drericgarland Addiction, Chronic Pain, Media, Mental Health, MORE, Opioids, Research

Center on Mindfulness and Integrative Health Intervention Development (C-MIIND)

The University of Utah has launched a new center dedicated to providing a transformative influence on healthcare by unifying research on mindfulness and other integrative behavioral health interventions.

Eric Garland, Associate Dean for Research at the U’s College of Social Work, will serve as Director of the new Center on Mindfulness and Integrative Health Intervention Development (C-MIIND). The Center, which will assume oversight of more than $17 million in federal research grants, will be housed in the College of Social Work.

“The center will advance a vision of a new model of healthcare, in which behavioral health experts work in tandem with medical providers to address the physical, psychological and social needs of people suffering from an array of health conditions,” said Garland, whose research focuses on using mindfulness to help individuals who experience chronic pain.

The center will bring together researchers and clinicians from across main campus and University of Utah Health, including faculty in social work, psychiatry, primary care, anesthesiology, neuroscience, oncology, psychology, and health, who are pioneering integrative interventions aimed at improving physical and mental well-being. C-MIIND will strive to attract top faculty and provide research opportunities for undergraduate, graduate and post-doctoral fellows interested in studying mindfulness and integrative behavioral health.

A focus of the center also will be to train post-graduates and health care providers in innovative therapies to be used in primary care clinics, hospitals, community mental health centers and addiction treatment facilities.

News coverage of the Center launch can be found here.

An NPR interview with Dr. Garland about the Center can be found here.

 

drericgarland Addiction, Chronic Pain, Mental Health, MORE, Neuroscience, Opioids, Research

New R01 Grant from the National Institute on Drug Abuse: Targeting Chronic Pain and Prescription Opioid Misuse in Primary Care with Mindfulness-Oriented Recovery Enhancement

nidaRecently, I was awarded a R01 grant from the National Institute on Drug Abuse to conduct a full-scale clinical trial of Mindfulness-Oriented Recovery Enhancement (MORE) as an intervention to reduce chronic pain and prescription opioid misuse in primary care. This five-year study will compare the efficacy of MORE to supportive therapy for 260 chronic pain patients receiving long-term opioid therapy who are at risk for opioid misuse.

Opioids may be medically necessary for some individuals experiencing prolonged and intractable pain, and most patients take medicine as prescribed. Unfortunately, opioids rarely completely alleviate chronic pain, and when taken in high doses or for long periods of time, can lead to serious side effects, including death by overdose, as well as risk for opioid misuse, which affects about 1 in 4 opioid-treated patients. Misusing opioids by taking higher doses than prescribed or by taking opioids to self-medicate negative emotions can alter the brain’s capacity for hedonic regulation, making it difficult to cope with pain (e.g., causing hyperalgesia – an increased sensitivity of the nervous system to pain) and experience pleasure in life (e.g., reducing sensitivity of the brain to natural reward). As such, non-opioid pain treatments that target hedonic dysregulation may be especially helpful for reducing chronic pain and prevent opioid misuse.

Multiple studies suggest that MORE improves hedonic regulation in the brain, resulting in decreased pain and an increased ability to savor natural, healthy pleasure. People who participate in MORE show heightened brain and body responses to healthy pleasures, and report feeling more positive emotions by using of mindfulness as a tool to enhance savoring. These therapeutic effects of MORE on savoring may be critically important, because findings from several studies show that increasing sensitivity to natural reward through savoring may lead to decreased craving for drugs – a completely novel finding for the field of addiction science (Garland, 2016). Our NIDA-funded R01 will provide a rigorous test of whether MORE improves chronic pain and opioid misuse by targeting hedonic dysregulation.

