, with all the tools that we've used, the effective communication, stop and thinking before you say something or react, so I guess just the proper way to come across and to talk to people. I notice that a lot, even at work, just talking to my boss even. Tell him how you feel, but in a nice way or something that you disagree with but not just saying, "I don't like the way you do this." (P6)

For this participant it was new to “stop” in order to consider the next course of action, and to communicate with awareness. For another participant, she described being more mindful and acting with awareness in communicating with her boyfriend:

I just try to be mindful of others especially because ... With my boyfriend, we fight here and there, and he's not an addict, so I used to get frustrated about that. I used to tell him he didn't understand me. It would just be a whole big argument, but now I try to use my "I feel" statements and communicate better instead of just attacking him. (P3)

Each of these participants described learning to be more aware of themselves and step out of an “automatic pilot” mode of reacting to situations in order to act with awareness in a more skillful manner.

Observing

One participant provided a good example of the mindfulness factor of observing.

He described noticing and attending to his inner experiences, this participant observed details of his body, mind and senses:

I mean, just experiences that I had was feeling just how your body feels. You don't really sit and think about it when you're every day, but if you actually stop to think, and you can hear yourself breathing, you can smell the smells. I never really experienced that, so just trying to put your mind with your body, I guess. (P6)

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He found it a new experience to pay attention to the body and many things that are going on which often go unnoticed. Another participant practiced observation for better outcomes, “For aftercare, like I said one of my biggest things that I do use is when I just stop and think. Especially when I observe around and I just think about more positive outcomes than the negatives.” (P4) Again this participant described a process of stopping the usual activity of the mind to redirect attention to observing their present moment experience which led to more positive outcomes.

Nonjudging inner experience

In MBRP participants noticed their mind evaluating their experience. Learning to take a non-evaluative stance towards her own thoughts and feelings and being open helped this participant be receptive to what they learned:

Yeah. Also maybe stress more about having an open mind and maybe saying, "Hey, if you can, try to clear your mind a little bit before you come in to be more receptive to the experience." I did that on my own, not because I was told, but it ultimately ended up helping me. (P8)

Practicing non-judgment towards experience enabled another participant to not take other’s anger personally which led to compassion and conciliatory action:

If somebody is mad. I don't take it personal. You know what is going on with you. If the time is right can we talk about it. Do you need to talk about it? If not, I am here. You know what I mean. It just taught me to be more compassionate towards others. (P9)

Describing

Only one participant clearly demonstrated the mindfulness factor of describing.

She was aware of and able to label or name her experiences:

Knowing your feelings. Naming your feelings and realizing how everything effects everything. Your thoughts, your feelings, your behavior. Now that I am

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aware of my own it helps me to be more aware of others around me. You know. (P9)

Self-compassion

Several participants described a change of becoming more compassionate towards themselves during MBRP aftercare. Participant 2 recalled a negative view of herself, and how the group helped lift her up and value herself and believe she can change:

I was like I'm not gonna change, there's no way and then, you get into this program and then [inaudible] especially. They just uplift you, you know. They make you feel like you're worth something and you can do something. It might take time but one step a day, you know.

The view she held of herself was more positive and affirming. Another participant also described her view of herself as, “it might be a little better now” (P1).

Participant 9 described her journey as starting with feelings of anger, guilt and shame toward herself, which through the relationships of group and her counselor changed to self-love and care:

I am no longer mad about where I am at in space, where I am in time. You know what I mean. I am cool with being who I am… So, I didn't see it that way before. Being in group. Talking with the other girls. Having Ms. [Counselor] guide us definitely brought that to the surface for me. Like I said, it was life changing. I just feel so much better about myself now. I feel stronger in my recovery simply because I can talk about the past, and the things that happened without so much guilt or shame. It has been alleviated. I am not alone. You know. (P9)

Her experience with recovery relationships helped her not feel alone (in Neff’s definition of self-compassion: common humanity). She was able to find herself and learn to love herself:

You lose track of yourself. That group helped. For one thing we were all women. You know what I mean. It just helped to stress that you need to have self-esteem. You need to love yourself. You have to take care of you before you can take care of anybody else. That was really beneficial for me. (P9)

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Ultimately, she recognized her value and humanity, “I just feel like I am a better human being. Period. Yeah. It was life changing for me.” And, “100%. I am worthy. I have value. You know what I mean. It changed my whole life in the way I can view myself. I am so grateful for it. So, very grateful.”

Impulsivity A few of the participants acknowledged a change in impulsivity. Impulsivity is described as a personality/behavior construct in the BIS-11 comprised of attention impulsiveness, motor impulsiveness, and non-planning impulsiveness; which should be distinguished from the FFMQ factor of non-reacting to inner experience. For example,

Participant 2 had a view of themselves as previously impulsive or “Instant do, whatever’”

(BIS-11 impulsivity) and then with treatment, “…they actually teach you like stop and think, ask them questions so you'll know all that and it's like wow” (non-reacting).

Participant 6 described a similar change, “Thinking, maybe just slow down and take things in, process them before reacting” (non-reacting), and he acknowledged previously,

“I was either spur of the moment or somebody either says something or does something and just instantly react of however I was feeling instead of taking it in and processing it before” (BIS-11 impulsivity). With treatment another participant found stopping, thinking and problem-solving or non-reacting became a positive conditioned response, “It just happened. Do you know what I am saying? I didn't have to stop and think, ‘Okay. I should use my problem-solving skills in this.’ I didn't have to do that. I just did it.” (P9)

Theme Three: Recovery of Mind, Feelings, Responsibility, and Future

In addition to participants’ experiences and the outcomes of mindfulness, self- compassion and impulsivity, there were four additional outcomes that the participants shared during their interviews. Four additional participant changes related to MBRP

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aftercare were “mind coming back”, recovery of feelings, handling responsibility and finding purpose and hope for the future.

Post-Detox “Mind Coming Back” Most participants recognized changes in their thinking and feeling that were directly related to clean time or time living sober versus MBRP aftercare. One participant attributed change in their life to, “just coming off drugs, really” (P2) , but did not elaborate on how.

Another participant stated, “Honestly, I really just feel like it's more that I'm not using-…Everything was way different when I was using and now, I'm not. I mostly think it's because of that to be honest.” (P4)

Two of the participants described being off drugs has cleared their “mind”, “You go through it and you don't really know anything about it until you get your mind clear and then you learn.” (P1) And, “Learning, abstinence from drugs. I think my mind coming back to what it was and utilizing these tools.” (P7)

Post-Detox Recovery of Feelings

Some participants described a process of recovering feelings and learning to regulate them which improved with clean time. Participant 2 recounted this process in her life, “I was happy before drugs so when I was on drugs, I was not a happy person. Not at all. Now getting off drugs, now I'm happy.” Another participant also connected more clean time with feeling better, “Hopefully when I get more clean time I'll feel better and I won't want to get high.” (P5) Participant 9 described her experience in addiction as being a “zombie”, then with sobriety feelings arise which can be frightening: “It might sound ...

It sounds probably crazy to somebody who hasn't been in addiction. That is really how you live. You are like a zombie. You are walking dead.” She elaborated that, “It was

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being sober, forced sobriety, and having those feelings was a whole new ball of wax for me. It was scary. It was frightening.”

Some of the participants experienced a fluctuation in emotions during early stages of recovery, as described by this participant, “I feel like my feelings change every day.”

(P3) She attributed time in aftercare as helping settle the emotions, “I have really bad anxiety and depression, so I do feel like that has gotten better since I've started aftercare.”

Another participant noted being able to express her feelings, “Yeah. I don't try and stuff things anymore.” (P7) But working with these fluctuating feelings took effort and practice of skills learned as described by Participant 8:

I had to make more of a conscious effort to ... I would get overwhelmed a lot, and not just about bad things. I know one time I got three pieces of mail and I was super happy. I got a hoodie in the mail and an mp3 player and a really good letter, and I was just so super excited but it made me feel really overwhelmed. I had to take a step back, go in my room, and quiet down a little bit. I use my bible a lot. I had to calm myself down that way.

Handling Responsibility

Participants expressed both the ability and confidence to handle responsibility in their life and rectify damaged relationships due to their addiction. As described in previous paragraph, Participant 8 noted that after learning to work with his emotions,

“Now I know I can handle situations better and without even thinking about it.”

Similarly, another participant described feeling life results adds up correctly, “More equipped to go through life sober and do the right thing and add two and two together and get four instead of nine.” (P7) And regarding suffering inflicted on others due to addiction, “[I] Took responsibility for that pain, and I don't want to do that anymore.”

(P9)

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Finding Purpose and Hope for the Future

Coming out of aftercare some participants experienced a new meaning in their lives. Participant 1 described, “It feels like I have a purpose or I found a purpose.” She remembered during addiction, “I spent most of the day sleeping and then waking up and going to work and staying up watching TV and just laying around being a bump on a log.

Now, I feel like a productive member of society.” Noting the change, she had a clear objective, “I know I could be a really good mom." Participant 9 knew she was not living a full life, “I wasn't in my potential. I was in the moment. I never neglected my family, but I wasn't at my full potential.” And now her life has a different direction, “my goals aren't the same. I am not manipulating. I don't want what you have. I want to give you what I got.”

