MBRP trial for CSBD
Mindfulness-based relapse prevention trial for compulsive sexual behaviour disorder
Paweł Holasa*,
Małgorzata Drapsb,
Ewelina Kowalewskac,
Karol Lewczuk d,&
Mateusz Golab,e,
aFaculty of Psychology, University of Warsaw, Warsaw, Poland
bInstitute of Psychology, Polish Academy of Sciences, Warsaw, Poland
c Department of Psychiatry, Centre of Postgraduate Medical Education, Warsaw, Poland
dInstitute of Psychology, Cardinal Stefan Wyszynski University, Warsaw, Poland;
eSwartz Centre for Computational Neuroscience, University of California San Diego
Submission date: 23.02.2020
Corresponding author:
Pawel Holas, Faculty of Psychology, University of Warsaw, ul. Stawki 5/7, 00-183 Warsaw, Poland;
Phone (48) 501254501; e-mail: [email protected]
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Funding sources: PH was supported by Internal Grant (BST, no 181400-32) of Psychology
Faculty University of Warsaw; MD, Mindfulness training was paid by Internal Grant of
Institute of Psychology Polish Academy of Sciences (granted to MG); EK and MG were supported by Polish National Science Centre, OPUS grant number 2014/15/B/HS6/03792 (to
MG); and MD was supported by Polish National Science Centre PRELUDIUM grant number
2016/23/N/HS6/02906 (to MD).
Authors’ contribution: Study concept and design: MG, PH; data collection: MD, EK, analysis and interpretation of data: PH, MG and KL; statistical analysis: KL; study supervision: PH and MG; writing manuscript: PH, MG.
Conflict of interest: The authors declare no conflicts of interest.
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Abstract
Background and aims: Compulsive sexual behaviour disorder (CSBD) is a medical condition that can impair social and occupational functioning and lead to severe distress. To date, treatment effectiveness studies of CSBD are under-developed; typically, treatment for CSBD is based on guidelines for substance or other behavioural addictions. Mindfulness-based relapse prevention (MBRP) is an evidence-based treatment for substance addiction aimed at, among other things, reducing craving and negative affect—i.e. processes that are implicated in the maintenance of problematic sexual behaviours. However, to our knowledge no prior research has been published evaluating mindfulness-based intervention in the treatment of
CSBD, except two clinical case reports. Therefore, the aim of the current preliminary research was to examine whether MBRP can lead to clinical improvement in CSBD. Methods:
Participants were 13 adult males with a diagnosis of CSBD. Before and after the eight-week
MBRP intervention, participants completed a booklet of questionnaires including measurements of porn viewing, masturbation and emotional distress. Results: As expected, we found that after MBRP participants spent significantly less time engaging in problematic pornography use and exhibited a decrease in anxiety, depression and obsessive-compulsive symptoms. Discussion and Conclusions: The findings indicate that MBRP could be beneficial for CSBD individuals. Further clinical effectiveness studies with bigger sample sizes, delayed post-training measurements and randomised control trial design are warranted. In conclusion,
MBRP leads to a decrease in time spent watching porn and a decrease in emotional distress in
CSBD patients.
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Keywords: Mindfulness-Based Relapse Prevention, MBRP, mindfulness, CSBD, porn addiction
INTRODUCTION
Compulsive Sexual Behaviours Disorder (CSBD), especially the problematic use of pornography, is a relatively new and still poorly understood clinical phenomenon and societal challenge (Gola & Potenza, 2018). People suffering from CSBD usually seek treatment because of a sense of loss of control over the amount of time they spend watching pornography and the frequency of masturbation; some people also report problems with a loss of control over paying for sexual services (Carnes, 2001; Kor, Fogel, Reid, & Potenza, 2013;
Reid et al., 2012; Gola et al., 2017; Wordecha et al., 2018). Based on website traffic data, it is estimated that 47% of men and 26% of women with Internet access use pornography at least on monthly basis (Lewczuk, Wójcik, & Gola, under review). For most people pornography viewing is a form of entertainment; for some, however, problematic pornography use is accompanied by excessive masturbation and results in negative consequences in other areas of life, which is a reason to seek treatment and to diagnose CSBD (Gola, Lewczuk, & Skorko,
2016; Kraus, Martino, & Potenza, 2016; Lewczuk, Szmyd, Skorko, & Gola, 2017).