In our NIDA-funded R01, patients are receiving MORE at community medical clinics throughout Salt Lake City. Providing MORE in the naturalistic setting where most chronic pain patients seek medical care will make the therapy accessible to the people who need it the most. Ultimately, my hope is that this project will advance a new form of integrative healthcare, in which doctors and nurses work alongside social workers and other behavioral health professionals to help patients reclaim a meaningful life from pain.

drericgarland Addiction, Chronic Pain, Mental Health, MORE, Neuroscience, Opioids, Research

New Interview by Mind and Life Institute

mind_and-_lifeI was recently interviewed by Michael Juberg for the Mind and Life Institute, the world’s premier multi-disciplinary organization for the study of contemplative science. Michael and I had a wide ranging discussion that covered the span from philosophy to science to alleviating human suffering. He asked me some seriously thought-provoking questions that made me reflect back on the roots of my career and where it is all headed in the future. At the end of the interview, I offered a bit of advice for folks aspiring to become scientists in this field. The interview was really well done and I’m pleased to share it with you here.

drericgarland Addiction, Chronic Pain, Mental Health, MORE, Neuroscience, Opioids, Research

New Research Funding: Neuroimaging Research on the Effects of Mindfulness-Oriented Recovery Enhancement on Hedonic Regulation

mindfulness-centered-regulation-in-brainChronic pain is often treated with extended use of opioid analgesics, yet these drugs can alter the brain in ways that may make it difficult to cope with pain and may reduce the experience pleasure in life. Mindfulness-based interventions appear to be a promising means of addressing these issues, but research is needed to understand how such interventions change the brain to reduce suffering.

To that end, in September, 2016, I was recently awarded a five-year phased innovation grant from the National Institutes of Health’s (NIH) National Center for Complementary and Integrative Health entitled Effects of Mindfulness-Oriented Intervention on Endogenous Opioid Mechanisms of Hedonic Regulation in Chronic Pain (R61AT009296). The objective of the project is to study the effects of an innovative mindfulness-based intervention on brain mechanisms linked with pain and pleasure.

In the first two-year phase of the study ($800,000), I (Principal Investigator), along with my Co-Principal Investigator Jon-Kar Zubieta (Co-Principal Investigator), chair of the University of Utah’s Department of Psychiatry, will use positron emission tomography (PET) neuroimaging to assess the effects of Mindfulness-Oriented Recovery Enhancement (MORE) on restoring brain levels of endorphins in patients with chronic back pain who are being treated with prescription opioids.

This study represents the first use of PET in the history of science to quantify the effects of a mindfulness-based therapy on levels of endogenous opioids in the brain.

We will also use functional magnetic resonance imaging (fMRI) methods to assess how mindfulness training through MORE may increase people’s capacity to savor natural pleasure from positive and meaningful events in everyday life – a capacity that becomes diminished over time through the deleterious effects of chronic pain and prolonged opioid use on the brain. We will use a fMRI paradigm developed by my Co-Investigator Brett Froeliger, Assistant Professor of Neuroscience at the Medical University of South Carolina.

This study aims to test whether MORE might reverse this insensitivity to natural reward by targeting the endogenous opioid system and brain reward functions.

Following a successful first phase of the project, a three-year second phase ($2.2 million) will investigate whether patients with a particular genetic makeup that affects the expression of opioid receptors in the brain might benefit more from the mindfulness-based treatment. The second phase of the project will also assess the dose of mindfulness skill practice as a predictor of changes in endogenous opioid function and clinical correlates.

Based on the results of previous research, we hypothesize that mindfulness meditation training through MORE will restore proper function to the brain’s opioid receptors.  We will be able to measure how MORE changes the brain’s ability to regulate pain and respond to natural rewards, as well as deepen our understanding of exactly how these changes in neural mechanisms happen.

more-conceptual-framework-opioid

Overall, this project will unite expertise in mindfulness-based interventions with expertise in neurogenetics and the use of PET and fMRI to probe the neurobiological mechanisms of pain and emotional experience. By elucidating a key mechanism of meditation-based therapies, this program of translational research will further the emerging field of social work neuroscience and enable us to rapidly optimize MORE to increase the effectiveness of the intervention as it is rolled out in clinical practice.

 

 

drericgarland Addiction, Chronic Pain, Mental Health, MORE, Neuroscience, Opioids, Research

New Research Funding: Targeting Chronic Pain among Veterans and Military Personnel with Mindfulness-Oriented Recovery Enhancement

 

mind-reappraise-savor-brain

I was recently awarded $3.4 million in research funding from the Department of Defense Congressionally Directed Medical Research Program for a five-year clinical trial award entitled “Targeting Chronic Pain and Co-Occurring Disorders in the Community with Mindfulness-Oriented Recovery Enhancement.” To help me to carry out this pragmatic, large-scale randomized controlled trial, I will be supported by an interdisciplinary team of expert co-investigators from the University of Utah, including Jon-Kar Zubieta, Craig Bryan, Yoshio Nakamura, Gary Donaldson, and Bill Marchand.