Some participants indicated it was their relationships in group that helped them find purpose and hope, “They make you feel like you're worth something and you can do something. It might take time but one step a day, you know.” (P2) While it took time their perception began to shift, “I guess more positive.” (P3) And, “I noticed that when I started participating. I started absorbing. I started listening and applying it. I just felt like the weight of the world had been lifted off me.” (P9)

Summary of Qualitative Findings

A cycled-coding and theming process was used to develop three themes to address the fourth and fifth research questions. Cycled coding processes were used to develop the three themes of (1) varying participant experiences of MBRP aftercare, (2) participant change in mindfulness, self-compassion, and impulsivity, and (3) recovery of

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mind, feelings, responsibility and future. The first theme addressed the varying participant experiences of MBRP as three types of experiences. Participants displayed either engaged, transitional, or disengaged experiences. These experiences were made up of five facets including sentiment, attitude, motivation, learning and relationships.

Participants with an engaged experience described positive feelings toward program, openness and active participation, inner motivation to change, learning and using MBRP skills, and connection to a recovery support network including family and friends.

Participants with a disengaged experience described negative feelings toward program, being closed and resistant to program, motivation to avoid consequences, not learning or practicing MBRP skills, and having little or no recovery support network. Participants with a transitional experience started as disengaged but through process of the program began shifting to an engaged experience of the MBRP aftercare program.

The second theme was developed from specific codes to represent the quantitative variables of mindfulness, self-compassion, and impulsivity to help address the fifth research question. Qualitative findings showed some evidence of change in participants’ mindfulness, self-compassion and impulsivity. Participants most frequently described the nonreacting to inner experience component of mindfulness. Participants shared that their practice of mindfulness meditation and skills helped them to respond versus react in difficult situations. A few participants described increasing their self-compassion, and their experience of beginning with negative feelings towards themselves shifting to self- love and care. Impulsivity was described by participants as more of a personality trait, and that they learned skills to respond instead of react to their experiences.

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The third theme of recovery of mind, feelings, responsibility and future emerged through coding of participant interviews. This theme addressed both important experiences of participants and additional outcomes of MBRP aftercare. Participants described “mind coming back” as a result of stopping use of drugs and getting clean time.

Similarly, they a process of recovering feelings and learning to regulate them as they have more sober time. Participants noted both the ability and confidence to handle responsibility in their life and to rectify damaged relationships that were a result of their drug use. Finally, some participants experienced finding new meaning and purpose in their lives as they completed their MBRP aftercare program. To further address the fifth research question, the following section integrated the qualitative findings with quantitative findings to produce convergent findings.

Integration of Quantitative Results and Qualitative Findings

To answer the fifth research question, the quantitative results and qualitative findings were merged. Interviews from a subsample of participants were coded for the main outcome measures, and the number of references to an outcome measure by participant was listed and then summed across all participants for each scale in a joint display (Creswell & Plano Clark, 2018; Guetterman et al, 2015). The total number of references for each scale was then compared to the quantitative level of significance for each scale in Table 13.

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Table 13 Number of Participants’ Coded References (Qual) from Interviews Corresponding to

Level of Significance for FFMQ (and subscales), SCS-SF and BIS-11 Outcome Scales

Participants' Coded References (Qual) p-value

Scales P9 P6 P8 P4 P7 P2 P5 P1 P3 Total (Quant)

NonReacting 3 4 3 3 1 0 1 0 0 15 0.006*

Acting 5 2 1 0 1 0 0 0 1 10 0.270

Observing 1 1 2 1 1 0 1 0 0 7 0.099

NonJudging 0 0 2 1 0 0 0 0 0 3 0.730

Describing 1 1 0 0 0 0 0 0 0 2 0.325

FFMQ 10 8 8 5 3 0 2 0 1 37 0.065

SCS-SF 12 0 0 0 0 1 0 1 0 14 0.139

BIS-11 1 2 0 0 0 1 0 0 0 4 0.153

Note. * p < .05 with Bonferonni adjustment. NonReacting was statistically significant with a Bonferroni adjusted p-value of 0.00625.

The comparison showed that the largest number of references by the subsample of participants converged with the significant finding on the nonreacting scale. Also, when comparing the three full scale scores for mindfulness, self-compassion and impulsivity there was a parallel pattern of more participant references for mindfulness (FFMQ), some for self-compassion (SCS-SF) and few for impulsivity (BIS-11).

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To detail the comparison of quantitative measures to the qualitative data Table 14 compares the basic quantitative results with key quotes from the participant interviews that represent each of the scales. Providing key quotations provides support for each of the quantitative scale and shows in the participants words their experience of mindfulness, self-compassion and impulsivity.

Table 14

Quantitative Results and Participant Quotes for Mindfulness, Self-Compassion &

Impulsivity

M Outcome SD p-value Participant Quotes Change

Nonreacting 2.33 3.82 0.006 For me it helps me to stay centered, and in the moment. (P9)

Thinking, maybe just slow down and take things in, process them before reacting. (P6) Now, being aware of my feelings and knowing how I think and knowing how I'm going to react to that now is natural. (P8) For overall, I personally thought it was helpful for mindfulness, ... A lot of times if I'm getting frustrated or irritated, whatever, I'll take the time to stop, think about it. I definitely use the breathing technique. (P4)

Observing 1.54 4.39 0.099 Just learning to be honest with your feelings. Knowing your feelings... Now that I am aware of my own it helps me to be more aware of others around me. (P9)

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that, so just trying to put your mind with your body, I guess. (P6)

One of my biggest things that I do use is when I just stop and think. Especially when I observe around and I just think about more positive outcomes than the negatives. (P4)

Acting 1.13 4.88 0.270 Meditation has helped me immensely. Just to visualize what I am going to do. What I want to be. How I am going to feel. (P9)

I think would help in situations when you might make that split decision of doing something and just sit back and think about the consequences and think about the turnout. (P6)

Describing 1.04 5.08 0.325 Naming your feelings, and realizing how everything effects everything. Your thoughts, your feelings, your behavior. (P9)

I meditate in the morning when I'm just relaxing, just I feel that a good 5 minutes is better for me than a half hour or 20-minute one because [inaudible 00:12:08], and then my mind just starts racing, and now I'm not meditating. (P6)

Nonjudging 0.42 5.85 0.730 Also maybe stress more about having an open mind and maybe saying, "Hey, if you can, try to clear your mind a little bit before you come in to be more receptive to the experience." I did that on my own, not because I was told, but it ultimately ended up helping me. (P8)

FFMQ 6.46 16.35 0.065 Full scale score comprised of five subscales listed above; participants described FFMQ mindfulness as “centered,” “aware,” “stop and think,” “observe,” “think about consequences,” “naming,” and “open mind…receptive”

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SCS-SF 2.17 6.92 0.139 100%. I am worthy. I have value. You know what I mean. It changed my whole life in the way I can view myself. I am so grateful for it. So, very grateful. (P9)

I didn't see it that way before. Being in group. Talking with the other girls. Having [Counselor] guide us definitely brought that to the surface for me. Like I said, it was life changing. I just feel so much better about myself now. I feel stronger in my recovery simply because I can talk about the past, and the things that happened without so much guilt or shame. It has been alleviated. I am not alone. (P9)

They just uplift you, you know. They make you feel like you're worth something and you can do something. It might take time but one step a day, you know. (P2)

BIS-11 −2.63 8.69 0.153 I was either spur of the moment or somebody either says something or does something and just instantly react of however I was feeling instead of taking it in and processing it before. (P6)

Instant do, whatever. Then you give them the treatment and they actually teach you like stop and think, ask them questions so you'll know all that and it's like wow. Then you use this stuff in daily life and you think back to IOP/Aftercare and you actually do use that stuff. (P2)

From the Table 14 there is a strong convergence between quantitative mindfulness and participant stated experiences, and many quotations can be found that directly relate to subscales of the FFMQ. For self-compassion there is partial convergence between SCS-

SF scores and participant quotations. The participants’ quotations were fewer in number, they supported a more accepting view of oneself, but they also appear rooted in recovery

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relationships experienced in aftercare rather than specific MBRP curriculum. For impulsivity there is partial convergence between BIS-11 scores and participant quotations. There were only a few supporting quotations. Participants indicated having impulsive traits such as “instantly react” or “instant do” and having learned to stop and think which would be more a practice of nonreacting rather than a change in an impulsive trait.

There was no direct connection between individual participant quantitative scores and interview qualitative data in this study. Despite this limitation, to further explore the convergence of qualitative results and quantitative findings, a comparison was made between interviewee types of experiences and interview references to outcome measure coding.

A preliminary step before final integration was to quantitize (Sandelowski et al,

2009; Teddlie & Tashakkori, 2009) the qualitative data for facets of experience and summing to get a total experience score as shown in Table 15. Facets were designated positive values for engaged experience and negative values for disengaged experience.