Recent, representative, self-report studies on US (n = 2,075; Grubbs, Kraus, & Perry,
2019) and Polish (n = 1036; Lewczuk et al., 2019;) samples showed that 9 to 11% of adult men and around 3% of adult women at least to some degree agreed with the statement ‘I am addicted to pornography’.
Diagnostic criteria for CSBD were recently proposed by the World Health
Organisation in the upcoming ICD-11 classification (WHO, 2019; Kraus et al., 2018). In line with this conceptualisation, CSBD is characterised by a behavioural pattern in which a person
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(1) dedicates excessive time to sexual behaviour to the point of neglecting other areas of functioning; (2) experiences reduced control, exhibited in multiple unsuccessful attempts to control sexual behaviour; (3) engages in sexual activities despite adverse consequences; (4) experiences distress or impairment across multiple areas of functioning; and (5) continually engages in sexual behaviour despite deriving little or no pleasure or satisfaction from it
(WHO, 2019; Kraus et al., 2018).
Clinical observations suggest that CSBD is an aggregate of symptoms of heterogeneous etiology (Raymond et al., 2003; Gola et al., 2015; Gola & Potenza, 2016).
However, due to the fact that CSBD is a fairly new phenomenon, not only is there a paucity of knowledge about the mechanisms underlying the disorder, there is also a lack of a recognised and empirically verified models of its treatment (Efrati & Gola, 2018). One review of the literature (Efrati & Gola, 2018) found no controlled studies for the treatment of CSBD or problematic sexual behaviours, except for one published in 1985 (McConaghy, Armstrong, &
Blaszczynski, 1985). Nevertheless, there were published a few attempts at clinical treatment, including: acceptance and commitment therapy (ACT; Twohig & Crosby, 2010); motivational interviewing (MI; Del Giudice & Kutinsky, 2007), cognitive behaviour therapy (CBT; Young,
2007) and emotion-focused therapy (Reid & Woolley, 2006). None of these studies, however, used experimental designs, and none was based on the hypothesised dominant neuropsychological mechanisms underlying CSBD. In respect to the later, there is hope that mindfulness training might be suitable for CSBD individuals as it targets craving and negative affect, potential core mechanisms of CSBD (Blycker & Potenza, 2018).
Mindfulness-Based Relapse Prevention
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A fairly recently established treatment for addiction, mindfulness-based relapse prevention (MBRP; Bowen, Chawla, & Marlatt, 2011; Witkiewitz, Marlatt, & Walker, 2005), was designed to reduce the experience of craving and negative affect and the role of both in the relapse process. MBRP combines the techniques of cognitive behavioural therapy focused on increasing relapse prevention skills (e.g. identifying high-risk situations, coping skills training; Marlatt & Gordon, 1985), mindfulness training in the tradition of mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) and mindfulness-based cognitive therapy
(MBCT; Segal, Williams, & Teasdale, 2002).
The main reasons to cultivate mindfulness in addiction are to develop awareness of external and internal triggers of problematic, addictive behaviour and to improve the ability to tolerate challenging emotional, cognitive and physical experiences (Bowen et al., 2009). More broadly, mindfulness training is a type of systematic practice for enhancing individuals’ metacognitive abilities, including that of decentring from challenging mental events
(Jankowski & Holas, 2014). Indeed, studies have shown that mindfulness practices taught in
MBRP may lead to greater attentional (Chambers, Lo, & Allen, 2008) and inhibitory (Hoppes,
2006) control by teaching patients to observe challenging or uncomfortable emotional or craving states without habitually reacting to them. MBRP has been shown to be effective in the treatment of a variety of substance addictions (Witkiewitz, Lustyk, & Bowen, 2013). In recent years, some initial empirical evidence has emerged demonstrating that mindfulness awareness training based on an MBRP programme led to a number of improvements in the lives of problem gamblers (e.g. Chen, Jindani, Perry, & Turner, 2014).