The co-occurrence of chronic pain, psychological distress, and misuse of prescription opioids undermines the mission of the U.S. Military and inflicts suffering upon Veterans and their families. Approximately one-half of service members have chronic pain following deployment, and nearly one-fifth engage in opioid misusing behaviors like unauthorized dose escalation and use of opioids to self-medicate stress and anxiety. The state of Utah (where the proposed study will be conducted) has one of the highest incidences of nonmedical use of opioids in the U.S. and a rapidly increasing rate of prescription opioid-related deaths. Indeed, an estimated 21% of Utah adults were prescribed opioids during the past year, of which approximately one-in-five report taking more than prescribed. Given that military personnel and Veterans have higher rates of pain-related conditions than the general population, their risk for opioid-related problems is significantly enhanced.

military

New scientific findings indicate that because stress worsens pain and increases habit responses in the brain, individuals who cope with stress and pain through opioids are likely to have the most serious and difficult-to-treat opioid-related problems. The recent wars in Iraq and Afghanistan have been marked by repeated deployments involving serious combat-related and occupational stress. Unfortunately, there are no evidence-based treatments that simultaneously address pain, opioid misuse, and psychological distress. To fill this gap, this research proposal aims to conduct a pragmatic trial of a novel integrative medicine approach combining Mindfulness-Oriented Recovery Enhancement (MORE) with conventional opioid pain management for service members and Veterans. MORE aims to strengthen self-control over habit behaviors, increase flexible thinking under conditions of stress, and promote the sense of reward and meaning in the face of adversity.

This research project will help active duty service members and Veterans with chronic pain and stress who are at-risk for opioid misuse, and will also inform the treatment of civilians with similar issues. Should MORE prove to be effective in a community-based context, it could be easily transported into military installations and Veterans Administration Medical Centers in the U.S. and around the world, as well as in communities where no major military medical center is present. In these settings, MORE could be offered as a form of standard integrative health care provided to service members and Veterans.

A secondary objective of the proposed project is to utilize lab-based assessments and mobile technology to understand how MORE works to create therapeutic change, and to predict whether and when service members and Veterans are at risk for relapsing back to opioid misuse. To accomplish this objective, lab-based assessments will evaluate physiological reactivity to cues associated with past episodes of pain and opioid use, and a smartphone-based assessment will be used to evaluate opioid craving, pain, and negative mood in “the real world.” Because changes in heart rate and other physiological factors may indicate the extent to which a person’s brain has been triggered by opioid craving, this application of mind-body assessments to predict opioid misuse risk and treatment outcomes could facilitate early risk detection.

The final objective of the project is to understand for whom MORE works best, to help ensure more efficient healthcare resource allocation to the service members and Veterans who need it most.  The proposed project will enable health care providers to more effectively deliver low-cost treatment to prevent progression toward opioid addiction, thereby averting costly inpatient stays, discharge from active duty military service, and social, legal, and occupational problems among Veterans. Ultimately, the proposed research could significantly enhance the psychological and physical health of military personnel and Veterans by addressing the need for new integrative medicine treatment options with findings from the leading edge of science.

drericgarland Addiction, Chronic Pain, Mental Health, MORE, Neuroscience, Opioids, Research

Research on MORE in the Annals of the New York Academy of Sciences – Targeting Hedonic Dysregulation with Mindfulness-Oriented Recovery Enhancement

mindfulness centered regulationIt is my pleasure to announce that the very first review paper summarizing the theoretical rationale and empirical evidence for Mindfulness-Oriented Recovery Enhancement (MORE) has been accepted for publication in the prestigious journal Annals of the New York Academy of Sciences. In this paper, I review data from multiple clinical studies on the biobehavioral mechanisms of MORE, and articulate a hedonic regulatory model of the intervention – proposing that restructuring reward processing is the final common pathway through which MORE ameliorates addiction, stress, and pain. I map this novel theoretical model onto an earlier conceptual framework of the neural circuitry underlying mindfulness-centered regulation of addiction (Garland, Froeliger, & Howard, 2014) and then describe new neuroimaging and psychophysiological data in support of the model. The paper abstract is as follows:

“Though valuation processes are fundamental to survival of the human species, hedonic dysregulation is at the root of an array of clinical disorders including addiction, stress, and chronic pain, as evidenced by the allostatic shift in the relative salience of natural reward to drug reward observed among persons with severe substance use disorders. To address this crucial clinical issue, novel interventions are needed to restore hedonic regulatory processes gone awry in persons exhibiting addictive behaviors. This article describes theoretical rationale and empirical evidence for the effects of one such new intervention, Mindfulness-Oriented Recovery Enhancement (MORE), on top-down and bottom-up mechanisms implicated in cognitive control and hedonic regulation. MORE is innovative and distinct from extant mindfulness-based interventions in that in unites traditional mindfulness meditation with reappraisal and savoring strategies designed to reverse the downward shift in salience of natural reward relative to drug reward, representing a crucial tipping point to disrupt the progression of addiction – something that no other behavioral intervention has been designed to do. Though additional studies are needed, clinical and biobehavioral data from several completed and ongoing trials suggest that MORE may exert salutary effects on addictive behaviors and the neurobiological processes that underpin them.”

drericgarland Mental Health, MORE, Neuroscience, Research

The Mindfulness-to-Meaning Theory: A New Process Model of Mindful Emotion Regulation

I am feeling particularly thankful today to my colleagues Norman Farb (University of Toronto), Philippe Goldin (University of California – Davis), and Barbara Fredrickson (University of North Carolina – Chapel Hill), with whom I wrote and recently published the target article for the December issue of the esteemed, international journal Psychological Inquiry. Our target article, entitled “Mindfulness Broadens Awareness and Builds Eudaimonic Meaning: A Process Model of Mindful Positive Emotion Regulation,” articulates the Mindfulness-to-Meaning Theory, a new conceptual model of the cognitive, emotional, and neurobiological processes by which mindfulness might stimulate positive psychological states and lead to a sense of meaning in the face of adversity. In brief, the Mindfulness-to-Meaning Theory asserts that mindfulness allows one to decenter from stress appraisals into a metacognitive state of awareness that broadens attention to previously unnoticed pieces of information about one’s life, accommodating a reappraisal (i.e., a reframing) of adverse circumstances that reduces distress and promotes positive emotions. This reappraisal is then deepened and enriched when one savors what is pleasant, growth promoting, or meaningful in life, a process which motivates values-driven behavior and engenders a deeper sense of purpose and self-actualization.

The entire journal issue is devoted to the discussion of our new Mindfulness-to-Meaning Theory. Our work was the subject of 10 erudite commentaries from leading scholars in the fields of contemplative science, addiction neuroscience, clinical psychology, affective science, psycho-oncology, social psychology, and consciousness studies, who extended, challenged, and pushed our theory into new and wider applications. We responded to the commentaries with our own article “The Mindfulness-to-Meaning Theory: Extensions, Applications, and Challenges at the Attention–Appraisal–Emotion Interface,” which broadens the theory to address how mindfulness re-configures structures within working memory, describes mindfulness as a domain general resource for promoting emotion regulation flexibility, and suggests future directions to be pursued toward the establishment of a more comprehensive contemplative science.

The target article may be downloaded here and our response to the commentaries downloaded here.