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Table 15

Participants’ Type of Experience Compared to Quantitized Number of References to

Experience Facet Codes

Participants’ Number of References to Facet Code

(Quanititized Qualitative)

Experience Facet P9 P8 P6 P7 P4 P1 P3 P2 P5 Codes (Qualitative)

Positive Sentiment 4 2 0 3 3 2 1 1 1

Negative Sentiment 0 -1 0 0 -2 0 0 0 -5

Positive Attitude 8 4 2 0 2 2 4 2 0

Negative Attitude -1 0 0 -1 -3 0 0 0 -5

Internal Motivation 9 9 3 3 0 1 4 1 3

External Motivation -8 0 0 0 0 0 -1 -5 -10

Learned 1 0 2 0 3 0 0 1 0

Not Learned 0 -1 0 0 0 0 -2 -1 -2

Yes Practice 5 2 4 3 5 1 0 4 1

No Practice 0 -1 0 0 -1 -1 -1 0 -2

Relationships 7 1 0 2 1 2 1 2 0

Total 25 15 11 10 8 7 6 5 -19

Counselor Group: D D C C B A A A B

-1 SD Median +1 SD

Type of Experience: ENGAGED TRANSITIONAL DISENGAGED

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The median score was 8 (P4) with an average score of 7.56 and one standard deviation of ±11.68. The result was a ranking interpreted as +1 SD or greater as engaged

(Participant P9) and -1 SD or less as disengaged (Participant P5). Participant scores in between were considered transitional experience. This continuum of qualitative participant experiences is compared in the summary at the end of this chapter demonstrating convergence between participant experiences and outcomes for mindfulness, self-compassion and impulsivity.

Also shown in Table 15 were counselor group assignments listed for comparison.

Previously noted in the quantitative section Groups A and B showed the most positive change, but in this table, it was Groups C and D that had participants at above median experience scores. This difference could be for two reasons – re-examining Group C & D they had much higher pretest scores and the difference to posttest score was smaller;

Group A & B had lower pretest scores and posttest scores had a larger change; in fact

Group A & B posttest scores were comparable to Group C & D. Also, no specific direction was given for selecting interviewees for each group, which could have influenced outcomes.

Summary of Results and Findings

To summarize the convergence of the qualitative findings and quantitative results for the MBRP aftercare program a joint display (Figure 9) combines results from Tables

12, 13 and 14 to show relationships of participant experience types, and the outcomes of mindfulness, self-compassion, and impulsivity.

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Figure 9

Joint Display: Integrating Qualitative Findings of Participant Experience and

Outcomes with Quantitative Results for Mindfulness, Self-Compassion and Impulsivity

Number of Coded References N =9 Qualitative

Participant Experience Rank (Table 15) Experience Type: ENGAGED TRANSITIONAL DISENGAGED

P9 P8 P6 P7 P4 P1 P3 P2 P5

Convergence between Engaged and Transitional Experiences and Higher Number of Mindfulness Coded References

Participant Outcome Measure Rank (Table 13) Outcome Measures: Mindfulness, Self- Compassion, P9 P6 P8 P4 P7 P2 P5 P1 P3 Impulsivity

Outcome Scales Level of Convergence between Qualitative Findings and Quantitative N =24 (Table 9) Results Quantitative

Scale p -value

FFMQ 0.065 Mindfulness - Convergence between Qual and Quan

10 8 8 5 3 0 2 0 1

SCS-SF 0.139 Self-Compassion - Partial Convergence between Qual and Quan

12 0 0 0 0 1 0 1 0

BIS-11 0.153 Impulsivity - Partial Convergence between Qual and Quan

1 2 0 0 0 1 0 0 0

Note. Coded References are the number of quotations coded from participant interviews. Rank shows participant location on continuum of experience, and participant higher mindfulness. Both ranks are based on number of coded references. Shading highlights findings of convergence between Qual and Quan.

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In Figure 9, convergence was shown between participants having more statements of engaged or transitional experience also had more statements of mindfulness in their interviews. Agreement was also demonstrated between quantitative mindfulness (FFMQ) scores and participants with higher expressed qualitative mindfulness. Both self- compassion and impulsivity had statistically insignificant change, and there was partial agreement in with only a few participants making references to these two outcomes.

Finally, with only a single coder, intrarater reliability analysis was conducted as a reflective exercise (Joffe & Yardley, 2003; O’Connor & Joffe, 2020) and percentage agreement was calculated (Shweta, Bajpai & Chaturvedi, 2015). Three interview transcripts (P4, P5, & P9) were coded twice across the five facets of client experience and the three types of client experience, and a coding comparison query was performed in

Nvivo. The percentage agreement for all five facets ranged as follows: sentiment (98.0 –

100%) attitude (95.0 – 100%), motivation (96 – 100%), learning (93.7 – 100%) and relationships (96.1 – 98.1%). The percentage agreement was 100% for coding each interview transcript as engaged, transitional, and disengaged types of experience.

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CHAPTER V

DISCUSSION

The purpose of this study was to use a mixed-methods research design to investigate the effects of MBRP aftercare program on participants who were in court- ordered opioid addiction treatment. This study examined (1) the results of changes in mindfulness, self-compassion, and impulsivity, and (2) the findings of clients’ experiences, and (3) the meta-inferences which could were drawn from integrating both quantitative results and qualitative findings. Regarding quantitative results, one statistically significant finding was that an increase in the nonreacting component of mindfulness occurred from pretest to posttest. All other quantitative results, while not reaching statistical significance, did show a change in mean scores regarding increased mindfulness and self-compassion, and decreased impulsivity from pretest to posttest.

Findings from qualitative analyses indicated three types of client experiences emerged from the data: engaged, transitional, and disengaged. These experiences were comprised of five facets: sentiment, attitude, motivation, learning and relationships. Convergence was found between quantitative results and qualitative findings for mindfulness, self- compassion, and impulsivity. A more detailed discussion of results, findings, implications, limitations and future directions follows.

Descriptive Summary and Interpretation of Statistical Results

Nonreactivity to inner experience was the only statistically significant result for all the scales and subscales undergoing the repeated measures dependent t-test. The

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nonreacting component of FFMQ mindfulness had a posttest increase with medium effect size. The first null hypothesis was rejected, and it was concluded that the participants’ nonreacting scores significantly increased from before to after treatment. This result is consistent with previous MBRP studies demonstrating increased overall FFMQ mindfulness for substance use populations (Brewer et al., 2009; Bowen et al., 2009), but is unique in finding specifically the nonreactivity subscale alone as statistically significant.

Mean differences in FFMQ full scale and subscales of observing, describing, acting with awareness and nonjudging were found to be not statistically significant utilizing the dependent t-tests. Further examination of descriptive statistics found mean increases in mindfulness for the FFMQ and subscales with an overall 63% of participants showing gains in FFMQ mindfulness, 4% no change, and 33% decreasing. All subscale

FFMQ scores fell between published mean scores for community non-meditators and regular meditators (Baer et al., 2008).

The full scale FFMQ increased for participants, but was just above the statistically significant level (i.e., p = .07). Perhaps a slightly larger sample size may have enabled this result to reach statistical significance. Examining the subscale components, FFMQ was influenced in the following order: nonreactivity, observing, acting with awareness, describing and nonjudging. High nonreactivity has also been associated with high observing (Eisenlohr-Moul et al., 2012) and lower substance use. Acting with awareness was also found related to participation in MBRP (Bowen et al., 2009) and lower substance use. Noteworthy, the subscale of nonjudgement that has been associated with acceptance (Bowen et al., 2007, 2011a; Witkiewitz, et al., 2014) was lowest for this study

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sample of persons in court-ordered opioid treatment. This result is consistent with Levin et al. (2014) who found deficits in acting with awareness and nonjudgement in persons with history of SUD.

Mean differences in SCS-SF self-compassion scores were found to be not statistically significant utilizing the dependent t-test. Therefore, the second null hypothesis was not rejected. Further examination of the descriptive statistics found mean increase in self-compassion for the SCS-SF with an overall 46% of participants showing gains in SCS-SF self-compassion, 17% showing no change, and 38% decreasing.

Examining individual participant scores across groups (see Figures 4-7) found consistently that participants with highest mindfulness scores also had highest self- compassion scores. Lower mindfulness scores had varying self-compassion scores. In the present study, most participant scores were within one standard deviation of a published

M = 36.00 and SD = 7.33 (Raes et al., 2011).

It could be expected that there is some overlap between self-compassion and mindfulness as the definition of self-compassion includes mindfulness as one of the sub- components (Neff, 2003; Raes et al., 2011). It is not clear from quantitative scores alone which of the three components of self-compassion were most prevalent: self-kindness, common humanity, or mindfulness for change. While the mean change in self- compassion increased over time, to reach significance it seems both a larger sample size and a separate training for self-compassion may have been needed (Germer & Neff,

2003; Mantzios & Wilson, 2013).

The third null hypothesis that there was no statistically significant change in impulsivity was not rejected. A dependent samples t-test showed that changes in BIS-11

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impulsivity were not statistically significant. Further examination of the descriptive statistics found mean decrease in impulsivity for the BIS-11 with an overall 50% of participants showing decrease in BIS-11 impulsivity, 8% showing no change, and 42% increasing. Examining individual participant scores across groups (see Figures 4-7) found no consistent pattern of change in impulsivity related to level or direction of change in mindfulness or self-compassion. Participant scores for this study were consistent with published scores related to substance abuse (Stanford et al., 2009) with 50% of participants having “high and at risk” scores (≥ 72) for impulsivity.

The data indicated that participants with opioid addiction do have higher impulsivity and are at risk, but the lack of significant change in BIS-11 impulsivity may reveal a trait-like impulsivity similar to other persons with substance abuse (Staiger et al.,

2014; Stanford, et al., 2009). The change in FFMQ nonreactivity to inner experiences indicates a statistically significant change in state-like impulsivity by means of a learned coping skill (Beaton et al., 2014; Griffin et al., 2017). Another consideration is that more time may be needed for neurocognitive regeneration (Crews & Boettiger, 2009) or the brain to heal; longer timeframes may be needed to register personality trait changes.