The neuroimaging literature has revealed several plausible mechanisms by which
MBRP may lead to a change in the neural responses to craving and negative affect that
6 MBRP trial for CSBD
underpin addiction. These mechanisms include an increase in functional connectivity between top-down prefrontal networks serving metacognitive attentional control and bottom-up limbic-striatal brain circuitry involved in reward processing and motivated behaviour
(Garland, Froeliger, & Howard, 2014, for a review see Witkiewitz et al., 2013). However, the effectiveness of MBRP in CSBD and neural substrates of change have yet to be established, which led us to conduct the pilot study presented in this paper. Investigating the effectiveness of novel treatment modalities for CSBD seems particularly important, since concerns regarding uncontrolled sexual behaviours are increasing due to the growth in Internet pornography consumption (e.g. Kor et al., 2013), and since there is no validated treatment for this challenging societal problem.
The Present Study
To our knowledge, although it has been proposed that mindfulness-based interventions
(MBIs) are potentially effective in treating CSBD (Blycker & Potenza, 2018; Efrati & Gola,
2018), only one clinical case report describing the effects of meditation awareness training
(MAT) on the symptoms and well-being of an individual suffering from sex addiction has been published (van Gordon, Shonin, & Griffiths, 2016). Following the application of MAT, these authors found clinically significant improvements in CSBD, as well as reductions in depression and psychological distress, in this individual. In addition, the results of several studies exploring the association between mindfulness disposition and CSBD symptoms suggest that increasing mindfulness could be beneficial for CSBD (e.g. Brem, Shorey,
Anderson, & Stuart, 2017; Reid, Bramen, Anderson, & Cohen, 2014; Shorey, Elmquist,
Gawrysiak, Anderson, & Stuart, 2016).
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Therefore, in the current pilot study we pursued this theme by investigating the effectiveness of mindfulness-based relapse prevention in patients seeking help for CSBD.
Based on evidence from other addictions and the modest literature on mindfulness and CSBD described above, we expected to find a decrease in CSBD symptoms, with decreasing time spent viewing porn in particular and a decrease in emotional distress following MBRP.
METHODS
Participants
Participants (N=13), Caucasian, white men aged between 23 and 45 years (Mage =
32.69; SDage = 5.74), were recruited from men seeking treatment for compulsive sexual behaviour through an advertisement posted on the Internet.
Measures
Before and after training, participants completed the following measures:
Brief Pornography Screener (BPS; Kraus et al., 2017).This is a short (five-item) self- report scale developed to detect problematic use of pornography (PPU) among clinical and non-clinical samples. Specifically, it assesses problematic pornography use in the previous six months. Individuals provide answers on a scale from 0 to 2; thus, the minimum possible score is 0, the maximum possible score, 10.
Hospital Anxiety and Depression Scale (HADS: Zigmond & Snaith, 1983). The HADS is a 14-item questionnaire measuring symptoms of depression and anxiety. Seven items measure depression and seven measure anxiety. Participants are instructed to read each statement and to choose the response that best describes how they felt during the past week.
Each item is scored using a 0–3 scale, with higher scores indicating stronger symptoms.
8 MBRP trial for CSBD
State Anxiety Inventory (STAI–S: Spielberger, 1989). The STAI–S is a 20-item measure of state anxiety. Participants answer using a four-point scale with the endpoints 0
(not at all) and 3 (very much so). Higher scores indicate higher state anxiety.
Obsessive-compulsive inventory–revised (OCI–R; Foa et al., 2002). The OCI–R is an
18-item self-report measure that assesses the degree of distress caused by OCD symptoms.
Items are rated on a 0 to 4 scale reflecting frequency of the symptom and intensity of the associated distress.
In addition, we assessed how much time subjects spent on sexual activity, pornography consumption and masturbation during the week before and after MBRP.
Procedure
Potential participants contacted research staff by telephone, provided verbal consent for screening and completed a telephone eligibility screening. We were looking for individuals fulfilling 4 out of 5 hypersexual disorder criteria proposed by Kafka (Kafka, 2010) as the recruitment was conducted before CSBD criteria publication. After the initial interview, patients were screened using the SCID-I (Validity, 2004) for mood disorders, anxiety disorders, OCD, psychotic disorders, substance abuse/dependence. Only those men who met the criteria for hypersexual disorder and none of the other above-mentioned disorders were invited to participate in the study. The exclusion criteria also included any type of psychiatric medication.
Following informed consent procedures, eligible participants completed a web-based baseline assessment. MBRP was subsequently delivered by two therapists in a group setting, with participants meeting weekly for eight two-hour sessions. The sessions included guided meditation, experiential exercises, inquiry, psychoeducation and discussion. Participants were
9 MBRP trial for CSBD
given CDs for daily meditation practice and exercises to do between sessions. Relapse prevention practices (Daley & Marlatt, 1992) adjusted for compulsive sexual behaviour were integrated into the mindfulness-based skills. The MBRP therapists held specialisations in psychiatry or master's degrees in psychology, and all had a long background in mindfulness- based and cognitive–behavioural interventions.