May our work help advance the field to promote human flourishing!

drericgarland Mental Health, Neuroscience, Research

Mindfulness Training Promotes Upward Spirals of Positive Emotion and Cognition

MBCT_upward spiral figEarlier this year, along with colleagues Marieke Wichers, Nicole Geschwind, and Frenk Peeters (Maastrict University and University of Groningen), I published a paper on the effects of mindfulness training on the dynamic change trajectories of positive emotions and thoughts over time. This study analyzed data from a randomized controlled study of 110 individuals with histories of depression who were randomly assigned to receive an 8-week Mindfulness-Based Cognitive Therapy intervention or a control condition. Study participants rated their experiences of positive emotions and thoughts on a daily basis using a method called “experience sampling” (also known as ecological momentary assessment, or EMA), in which they were prompted at random times throughout the day to describe their mental state in the midst of everyday life activities. To analyze this data, we employed a sophisticated statistical technique called multivariate autoregressive latent trajectory modeling (see the Figure above). We found that mindfulness training significantly enhanced positive emotions and positive thoughts from moment-to-moment. Importantly, we also found evidence that mindfulness training may stimulate an upward spiral of positivity, such that increasing experiences of positive emotions on one day stimulated positive emotions and thoughts on the following day, and so forth. In other words, it appears as mindfulness training can enhance positive emotion-cognition interactions that may be important to psychological flourishing (and physical health). These data provideUpward Spiral - horizontal over time support for my new Mindfulness-to-Meaning Theory (see the Figure above), which will be featured on this website in a month or two when my paper about this theory will be published as the target article of the December issue of the esteemed international journal Psychological Inquiry and receive commentary by some of the leading contemplative scientists in the world. Stay tuned!

drericgarland Addiction, Mental Health, MORE, Neuroscience, Opioids, Research

News: Dr. Garland’s Article Ranked in 93rd Percentile! – Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface

An article I published with my colleagues Brett Froeliger from MUSC and Matthew Howard from UNC Chapel Hill in the journal Frontiers in Psychiatry entitled “Mindfulness training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface” was designated in the 93rd percentile of 3,480,147 articles tracked by Altmetric. The Altmetric score is a measure of the quality and quantity of online attention that this article has received. The paper details the model depicted below.

mindfulness centered regulation

In this review paper, we describe how mindfulness-based interventions (MBIs) may target neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Empirical evidence is presented suggesting that MBIs ameliorate addiction by enhancing cognitive regulation of a number of key processes, including: clarifying cognitive appraisal and modulating negative emotions to reduce perseverative cognition and emotional arousal; enhancing metacognitive awareness to regulate drug-use action schema and decrease addiction attentional bias; promoting extinction learning to uncouple drug-use triggers from conditioned appetitive responses; reducing cue-reactivity and increasing cognitive control over craving; attenuating physiological stress reactivity through parasympathetic activation; and increasing savoring to restore natural reward processing. Treatment and research implications of our neurocognitive framework are presented. We conclude by offering a temporally sequenced description of neurocognitive processes targeted by MBIs through a hypothetical case study. Our neurocognitive framework has implications for the optimization of addiction treatment with MBIs.

The paper is free for download here.

drericgarland Mental Health, MORE

“Savoring the Good Life” with Mindfulness-Oriented Recovery Enhancement

A new and exciting research study from my lab was recently accepted for publication in the esteemed journal Psychopharmacology. This paper describes a subset of findings from a randomized controlled trial (RCT) of Mindfulness-Oriented Recovery Enhancement (MORE) for chronic pain patients who had been prescribed long-term opioid treatment (e.g., oxycontin, vicodin) for pain management. To my knowledge, the study is the first in the scientific literature to demonstrate that a mindfulness-based intervention can increase physiological sensitivity to natural, healthy pleasures in life.

In this study, individuals suffering from low back pain, neck pain, arthritis, fibromyalgia, and other pain conditions were randomly assigned to participate in the experimental MORE treatment or a control condition consisting of a social support group led by a therapist. Participants in the MORE group received 8 weeks of instruction in applying mindfulness and other psychological techniques to alleviate pain and craving while strengthening positive emotions and a sense of meaningfulness in life.

In that regard, parti2 (6)cipants were taught a savoring practice, which involved using mindfulness to intentionally focus on the sensory features (e.g., sight, sound, smell, or touch) of a pleasant experience or object (e.g., a beautiful nature scene like a sunset or the feeling of connection with a loved one) while noticing, appreciating, and absorbing any positive emotions arising in response to the pleasant event. For example, in one meditation session, participants were taught to mindfully focus on the colors, textures, and scents of a bouquet of fresh flowers, and to absorb and appreciate the emotions of contentment and joy arising from this savoring practice. Participants were asked to practice savoring in everyday life as part of a weekly homework assignment (along with a daily practice of mindful breathing meditation).