Mean differences across counselor groups A, B, C and D showed that while two groups (A and B) had more differential change all four counselor groups had increases in mindfulness and similar posttest mean group scores. Groups A and B started with lower pretest mindfulness scores. Groups A and B also had greater increases in self-compassion with posttest scores for all counselor groups being similar. Highest increases in mindfulness had an associated higher increase in self-compassion. Impulsivity pretest scores were high for all groups and posttest scores had mixed results. Factors that may

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have influenced different scores between group could include counselor fidelity to protocol, amount of time spent in session teaching and practicing skills, amount of time practicing skills outside of sessions by both counselors and participants, or other factors.

This study did not include the counselor’s perception and experience of MBRP, a fidelity protocol, measurement of practice time or field observations that would have helped explain group differences.

Descriptive Summary and Interpretation of Qualitative Findings

Three types of experience and five facets.

A major finding of this study was the emergence of three types of participant experiences: engaged, transitional, and disengaged. These three types of experience express different levels and directions of participant sentiment, attitude, motivation, learning, and relationships. Engaged experience described positive sentiment toward the

MBRP aftercare program, they were open to learning, had more internal motivation for recovery, and valued recovery relationships. Participants with a disengaged experience described a negative sentiment toward treatment and MBRP aftercare, were compliant but not engaged in learning, had primarily external motivation for compliance with program, and were not connecting to recovery relationships. Participants with transitional experience, which represent most participants, described shifting in their sentiment, attitude, learning, motivation, and relationships. They described moving from an initial disengaged experience to an increasingly engaged experience of the MBRP aftercare program. In conducting qualitative analysis a final step is to compare the emergent themes to existing theories. Going back to the literature, two major theories that intersect

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with the three types of participant experiences are the transtheoretical model of change

(Prochaska et al., 1992) and self-determination theory (Ryan & Deci, 2019, 2020).

The transtheoretical model of change (Prochaska et al., 1992) posits five stages of change: precontemplation, contemplation, preparation, action, and maintenance.

Precontemplation is lack of awareness or resistance to change. Contemplation is when a person recognizes the need to change and begins to weigh the pros and cons of changing but has not committed to change. Preparation is a combination of commitment and early action towards making a change. There is a decision to change and may have some small behavioral changes (i.e. cutting back on use) but have not made the effective change yet.

Action is when person has changed their behavior, experiences and environment in a manner which produces visible effective change. Maintenance is a continuation of action to prevent relapse and consolidate gains.

Our participants paralleled this model of change moving from disengaged through transitional to engaged. Our model is different in that it focused on development of self- awareness (mindfulness), and helps participants practice non-reacting to situations (self- efficacy). It also notes the shifting of motivation from external to internal as a factor of change. Lastly our model acknowledges the social healing that occurs in recovery relationships and moves a person towards change. The transtheoretical model is primarily a cognitive and individualistic model describing temporal changes.

Another three-stage model of motivation for treatment considers participant awareness and motivation (internal motivation versus external pressure) for corrections populations (Rosen et al., 2004). The Texas Christian University (TCU) model considers three motivational stages (1) problem recognition, (2) desire for change, and (3) treatment

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readiness as factors of therapeutic engagement with a prison-based population.

Addressing these factors help move a person along the stages of change in the transtheoretical model and are thus targets for treatment.

Participants in the MBRP study similarly describe different levels of problem awareness as well as an increase in awareness through the practice of mindfulness skills.

There is also a noticeable shift in transitional type of participant experience that participants in the MBRP experience in attitude and motivation. While the TCU model shows motivation which leads to engagement, the MBRP aftercare program provides experiential engagement which increases awareness, commitment and skillfulness for participant recovery in a court-ordered population.

Self-determination theory (SDT: Ryan & Deci, 2019, 2020) is a general theory which proposes people are inherently prone toward psychological growth, integration, mastery and connection with others. SDT argues healthy human development is based on three psychological needs of autonomy, competence, and relatedness. SDT has been developed over 40 years and has implications for many fields including education, healthcare and psychotherapy. SDT promotes a non-defensive or open experiencing of what happens within and outside of oneself versus controlled motivation which is typical of many institutions (Deci, Ryan, Schultz, & Niemiec, 2015; Ryan & Rigby, 2015). SDT specifically identifies mindful awareness as a buffer against compartmentalization and defensiveness, which are cardinal features of controlled motivation (Ryan & Deci, 2017).

In two studies of SDT, Ryan and Brown (2003) associated mindfulness with autonomy at both state and trait levels of analysis and suggested that more mindful people act in more congruent, integrated, ways. Weinstein, Brown, and Ryan (2009)

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associated mindfulness with lower stress resulting from having less negative appraisal of situations, and more adaptive coping strategies. Mindfulness within SDT appears to have facilitated more integrated self-regulation.

Participants in this study showed similar experiences which could be described through a SDT lens. Engaged participants more frequently described having internal motivation and valuing relationships, which may be why they express more positive sentiment and learning in MBRP aftercare. Disengaged participants described having primarily external motivation and less connectedness to recovery relationships; they express more negative sentiment and less learning. MBRP aftercare’s primary focus is on developing mindful awareness of ones inner and outer experiences, which is similar to

SDT. Mindfulness in MBRP also appears to have facilitated greater self-regulation, specifically through nonreactivity to experience.

In a study that appears to parallel this study’s concepts of types of experience and facets of experience, Kennedy & Gregoire (2009) utilized the two prevailing theories for

SUD treatment, the transtheoretical model of change (TTM) and self-determination theory (SDT) as a basis for examining differences in participants addiction treatment.

They used TTM to model to describe a participant’s location or stage in the process of change, and used SDT to describe the variation in motivation, specifically intrinsic versus extrinsic motivation. Their research found participants with high levels of intrinsic motivation were more likely to be at an action or contemplation stage of the change process.

MBRP aftercare is a program of practice based on Buddhist mindfulness meditative practice. The practice is based on hundreds of years of experience of

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meditators. SDT and TTM are general theories that explain general human motivation and behavioral change. It may be that SDT and TTM could provide a theoretical basis for exploring why or how MBRP works in clinical applications. TTM may explain the stage of change someone is in, and SDT may explain why or how they are in a particular stage.

An SDT approach may help respond to McKay’s (2009) call to explain why some participants respond to addiction treatment and others do not.

Finally, Wild et al. (2016) showed SDT provided a helpful theory to explain the behavior of participants in court-ordered addiction treatment. Participants in court- ordered treatment have high external motivating factors at the start of treatment

(coercive) which is different than non-court-ordered addiction treatment seekers.

Similarly, most of the court-ordered participants in MBRP aftercare began with high external motivation. Transitional experience type participants described a change to a higher internal motivation as MBRP aftercare progressed.

Qualitative changes in mindfulness, self-compassion, and impulsivity.

Mindfulness. Qualitative findings of this study showed that most participants comments expressed greater mindfulness in situations, and that they learned to non-react

(non-reactivity) to situations and “stop and think”.

Studies to date on implementing MBRP with various populations and understanding the mechanisms have been promising, but also limited (Liu et al., 2017;

Witkiewitz & Black, 2014). The first large RCT (N=168)) of MBRP (Bowen et al., 2009) showed feasibility, reduced craving, and increased acting with awareness. Studies doing secondary analysis of this data also showed reduced depression and substance use days

(Witkiewitz & Bowen, 2010) and increased acceptance, awareness, and non-judgment in

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relation to reduced craving (Witkiewitz et al., 2013a). In a larger RCT (N=286) of MBRP compared to 12-step and relapse prevention programs (Bowen et al., 2014), MBRP was found to have superior reduced relapse rates and lower substance use days at 12-month follow-up. Two studies of MBRP with corrections populations found positive satisfaction, lower SUD severity and lower stress (Amaro et al., 2014); lower depressed mood and higher negative expectancy for use (Lee et al., 2011); more efficacious than active treatment, lower use days, and lower legal and medical issues (Witkiewitz &

Warner, 2014); lastly, a small mixed method study (Holt, 2016) found improvements related to anger management, empathy and mindfulness.

For this study, most participants had positive sentiment towards the MBRP aftercare program which could represent satisfaction with the program. Most participants had a transitional experience with MBRP showing an early negative attitude towards mindfulness training but later seeing the benefits. Of the five factors of mindfulness from the FFMQ, most participants expressed an ability to respond versus react (nonreacting factor) to circumstances in their lives. Many of the participants also expressed increased acting with awareness. Few participants reported in interviews evidence of observing, describing and non-judging inner experience factors of the FFMQ. These qualitative findings converge with the quantitative findings of this study. The findings of this study are like previous studies of MBRP showing increases in mindfulness, but in contrast did not address craving, substance use days, or psychological factors. This study is also the first study to specifically apply MBRP to persons with opioid addiction in court-ordered population and showed feasibility and increases in mindfulness for this population.