Ethics
The study procedures were carried out in accordance with the Declaration of Helsinki.
The Institutional Review Board of [deleted for blind review] approved the study. All subjects were fully informed about the study, all provided informed consent and all were granted the right to refuse to participate.
RESULTS
Basic descriptive statistics along with Wilcoxon signed-rank test results for the outcome measures in Measurement 1 (Baseline) and Measurement 2 (post MBRP -raining) are presented in Table 1. Table 1 also contains the r effect sizes for corresponding rank comparisons (Cohen, 1988). As not all participants were available to complete the whole set of questionnaires, the sample sizes for each measure differ and are also reported in Table 1.
The results obtained indicate that following the mindfulness intervention, participants spent significantly less time engaging in problematic pornography use (as indicated by reported use in the last week; large effect size: r = .64). This is crucially important, as problematic pornography use is the most prominent behavioural symptom of CSBD.
Additionally, problematic pornography use symptoms as measured by the Brief Pornography
Screener decreased, the statistical comparison result being at the trend level (p = 0.075;
10 MBRP trial for CSBD
medium effect size: r = -.40). Mindfulness training also resulted in reduced emotional distress following MBRP - reduced anxiety as indicated by both the HADS (test significance: p =
0.062; medium effect size: r = -.47) and the STAI-state (p = 0.050; medium effect size: r =
-.44) - and reduced depressive symptoms as indicated by the HADS (p< 0.027; large effect size: r = -.52). There was also a decrease in obsessive-compulsive symptoms (measured with
OCI-R) following the training (p = 0.052; medium effect size: r = -.43). We found no decrease in time spent on masturbation or dyadic sexual intercourse (p > 0.1) after MBRP.
DISCUSSION AND CONCLUSIONS
Thirteen adult males suffering from compulsive sexual behaviours were assessed before and after a mindfulness-based relapse prevention programme tailored to target compulsive sexual behaviours.
Overall, we found medium to large effect sizes (r of between 0.4 and 0.65; Cohen,
1988) for most comparisons of MBRP’s effectiveness. In accordance with expectations, we observed a self-reported reduction in time spent viewing pornography in the week following
MBRP compared with the week prior to the start of the intervention, while symptoms of problematic pornography use as measured by the Brief Pornography Screener decreased to trend level. This latter decrease to tendency level might be due to the small sample size (n =
10), and/or to the fact that the BPS considers a period of six months—a period far longer than the eight weeks of the MBRP intervention. We also noted non-significant decreases in time spent on masturbation and dyadic sexual activity. As the non-significance of these decreases might also stem from the low number of participants, future studies should include bigger, more statistically powerful, samples.
11 MBRP trial for CSBD
A reduction in pornography consumption was also found in the Twohig and Crosby
(2010) study, which assessed the effectiveness of acceptance and commitment therapy (ACT) on problematic pornography viewing. In that study, five of the six participants showed notable reductions in their viewing as a result of the treatment. Significantly, mindfulness is one of key elements of ACT (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Together, these findings suggest that mindfulness training, which promotes open and acceptance awareness of any kind of experience including triggers and urges for a particular behaviour, might be helpful in decreasing problematic pornography viewing.
As expected, we also found evidence of emotional distress reduction, in that participants were found to be significantly less depressed and anxious following treatment.
This finding is consistent with a number of studies showing that Mindfulness Based
Interventions (MBIs) effectively reduce anxiety, depression and stress levels in a variety of clinical psychiatric conditions (for a meta-analysis, see Goyal et al., 2014 and Khoury et al.,
2013) including substance misuse and addictions (e.g. Garland, Roberts-Lewis, Tronnier,
Graves, & Kelley, 2016, Liehr et al., 2010). MBIs has been found to promote abstinence or other positive outcomes in addictions (e.g. Hendershot, Witkiewitz, George, & Marlatt, 2011;
Price & Smith-DiJulio, 2016).