Due to its emphasis on savoring naturally rewarding experiences, we hypothesized that MORE would increase the sensitivity of the autonomic nervous system to images representing such positive experiences. To measure this in the lab, we used a computerized task, in which participants were asked to pay attention to series of pain-related (e.g., a picture of someone grimacing in pain), opioid-related (e.g., a picture of a bottle of prescription painkillers), or pleasure-related images (e.g., a picture of a smiling baby) rapidly presented for 200 – 1000 milliseconds. During this task, we measured heart rate variability – that is, the beat-to-beat changes in heart rate controlled by the parasympathetic nervous system, the branch of the nervous system responsible for rest and recovery from stress. We also asked participants to rate how much they desired or craved their opioids before and after the task.

In summary of our study results, we found that MORE significantly decreased the desire to take opioids and led to large heart rate decelerations while participants focused their attention on the pain-, opioid-, and pleasure-related photographs. In other words, after completing the MORE training, participants’ heart rates slowed down from resting levels while they were paying attention. Heart rate variability analysis indicated that this heart rate slowing was caused by increased activation of the parasympathetic nervous system following MORE. The heart rate decelerations were dramatic, and particularly so for the pleasure photos; on average, the heart rate of participants in the MORE intervention dropped 10 beats per minute while they focused on the pleasure photos! Importantly, although heart rate slowed to all three types of photos, only the heart rate slowing to pleasure photographs was related to changes in opioid craving. Participants who experienced the most heart rate slowing to pleasure photographs experienced the greatest reduction in the desire to take opioids.

This finding is extremely important. A large body of research suggests that as chronic pain and addiction progresses, people may become less physiologically responsive to natural pleasure. As their brains become less sensitive to naturally-rewarding experiences, they get less enjoyment out of life. Consequently, they may feel more compelled to take drugs (such as opioids) to achieve a normal sense of well-being.

Results from this new study suggest that through mindful savoring practices, MORE may help people to become more sensitive to healthy, positive experiences in everyday life, and in doing so, assist them to become freer from the clutches of addiction.

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drericgarland Mental Health, Research

New Paper Accepted for Publication: State Mindfulness During Meditation Predicts Enhanced Cognitive Reappraisal

My colleagues Adam Hanley (Florida State University), Norm Farb (University of Toronto), Brett Froeliger (Medical University of South Carolina), and I had a new research paper accepted for publication in the journal Mindfulness. In a sample of people receiving brief mindfulness training (one to four sessions delivered by audio CD), we found that the state of mindfulness achieved during the act of mindfulness meditation predicted enhanced cognitive reappraisal over the following week. In other words, people who attained deeper states of mindfulness during meditation experienced an increased tendency to think in more helpful and healthy ways about the stressors in their lives over the following week. This research finding suggests that the state of mindfulness may enhance cognitive flexibility and allow individuals to adopt a broadened perspective on their current life challenges. Study results provide support for a theoretical model I developed, the Mindful Coping Model, and reveal one more piece of the puzzle linking mindfulness with human flourishing. More experimental tests of this theory are needed to replicate and expand these results.mind-reappraise-savor

drericgarland Addiction, Chronic Pain, Mental Health, Neuroscience, Opioids, Research

New Paper Accepted for Publication! The Downward Spiral of Chronic Pain, Prescription Opioid Misuse, and Addiction: Cognitive, Affective, and Neuropsychopharmacologic Pathways

My colleagues and I recently had a new paper accepted for publication in the highly esteemed, international journal Neuroscience and Biobehavioral Reviews. This paper draws upon current neuropsychopharmacologic research to provide a conceptual framework of the downward spiral leading to opioid misuse and addiction among chronic pain patients taking prescription opioids for pain relief. In brief, we theorize that addictive use of opioids is the outcome of a cycle initiated by chronic pain and negative emotions, leading to attentional hypervigilance for pain and drug cues, dysfunctional connectivity between self-referential and cognitive control networks in the brain, and allostatic dysregulation of stress and reward circuitry. We conclude the paper by introducing Mindfulness-Oriented Recovery Enhancement (MORE) as a potentially effective approach to disrupting the downward spiral. This is a particularly exciting publication for our research team, because it lays the theoretical groundwork for developing new and innovative efforts to help people recover from chronic pain and opioid addiction.