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Self-compassion. Qualitative findings of this study showed that several of the participants described becoming more compassionate towards themselves. It was also in the context of the group that they experienced growth in self-compassion and connection with others. These findings are consistent with at least two Neff’s (2003) components of self-compassion: kindness towards oneself and sharing common humanity. From the participants’ perspectives it appeared to develop out of a social process in the group, and a growing epiphany of self-worth as one progresses through recovery. There was no qualitative evidence in the interviews of a specific MBRP practice that was identified as the source of self-compassion. This finding aligns with Davis et al. (2017) relational contemplative approach to counseling which emphasizes that both the relationship and mindfulness-based intervention are integrated in therapy.

Current research on self-compassion and addiction is limited (MacBeth &

Gumley, 2012), yet promising (Germer & Neff, 2013; Paniagua et al., 2107). This study contributes to the literature in identifying increases in self-compassion through MBRP aftercare, but perhaps related to social processes. The literature suggests that more specific self-compassion practices versus general mindfulness practices may be necessary to achieve a significant effect of increased self-compassion (Neff & Germer, 2013).

Impulsivity. Previously discussed, the quantitative findings of this study indicated most participants had high BIS-11 trait impulsivity and this did not significantly change between pretest and posttest measurements. In contrast, the qualitative findings of this study indicated only a few participants described themselves as impulsive, and when describing change, it was more in terms of non-reactivity. This is consistent with the evolving literature on impulsivity. Impulsivity is recognized as a risk factor for substance

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use (Allen et al., 1998; Beaton et al., 2014). Conceptualizations of impulsivity are under debate (Beaton et al., 2014; Heinz et al., 2015) and include trait (Patton et al., 1995;

Staiger et al., 2014) versus state impulsivity (Beaton et al., 2014) and/or neurobiological processes (Tomko et al., 2016; Winstanley et al., 2010). From the qualitative findings of this study a few participants acknowledged having impulsive tendencies in a trait-like manner, but none described a this aspect of themselves as changed. But, most did acknowledge a greater capacity to self-regulate their impulsive urges which would supports the quantitative non-reacting results.

Qualitative recovery of mind, feelings, responsibility, and future.

The qualitative inquiry of participant’s experiences also showed unsolicited evidence of positive changes in recovery of mind, feelings, responsibility, and future.

Participants described their “mind coming back” and a process of regaining their feelings again. This process also occurs over time, and most participants started this MBRP aftercare program a minimum of 10 weeks or more after their first day of abstinence.

Post-acute withdrawal syndrome (PAWS) has been historically reported in treatment communities and popularized by Gorski’s model (1990). While a review of evidence for protracted withdrawal has reports of symptoms for alcohol and opioids, there has not been enough scientific evidence to include in the DSM (Satel et al., 1993).

In Gorski’s (1992) workbook PAWS includes impaired cognition, difficult feelings and emotions, sleep disturbance and difficulty with stress. Miller & Harris (2000) grouped

PAWS into depression/demoralization which includes loss of purpose. Currently, some studies acknowledge brain changes due to neurotoxicity from substance misuse

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(Bankston et al., 2009; Staiger et al., 2014) and long-term neurological recovery of the central nervous system (Crews & Boettiger, 2009).

The findings of this study provided evidence for protracted withdrawal symptoms of impaired cognition and affect which are improving with time. Also, participants indicated growing ability to handle responsibility and hope and purpose for the future which would be a sign of the remission of depression and demoralization of substance addiction.

Integration and Meta-Inferences of Quantitative and Qualitative Analysis

In this study the statistically significant finding of FFMQ nonreacting factor was supported by the qualitative findings of participants statements indicating a new ability to respond rather than react (nonreactivity) to experiences. MBRP aftercare for court- ordered participants with opioid addiction may provide a key skill or capacity for recovery that has not yet been shown in research.

While not statistically significant, results for full scale FFMQ, and the SCS-SF showed mean changes in a positive direction and were supported by the participants’ voiced experiences. For mindfulness, the qualitative findings support participants learning new mindfulness skills that help them self-regulate and access skills they may have learned in prior IOP treatment. For self-compassion it was found that the change may be related to group process versus explicit training in MBRP aftercare. MBRP aftercare for court-ordered participants with opioid addiction does improve both mindfulness and self-compassion but may benefit from self-compassion specific training and further attention to relationships as part of the recovery process.

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In this study while the BIS-11, which measures trait-type impulsivity, showed a mean change in a positive direction it was statistically insignificant and the weakest result. The findings from qualitative side only showed partial convergence of a few participants acknowledging having impulsive traits, but more participants’ statements supported nonreacting as a factor that reduces state-type impulsivity. The results and findings regarding impulsivity provided more support for MBRP aftercare as intervention to assist with state-type impulsivity versus trait-type impulsivity.

In this study, participants could be differentiated as having engaged, transitional, and disengaged experiences and when integrating the quantitative scores and qualitative findings convergence was found to be between engaged and transitional experiences having higher mindfulness coded references. Giving voice to participants’ experiences provided rich insight into the process of change, showing many participants moving through a transitional experience, and achieving positive results in mindfulness and recovery through MBRP aftercare program.

Implications for Counselor Practice in Court-Ordered Settings with

Participants Recovering from Opioid Addiction

This study was conducted with a court-ordered population and was subject to the

American Counseling Association’s (ACA) Code of Ethics (2014) for research (ACA,

2014: Section G), and for special consideration to mandated clients (A.2.e) even though this was archival data. Also, the Council for Accreditation of Counseling and Related

Educational Programs (CACREP) in its CACREP Standards 2016 calls upon counselor education and supervision programs to advance the counseling profession through

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research that informs counseling practice (2.F.8.a) and identification of evidence based counseling practices (2.F.8.b). This study, a mixed-method study of MBRP aftercare program on clients with opioid addiction in a court-ordered population is an example of fulfilling this mandate. This study also addresses social and cultural diversity (2.F.2.h) by using archival data from an historically disadvantaged population, persons with both addiction and in court-ordered program, as a strategy for identifying and eliminating barriers, prejudices, and processes of intentional and unintentional oppression and discrimination.

First and foremost, this study’s findings of participant positivity towards program and demonstrated gains in mindfulness recovery skills suggest that MBRP aftercare program is a beneficial and feasible aftercare program for court-ordered participants with opioid treatment program. Aftercare is one stage of overall treatment, and this study supports MBRP aftercare as an evidence-based program for use with this population.

Professional counselors are called upon to exercise leadership and advocacy in their communities and respond to current crises (6.B.5.f; CACREP, 2016). This study was a direct response to the opioid crisis occurring locally and nationally. This study obtained its archival data from a local substance use treatment program using typical treatment counselors who had little or no previous knowledge of MBRP and with a minimal level of training and supervision were still able to obtain positive results with participants. While not ideal according to the literature, results may be improved with longer training and counselor practice of MBRP. Most agencies do not have the luxury of large training budgets or expert staff. During the opioid crisis there has been a dire need for effective interventions for persons with opioid addiction. This practical

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implementation of MBRP suggests not only its feasibility, but utility and economy as an aftercare program.

This study with MBRP aftercare participants who were court-ordered for opioid addiction treatment had a statistically significant change in nonreactivity subscale which is an interesting result and finding. It suggests a target for treatment that improves a participant’s ability to cope with negative experiences, but also may help them access other skills they previously learned. Participants in this study repeatedly recalled their new ability to “stop and think” or to take time to appraise their situation and apply skill they learned. This is a remedy to negative emotional states and trait impulsivity which may limit recall of learned coping skills and possibly lead to relapse.

This study added to the currently limited research in self-compassion and addiction (MacBeth & Gumley, 2012) and may be one of the first studies specifically to consider self-compassion and opioid addiction treatment. In this study, MBRP aftercare was hypothesized to show some increase in self-compassion and the results and findings suggest that there is a need for more explicit training in self-compassion, and there should be greater attention to the relationship dynamics for fostering self-compassion in recovery.

Participants in this study expressed a process of change characterized by a simple model comprised of three types of experience and five facets. These findings could be used to assist with recognizing where a participant is at in the process of change during

MBRP to better adapt or tailor the program interventions. In assessing a participant’s progress, it should not only include a stage of change, but the type of motivation a person has. It is also helpful to recognize there may be many participants with a transitional type

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experience, showing initial resistance to meditative practice, but who will later experience the benefits. It is also not uncommon in mindfulness meditation training to experience some difficulties or hindrances in the beginning of training.

Implications for Counselor Education Programs

The American Counseling Association (ACA) Code of Ethics (ACA, 2014) calls upon counselor educators and supervisors to integrate study and practice (F.7.d), as well as to ethically promote new or innovative theories and practices (F.7.h). Counselor educators and supervisors are positioned to facilitate field-based research utilizing smaller sized research models with benefits for both counselor trainees and the participants. This study is an example of analyzing archival data from a program which trained counselors in the field a new practice, MBRP aftercare, and obtained results that both serve for program evaluation and add to the knowledge and practice in the field.

This study demonstrates the utility and economy of mixed-methods design and integration of quantitative results and qualitative findings to provide meaningful information to counseling practice. This approach may be used for smaller scale field studies in typical agency settings. With budgets and staffing levels decreasing at treatment agencies and institutions of higher education, new models need to be implemented that have direct clinical impact. The MBRP aftercare program was implemented at a local agency by one experienced trainer to four typical treatment counselors utilizing a small grant from the local alcohol, drug, and mental health board.

The archival data was then analyzed in this study as part of doctoral research for the benefit of the field.