Overall, our results indicate positive effects of the MBRP on CSBD and are in line with the results of studies evaluating effectiveness of MBIs in the treatment of substance addictions. A recent meta-analysis showed significant small-to-large effects of MBIs in reducing the frequency and severity of substance misuse, the intensity of craving for psychoactive substances and the severity of stress (Li et al., 2017). Our findings are also in line with several studies showing negative correlations between a mindfulness disposition and
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problematic sexual behaviour. For example, Shorey et al. (2016) found that dispositional mindfulness was negatively associated with all the compulsive sexual behaviour indicators in individuals with substance disorder and comorbid CSBD. In similar vein, Brem and colleagues (2017) reported a significant relationship between CSB and dispositional mindfulness such that CSB was positively related to shame at low, but not average or high levels of dispositional mindfulness in substance use disorder. Moreover, Reid and colleagues
(2014) showed an inverse relationship of mindfulness to hypersexuality over and above associations with emotional regulation, impulsivity and proneness to stress.
Increasing neuroscientific evidence indicates that MBRP affects both bottom-up and top-down processes implicated in substance addiction disorder. Future studies should investigate the effectiveness of MBRP for CSBD using a randomised control design; they should also investigate the underlying neuro-behavioural mechanisms of porn consumption reduction following MBRP in order to test whether this is an effect of reduced craving, a function of improved tolerance to arousing stimuli, or both.
There are several limitations of the current research that should be addressed by future studies. First, the sample was small and consisted of Caucasian males only. A bigger and more ethnically diverse sample would enhance the statistical power and generalisability of the results and may lead to other effects of the treatment being revealed that were not observed here. Second, no control group was used in this study. Furthermore, all the data used were based on self-reports, which may have been influenced by the social demands imposed by the therapist or by the participant him- or herself.
Future randomised controlled trials of MBRP, and other psychosocial interventions such as CBT, ACT, MI, 12-step or emotion-focused therapy, should be systematically
13 MBRP trial for CSBD
examined in order to develop a validated therapy protocol for CSBD. Further, such studies may benefit from including more objective methods of measurement, such as eye-tracking, which by permitting the direct assessment of overt attention to porn stimuli and neuroimaging would allow the neural mechanisms of change due to treatment to be investigated. Future studies should also employ delayed or extended post-intervention measurement to investigate the sustainability of any training effects.
In summary, as the first mindfulness-based intervention examined in the context of
CSBD, the current study provides promising preliminary results on MBRP. It is hoped that future applied research on CSBD will produce data on the effectiveness of various methods of psychosocial and pharmaceutical treatment, singly and combined, in order to identify the most effective and personalised therapies in this, very probably growing, area of clinical concern.
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Table 1. Descriptive statistics and Wilcoxon signed-rank test results along with r effect sizes, comparing Measurement 1 (baseline) and Measurement 2 (post-training)
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Measu Measu Wilcoxon r effect rement 1 rement 2 sign test size
Variables N M S M S Z P D D
Time spent using 2 2 3 2 - .02 pornography (last week, in 6 -0,64 00.00 35.97 9.00 3.68 2.20 8 min.)
Time spent on 5 2 4 3 - .23 masturbation (last week, in 7 -0,32 .86 .80 .00 .00 1.19 5 min.)
Time spent on sexual 2 4 3 3 - .59 intercourse (last week, in 5 -0,17 2.40 2.88 .60 .58 0.54 3 min.)
BPS 1 6 3 4 3 - .07 -0,40 0 .00 .30 .20 .46 1.78 5
HADS Anxiety 8 5 4 2 - .06 8 -0,47 .88 .30 .63 .13 1.87 2
HADS Depression 6 4 3 2 - .02 8 -0,55 .25 .53 .00 .07 2.21 7
STAI State 1 4 1 3 1 - .05 -0,44 0 3.50 6.74 6.60 4.26 1.96 0
OCI–R 1 1 1 1 9 - .05 -0,43 0 5.80 0.49 1.20 .11 1.94 2
Note. BPS – Brief Pornography Screener; OCI–R – Obsessive-Compulsive Inventory Revised; HADS – Hospital Anxiety and Depression Scale; STAI – State-Trait Anxiety
Inventory; r effect size was computed using the formula Z/√nx+ny (Pallant, 2007). Cohen’s proposed interpretation of the r effect size strength is as follows: 0.1 – small effect; 0.3 – medium effect; 0.5 – large effect (Cohen, 1988).
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