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This study suggests a minimum level of practice by participants needed to achieve some measurable result. The results and findings of this study may have been more robust with the benefit of more time given to prior training and practice delivering MBRP aftercare. Further study is needed to determine what additional level of practice and skill may improve the outcomes.

Counselor educators are called upon to examine their teaching methods and pedagogy (6.B.3.b; CACREP, 2016). MBRP is an experiential approach to learning and recovery, which sets it apart from many didactic models of substance use treatment. This study shows participants learning from their experiences in an open and nonjudgmental manner. This has implications for counselor educators and supervisors to put a priority on developing their own experience with MBRP to embody practice and model inquiry into their own experience, rather than teaching from a manual or as in a typical classroom setting.

CACREP calls upon doctoral programs to extend the knowledge base of the counseling profession, prepare students to generate new knowledge for the profession and demonstrate leadership in their area of specialization (6.A.2; CACREP, 2016). This study gives an example of generating new knowledge in the specialization of addiction counseling and using an advanced mixed-methods research design. This study was both simple and complex, and a counselor trainee pursuing this type of study has numerous considerations. Obtaining archival data for a small sample was relatively simple. But, in order to complete this type of research it was necessary to have prior training completed in both quantitative and qualitative methods, and to get training or mentoring in mixed methods approaches (6.B.4; CACREP, 2016) . It was essential to learn to use qualitative

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research software, and in this case NVivo. All three approaches have specific differences and it would be beneficial and advisable to have practice through classwork and other research experiences prior to using this approach for a dissertation. In terms of dissertation planning it required a longer timeframe due to collecting, analyzing and writing up two different arms of data plus integration of both data sets. The potential outcomes are richer as this study exemplifies. Also, learning a mixed-method approach can prepare a counselor trainee to handle many types of program evaluations they may encounter in their professional experience.

This study also demonstrates the responsibilities of counseling supervisors to assess the needs of trainees, understand and implement new frameworks or models and administration of a new program (6.B.2; CACREP, 2016). Specifically, this study showed that the MBRP aftercare was feasible to implement and achievable for typical counselors to learn and use. This study suggests that counselor trainees should have a minimum of two days of workshop training, followed by cofacilitating one full eight- session program of MBRP with an experienced trainer. Ongoing group supervision sessions were held on a biweekly basis ongoing throughout the program. This would be equivalent to a minimum of 40 hours of training. The supervisor should also attend observation sessions to view and assure adherence to the protocol. The literature suggests optimal results would come from ongoing regular personal practice, more training than two days, and feedback on delivering a mindfulness-based intervention. It is highly recommended that the program trainer has extensive experience with MBRP to model the practice and to assist with overcoming obstacles that inevitably arise with learning meditation and implementing a new program.

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MBRP may have a beneficial effect for counselor trainees in that they learn an experiential approach to therapy which is different than many of the more didactic CBT approaches to substance use treatment in use today. MBRP like many other mindfulness- based interventions has potential to personally benefit the counselor trainee as a form of self-care and improving counselor presence to clients.

This study demonstrates to counselor trainees the value of incorporating participant input (qualitative data) into program implementation and review can help obtain rich results and novel findings. This study shows that giving voice to participants’ experiences both confirmed the quantitative numbers and gave the results fuller meaning and new directions. For example, the client experience typology was not known prior to the beginning of this research project, it emerged as clients’ voices were heard through the interviews. Giving voice to participants’ experiences is also a form of advocacy

(6.B.5.j & k; CACREP, 2016) on behalf of a vulnerable population whose experience is often stigmatized.

This study is an example to counselor trainees of research in the field to determine feasibility, effectiveness, and specific tailoring of treatments. Future careers of counselors may often require them to participate in implementing and doing program evaluation for publicly funded or grant funded counseling programs. Mixed method approaches lend themselves to both utility and economy for this task.

Implications for Future Research

The key significant result of this study was the gain in nonreactivity for participants in the MBRP aftercare program. It suggests that court-ordered participants in

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the opioid treatment program developed a new skill vital to their recovery. The qualitative findings suggest that this may have a role in diminishing state-type impulsivity. This study suggests further research is warranted focusing on skills to cope with trait-type impulsivity versus trying to change trait-type impulsivity.

Previous research in MBRP has focused on reduced craving, substance use days, and psychological distress utilizing primarily quantitative measures. This study was one of the few mixed methods approaches and demonstrates the richness mixing qualitative data can have to better understand quantitative results and suggest new avenues of research that would not have been discovered. This study showed a new typology for participant experience in MBRP. Several lines of research would include further exploring client experiences and how they relate to major theories such as the transtheoretical model and self-determination theory.

This study added to the sparse literature of application of MBRP to persons who are court-ordered to treatment and to persons with opioid specific addiction. Further research could continue to note differences and similarities of persons whose participation in MBRP is either voluntarily or compulsory.

This study was one of the first to consider MBRP aftercare and the outcome of self-compassion, the results and findings suggest further research is needed in providing self-compassion training as a specific or separate component of MBRP, and that study may be useful in understanding the role recovery relationships play in MBRP.

Some of the qualitative findings suggest that during MBRP aftercare some participants may have been experiencing symptoms of protracted withdrawal. Further research is needed to better understand the neurobiological consequences of opioid

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addiction, and the process of healing to help coordinate both biological and psychological treatments.

This study’s results were obtained by typical treatment counselors with a minimum program of training and ongoing supervision. While participants in this study showed positive benefits, further study is needed to optimize counselor training, practice, and experience and to correlate it to improved participant outcomes. Also, for this study it was recognized that participants had minimal mindfulness practice outside of the training sessions. Further research into improving the amount and quality of outside practice of participants in a court-ordered program are warranted.

For those who may try to replicate or further the research presented by this study several other considerations could be beneficial. Further study of the counselors’ experiences of delivering MBRP may have a unique contribution to the participants’ experiences and outcomes. Counselor interviews and field observations could explain some of the differences between outcomes between counseling groups and inform counselor training and development with MBRP. In this study, using archival data, it was not possible to directly connect participant interviews with results from their pretest and posttest questionnaires. A future study could make this connection which would then allow for a mixed-methods sequential explanatory model that would add significantly to the credibility of the findings. Finally, results would be further enhanced by providing some form of control group. The gold standard is randomized controlled trials, but in the absence of this at an agency, using a quasi-experimental design would be an improvement over having no comparison group.

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Limitations

Limitations of the present study which limit generalizability were that the study used archival data and the participants were limited to one court-ordered opioid treatment program in northeast Ohio. Counseling groups were segregated by adult women and men by the treatment center. The study also utilized four available treatment counselors who had no previous experience with MBRP and only one who had any familiarity with mindfulness practice prior to the study. Participants had received a prior CBT intensive outpatient program immediately prior to entering the MBRP aftercare program.

There were several limitations of the present study which also limits generalizability and requires caution when interpreting results and findings. This study had a small sample size of N = 24 for dependent t-tests which likely had insufficient statistical power for all but one of the measures. The study did not have a comparison group or randomized assignment to treatment groups. The sample was from a court- ordered setting and no measure to account for social desirability was done. Treatment counselors had none or little prior experience with mindfulness-based interventions and the MBRP training was limited to a 2-day workshop, biweekly team meetings, and one round of cofacilitated MBRP groups prior to groups from which data for this study was collected.

No measure of fidelity to protocol or measurement of participant and counselor outside practice were included in the study. Inclusion of the counselors’ perspectives and experiences and field observations of their work were not included which could have helped explain individual and group differences and dynamics. There were While the

BIS-11 measure for impulsivity has had many years of wide use, it may be measuring

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longstanding trait characteristics where what occurs in MBRP training is skill building to manage momentary impulsive states.

Additional threats to validity were the use of a single coder versus two or more coders, interviews were obtained by convenience and self-selection versus purposive sampling. It was apparent from the interviews that practice of mindfulness outside of

MBRP sessions was minimal or none by most of the participants. Also, archival data was gathered from a rolling group versus a closed group which may have introduced differences that were not accounted for in this study even though all participants completed a minimum of six of eight sessions of MBRP.

Conclusions

The purpose of this study was to use a mixed-methods research design to investigate the effects of MBRP aftercare program on participants who were in court- ordered opioid addiction treatment. This study added to the field of professional counseling through practiced-based research and showed statistically significant improvement in participant nonreactivity which may counter trait-type impulsivity. Also found were mean increases in mindfulness and self-compassion. This was the first study to specifically address MBRP with court-ordered participants in an opioid specific program, and it was one of the first studies to address self-compassion in MBRP aftercare. Through qualitative inquiry this study gave voice to participants varying experiences of MBRP aftercare which allowed a new typology of experience to emerge.

This study is an exemplar of CACREP (2016) ideals for leadership, scholarship and client advocacy through the innovative mixed-methods approach. Finally, this study showed the benefit of a mixed-methods approach to providing an economical and practical means for

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obtaining useful results from the field, it supported MBRP as an evidence-based practice, and added many new questions for further research on MBRP.

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APPENDICES

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APPENDIX A

IRB APPROVAL LETTER

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APPENDIX B

PERMISSION TO CONDUCT RESEARCH, OHI

235

APPENDIX C DEMOGRAPHIC QUESTIONNAIRE

MBRP Aftercare Study – Demographics Form

Counselor Name: EXAMPLE ENTRY

Client ID# A1Example

Gender M/F M

Race African American

Birthdate 2/4/1970

Diagnoses - list up to 5 codes: Dx1 F11.20 Opiod Dependence

Dx2

Dx3

Dx4

Dx5

Employment working roofer

Education 12

Prior Treatment 2 prior IOP

MAT Status Vivitrol

ORAS (L, M, H, N/A) M

Reason for Discharge Successful completion

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APPENDIX D

FIVE FACET MINDFULNESS QUESTIONNAIRE

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APPENDIX E

SELF-COMPASSION SCALE – SHORT FORM

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APPENDIX F

BARRATT IMPULSIVITY SCALE – 11

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APPENDIX G

SEMI-STRUCTURED INTERVIEW GUIDE

MBRP Study – Interview Guide

Client Interviews

Introduction script

Hello, this is (Andy Davis) for the Oriana House Inc. Aftercare Study. We are doing research and evaluation of this program to determine benefits to participants. As part of this research we want to gather information on your experience of your Aftercare program. You have been asked to participate in this interview because of your recent participation in the Oriana House Inc. Aftercare program.

This interview will take approximately 30 minutes. Please answer the questions to the best of your ability. Although we audiotape the interview, your identity will never be revealed, or connected in any way with your comments. While we may report quotes collected during the interview, at no time will we connect those comments with any individual. You are free to stop participating or withdraw at any time.

May I turn the audiotape on now?

1. Describe your overall experience in the Aftercare program. **

2. What did you learn, if anything, in the Aftercare program? **

▪ Did you use skills you learned in the Aftercare program? If so how? ▪ Describe that experience.

3. Has the way you think changed from when you started the Aftercare program? **

4. Has the way you feel changed from when you started the Aftercare program? **

5. Has the way you behave or act changed from when you started the Aftercare program? **

6. What do you believe led to these changes, if anything? **

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7. Do you plan to continue using aspects from the Aftercare program? Why or why not?

8. How do you view yourself now regarding your recovery, compared to before beginning the Aftercare program?

▪ Follow-up questions: i. Was anything helpful? In what way(s)? ii. Was anything not helpful? Why was this not helpful? iii. Was there anything you felt was missing that might have been more helpful?

9. What is most important to you for continuing in recovery? **

10. What challenges, if any, have you faced in recovery going from IOP to the Aftercare program?

11. Do you want to share anything else about your experience in the Aftercare program or your recovery process? **

** Dissertation research qualitative data

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APPENDIX H

INFORMED CONSENT FORM

Mindfulness-Based Relapse Prevention (MBRP) Aftercare Program Research & Evaluation of Innovative Program

You are invited to participate in an important research project being conducted by Andy Davis, a licensed independent Counselor, an OUTSIDE Volunteer, who is working with Oriana House’s Clinical Manager, Sally Longstreth-Fluck, a licensed independent Social Worker.

The purpose of this study is to evaluate the effectiveness and how people like a mindfulness- based aftercare program for clients at Oriana House, and its use by treatment counselors.

Mindfulness-Based Relapse Prevention (MBRP) is a new aftercare program that teaches mindfulness (meditation) skills to support addiction recovery. Mindfulness-based treatment already has some evidence for positive treatment outcomes, and is currently used in locations outside of Ohio. MBRP is being introduced in Akron, OH for the first time and we want to see if it works well as Oriana House clients and their treatment counselors.

Participants are asked to complete several questionnaires at the beginning of their aftercare program and at 8 weeks following the start of aftercare. A few participants will be invited to participate in an interview to share their experience of the MBRP aftercare program.

There are no known risks to participating in this research (completing questionnaires or participating in interviews). Your treatment counselor is available for any questions or needs that may arise during your participation in this project.

You receive the benefit of participating in a state-of-the-art treatment not found anywhere else in Ohio. Your participation will help us better understand if MBRP is useful to clients and treatment counselors at Oriana House and Northeast Ohio.

Participation in the questionnaires and interview is voluntary. If you do not want to participate or choose to withdraw from doing the questionnaires at any time, there is no penalty or loss of benefits, and this will in no way influence your case.

You will still be required to fully participate in the aftercare program is because it is part of your successful completion of your Oriana House Treatment program.

All information collected is kept confidential, and no information will identify your participation in this study

If you have any questions about this study, you may call Andy Davis, LPCC-S at his cell phone (330)-715-1368 or Sally Longstreth-Fluck at her work number (330) 996-2222.

I have read the information provided above, and all of my questions have been answered. I voluntarily agree to participate in this study. I will receive a copy of this consent form for my information.

______

Participant Signature Date

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APPENDIX I

INDIVIDUAL PARTICIPANT SCORES

Difference in Scores for FFMQ, SCS-SF, and BIS-11 by Participant

Δ SCS- SCS- ΔSCS- BIS11- BIS11- Δ CASE FFMQ1 FFMQ2 FFMQ SF-1 SF-2 SF 1 2 BIS11

A01 125 140 15 46 46 0 73 69 −4 A02 133 116 −17 26 26 0 98 80 −18 A03 90 119 29 19 36 17 81 70 −11 A04 114 114 0 37 35 −2 76 78 2 A05 117 143 26 36 44 8 84 74 −10 A06 119 126 7 28 30 2 84 82 −2 A07 92 95 3 24 29 5 99 92 −7 A08 134 148 14 45 43 −2 83 66 −17 A09 131 125 −6 31 28 −3 73 63 −10 B10 125 129 4 41 46 5 65 82 17 B11 126 135 9 39 43 4 61 56 −5 B12 124 146 22 31 48 17 64 64 0 B13 138 145 7 38 38 0 73 75 2 C14 163 170 7 50 42 −8 47 54 7 C15 144 158 14 52 52 0 52 60 8 C16 135 116 −19 39 36 −3 70 74 4 C17 126 150 24 42 52 10 62 63 1 C18 115 104 −11 44 40 −4 83 85 2 D19 118 112 −6 22 21 −1 99 92 −7 D20 161 155 −6 53 54 1 41 44 3 D21 149 126 −23 47 43 −4 65 69 4 D22 137 177 40 42 57 15 60 41 −19 D23 153 149 −4 36 38 2 84 81 −3 D24 112 138 26 39 32 −7 75 75 0 MEAN 128 135 6.46 38 40 2.17 73 70 −2.63

Note. The participants are listed by case number with the letter designation A, B, C or D indicating which of the four counselor groups they belonged. 244

APPENDIX J FALSE REFUGES EXERCISE

MBRP Supplement: New Exercises and Additions

“False refuge” exercise:

(Can be in Session 3 if not showing the video)

1) “Reflect on what it was that you were seeking (and that you temporarily got) from substance use or other addictive/reactive behavior. Think about when you used to engage in this behavior, or when you experienced cravings:

What were you looking for?

What need did you hope that substance or behavior would fill?

What is it that you really needed in those moments?

(List these up on the board in a column on the left. Themes such as freedom, relief, social connection, love, etc., typically emerge).

2) “What did you actually get, though?”

(List these up on the board in a column on the right. Themes such as self-doubt, shame, loss of trust, jail, loss of relationships, etc.)

3) “What do you think as you look at this?” (elicit from group)

“What I am struck by here is how wholesome these needs and desires on the left column are. Of COURSE we want these things. Humans want those things. We are just trying to take care of ourselves, to be happy. There’s nothing wrong with that. So what’s the problem?” (elicit from group…)

The intention of this practice is to de-pathologize craving: We are just trying to be happy. The problem is not US; the problem is that what we are turning to (i.e., substances) aren’t reliable. They don’t really fill our needs, not in the long run. They are a False Refuge. We as people aren’t always great at finding happiness, because we often look in the wrong places.

[Exercise provided by Joel Grow, PhD]

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APPENDIX K CODE BOOK

Nodes

Name Description

Accountability [In Vivo] Client expresses need or value of accountability to others for one's actions, or progress in recovery. Use when client specifically mentions word or similar word to "accountability". Do not use when client is using words "Checkin" which is a part of the MBRP session for sharing lapses (risky thought, emotion, behavior), or relapses.

Calm-Relax [In Vivo] When words "calm" or "relax" or "peace" or their stems occur in the text. Refers to a participant's experience of calm or relaxation mentally, emotionally and/or physically.

Change as Client [Structural] Code based on client interview questions regarding change in thoughts, feelings, body & why. Describes client's self-report of how they have changed as a result of AC. May include other references to client change in interviews. This code is large and requires subcoding.

Connecting It - [Process] Relating, listening, communicating with others versus Relationships isolation or destructive relationships.

Feeling It - Emotions [Process] Feelings coming back; accepting and working with feelings versus numb or avoid feelings; or in pain.

Finding It - Purpose [Process] Finding purpose and meaning in life versus feeling lost, confused, without purpose.

Getting It - Willingness [Process] Usually overcoming initial resistance, and being open minded, willing to change, and try new behaviors.

Handling It - [Process] Taking responsibility; owning; doing it; managing one's affairs Responsibility (better than before).

Healing It - Physical [Process] Time off drugs and alcohol. Body is healing and mind is clearing.

Hoping For It - Future [Process] Change from pessimistic outlook to optimistic outlook. Increase in positivity and hope for the future.

Knowing It - Recovery [Process] Gaining new knowledge that one did not know before. Wisdom

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Name Description

Using It - Recovery [Process] Applying the knowledge and skills learned in treatment. Skills

Clear Mind [In Vivo] Codes for words "clear" and "mind" used together, stems and "clarity". Self-report description from participant that their "mind has cleared" or they have "clear mind" or some form of mental clarity that was not present before.

Client challenges or [Provisional] Client reported challenges or obstacles to Treatment, obstacles specifically to AC engagement. It may overlap with challenges to their recovery in general. May also include counselor descriptions of client challenges.

Change Format [Descriptive] Client challenges related to change in format from IOP to MBRP AC.

Compulsory [Value] When a program or aspects of program are not optional.

Counselor struggle [Descriptive] Any data indicating the counselor struggling with program; related to client challenges.

Meditation Practice [Descriptive] Client describes difficulties with doing meditation Difficult practice.

Negative Affect [Emotion] Any negative affective state that interferes with program/practice or client's recovery. i.e. depression, anxiety, boredom, agitation

Negative Attitude [Value-Attitude] Client having a negative attitude towards MBRP AC or treatment they are in. Negative attitude interferes with engagement in program or exercises.

Not getting it [Process] Not understanding what is being done, or rationale. Opposite of "Getting It" code.

Outside challenges [Descriptive] Challenges or obstacles to Clients that come from outside of MBRP AC program.

Post-acute withdrawal [Descriptive] Coding for when drug post-acute withdrawal interferes interference with engaging in program.

Social Pressure [Value] Concern regarding negative group peer pressure influencing engagement in program.

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Name Description

Client characteristics for [Provisional] Includes Counselor descriptions of client differences that aftercare MBRP help them engage in AC; in reference to counselor interview question. Also includes Client description of what helps them engage in AC.

All should do it [Value] Expressed belief that all benefit from exposure to meditation practice.

Experience with [Descriptive] Data indicating a client has had previous experience with Meditation meditation prior to MBRP.

Client Practice [Provisional] Meant to capture how a Client practices MBRP skills; extended to more broadly describe how they practice any skills they learned during AC period. This may include skills transferred from IOP or elsewhere that occurred during AC period which client indicates they practice. Also related to one of client interview questions.

No Practice [Descriptive] Data indicating no outside practice of MBRP/Meditation is being done.

Yes Practice [Descriptive] Data indicating outside practice of MBRP/Meditation is occurring.

Client Program Experience [Structural] Captures client's response to interview question. Also, in the Client's words summarizing statements of their own experience of the MBRP AC program. I May also have some specific highlights of what was important to them. Also, may capture general satisfaction/dissatisfaction evaluation or sentiment with program experience.

Just relaxing (Feel [In Vivo] Client describes AC experience as relaxing. good)

Just talk-Not Learn [In Vivo] Client expresses talking as a main feature of AC. May specifically use the words "just talk"

Lapse reviews [In Vivo] Noted as an important part of aftercare.

Learned something [Value] Client notes they learned something new in Aftercare; versus did not learn anything new.

Maintaining [Process] Aftercare is a process of maintaining what was learned; downgrade in intensity from IOP, refresher, anticipating the end of Treatment.

Negative Sentiment [Value] Expressed negative sentiment towards MBRP aftercare.

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Name Description

Positive Sentiment [Value] Expressed positive sentiment, emotion or value towards MBRP aftercare experience.

Client Self View [Structural] Client's response to interview question, Client's report of their view of themselves at the point of time of their interview & after completing AC. May include references to prior view before Tx.

Before [Descriptive] Data expressing one's view of self before getting into Treatment/AC.

Better [In Vivo] Use of the word better in describing self view now versus before.

Common humanity [Descriptive] Sense of not being alone. Sharing similar experiences. Part of Neff's definition of Self-Compassion.

No Change [Descriptive] A view expressed that one is the same now (in aftercare) as one was years ago. Drugs may have changed for a time, but still the same person.

Client skills learned [Descriptive] Client's self-report description of what skills they learned in AC. May also include what they did not learn if stated by client. Based on client interview question.

IOP Skills [Descriptive] Skills learned in IOP, not in MBRP AC.

MBRP Skills [Descriptive] Skills learned in MBRP AC, not in IOP.

No Skills [Descriptive] Client expresses learning no skills.

Exemplar Codes for Quotes

External Motivation for [Value-Attitude] Data that shows a client's motivation for recovery Recovery coming from outside sources or agents - i.e. correctional system or family. Reasons that are not internal motivation.

Important for Client [Value-Belief] Client and Counselor responses to question regarding Recovery what is important for Client Recovery. May include other data from interviews addressing key factors that are important for Client Recovery.

Desire [Descriptive] Attitudes important for recovery.

Fear of Relapse [Descriptive] Fear of relapsing or going back to use as a motivator to stay sober.

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Name Description

Knowledge [Descriptive] Knowledge or wisdom as a factor important for recovery.

Mindful Awareness [Descriptive] Mindfulness or awareness noted as a factor important to Recovery

Practice [Descriptive] Practicing and using skills and knowledge from treatment.

Relationships for [Descriptive] Relationships as an important factor for recovery Recovery

Time [Descriptive] Time as a factor important to recovery. Assuming clean time or time off drugs.

Impulsivity [Provisional/Hypothesis] Data from interviews related to construct of impulsivity in BIS-11 - (attention, motor, non-planning); May also overlap with non-reacting (NONR) and "Stop & Think" (separate code).

Internal Motivation for [Value-Attitude] Data indicating internal motivation for recovery such recovery as values, self-worth, self-reflection. May indicate willingness and openness versus external compulsion to engage in treatment/recovery.

Empowered [Value] An attitude or feeling of worth and self-efficacy for change.

Goals for recovery [Value] Expressed goals to be achieved in recovery.

I don't want to be [In Vivo] Use of these terms or similar expression of avoiding a negative that... future.

Positive gains in [Value] New things valued in Recovery that become a deterrent for Recovery relapse/motivation for continued growth in recovery.

Self-Compassion as [Value] An attitude of self-compassion - care for oneself as an internal Motivator motivation for recovery.

Understanding [Value-Belief] Understanding addiction as a chronic disease process as Addiction as Chronic an internal motivator. Disease

Willingness [Value-Attitude] Expresses desire to be sober, willing to try, open, surrendered vs resisting. Versus willpower, desire to still be able to use. It is a fundamental conversion of heart to commitment to recovery.

Life - Save; Got Back [Invivo] The word "life" in the context of saved life or got life back, or similar terms related to result of MBRP program and recovery.

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Name Description

Mindfulness [Provisional/Hypothesis] . Definition for this study includes attending to moment awareness of experience in a non-judgmental, non-reactive manner. FFMQ subscales are: Observing, Describing, Acting with Awareness, Non-Judging Inner Experience, and Non-Reacting Inner Experience. Any data related to construct of FFMQ mindfulness, using specific words mindfulness, meditation practice in MBRP aftercare

Acceptance [Provisional/Hypothesis] Expressed non-judgment of experience which may be external (outside circumstances and persons) or internal (attitude towards oneself and/or actions). May include words but not limited to: acceptance, (non)judgment and open-mind(ed), (Ran text search for these terms for additional coding.) May overlap with Mindfulness and Compassion/Self-Compassion as these constructs also have a component of Acceptance.

Acting with Awareness [Hypothesis] attending to one’s activities of the moment and can be contrasted with behaving mechanically while attention is focused elsewhere (often called automatic pilot).

Automatic Pilot [in Vivo] Code used to note instances of words "automatic pilot" or "auto-pilot" in text. A specific term used in MBRP to denote the opposite of mindfulness.

Describing [Hypothesis] Refers to labelling internal experiences with words.

NonJudging [Hypothesis] To taking a nonevaluative stance toward thoughts and feelings

NonReacting [Hypothesis] Is the tendency to allow thoughts and feelings to come and go, without getting caught up in or carried away by them.

Observing [Hypothesis] Noticing or attending to internal and external experiences, such as sensations, cognitions, emotions,sights,sounds,and smells

Practice of Mindfulness [Descriptive] Any reference to the practice of mindfulness meditation - formal or informal

Multiple Paths [Value-Belief] Data indicating the need for multiple pathways for recovery. It may include suggestions for alternatives for AC or indications of different client preferences for treatment. Based on researcher's familiarity with recovery literature advocating for multiple paths to recovery from SUD.

Overdose [Descriptive] Added during first reading to capture any discussion of "Overdoses". Many clients have experienced overdose themselves or

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Name Description

others. During time of study (Summer-Fall 2016) there was a peak in OD deaths in Summit County.

Purpose-Service [Value] Clients indicating meaning and purpose as part of their recovery. Includes new attitudes towards service to others.

Relationship connection [Provisional] Data that shows the place of Relationship connections in recovery. More as a factor supporting recovery. Different from Social Interactions code which is focused on immediate social interactions in MBRP.

Relationships Factor [Descriptive] Demonstrates connection in relationships that supports recovery. Drawn from review of other "Relationship" codes.

Self-Compassion [Provisional/Hypothesis] Any participant reference to having compassion towards self or others. Includes Neff's definition of self- compassion - kindliness to one's self; common humanity; mindfulness. Is not mindfulness by itself.

Social Interaction [Provisional] Meant to describe social interactions specifically during aftercare programming. Includes difficulties, benefits, need for... Different than "Relationship connection" which is on support for recovery outside of MBRP AC programming.

Stop&Think [In Vivo] The term "Stop and Think" kept coming up with different clients, so this code is to track its usage. It can be the specific words or something very close.

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