drericgarland Mental Health

Mindfulness and Reappraisal

Inevitably, we encounter hardship in our lives. We become ill, fall into debt, are subject to criticism, harried by rumor and jealousy, and assailed by the many challenges and unrelenting demands of the world. Yet, individuals differ to the extent to which they remain resilient in the face of such stressors.  One key to resilience is positive reappraisal – the capacity to reframe or re-interpret difficult life experiences such that they become imbued with personal meaning. For instance, after facing a stressor, one might come to believe, “Dealing with this experience has made me a stronger person,” or, “I have grown and learned from adapting to this situation,” or even, “I would not be who I am today without this experience, no matter how difficult it has been.” Through positive reappraisal, we come to find meaning in the face of adversity.

Such positive reappraisals may be essential means of adapting to the rigors of life. People often believe that they have personally grown or learned from dealing with the stressful events of their lives. For example, over half of 2000 survivors of the devastating 2008 earthquake in Sichuan province, China, which reached 8.0 on the Richter scale, reported having experienced a form of meaningful growth in its wake, such as developing personal strength, a sense of appreciation of life, or an opening to new possibilities (Xiu & Liao, 2011). Similarly, after a deadly tornado struck Madison, Florida in 1998 and obliterated over 100 homes and business, 9 out of 10 survivors reported experiencing psychological benefits from the event, such as greater appreciation for others and a deepened sense of personal growth (McMillen, Smith, & Fisher, 1997). Innumerable examples may be found in the annals of history. Every time another tragedy is announced on the news, from devastating floods to acts of savage terrorism, positive reappraisals emerge during the interviews of survivors. The common theme echoed such tragic incidents is “This experience brought our community closer” and “This experience is a reminder of what is really important in life.”

At the same time, finding positive meaning in adversity does not only occur in the aftermath of large scale disasters; it is also commonly occurs in the face of daily stressors. For example, after being snubbed and disrespected by a work supervisor, one might reappraise the mistreatment into an opportunity to realize the importance of being sensitive to the opinions and viewpoints of others.  And after a long, exhausting day at the office, being treated rudely by the clerk at the grocery checkout line might be seen as an opportunity to feel empathy for the fact that she was probably standing on aching feet for more than eight hours. Similarly, a person stricken with a non-fatal heart attack might positively reappraise the event as a chance to change their diet and start exercising more. A person who has recovered from a vicious rape might view their survival of the assault as evidence of their strength and resilience, and they might decide to dedicate their life to helping others make similar recoveries. A person entangled in a fight with her spouse might initially villanize him and recoil from his attempts to resolve the conflict, and then, after recognizing his unwavering devotion to their relationship, redouble her efforts to understand his point of view.

Though reappraisal is well-known to enhance resilience and help individuals cope with stress, less is known about how this strategy works and how it can be strengthened. It is my contention that mindfulness promotes reappraisal. Mindfulness is a state of mind in which one observes his or her mental experiences without becoming “stuck in” or “trapped by” them. In the state of mindfulness, you become aware of thoughts, feelings, sensations, and perceptions without trying to hold on to them, and without trying to push them away. As the state mindfulness deepens, you not only become aware of where your mind is in the moment (i.e., on what content is it focused), you also become aware of the quality of that observing mind itself.  At the deepest levels of mindfulness practice, this metacognitive observation can be a bit like a mirror mirroring mirrors – being aware of being aware (and maybe, if you are really good, being aware of being aware of being aware!). Some neuroscientists suppose that the folds of the prefrontal cortex have evolved over millennia to allow for this metacognitive reflection.

So what do these abstract ideas have to do with reappraisal? Well, to make a positive reappraisal, one must first be aware of the initial negative or stressful appraisal (e.g., “This situation is horrible!”). Next, one must “step back” or disengage from that reappraisal. My colleagues and I (Garland, 2007; Garland, Gaylord, & Park, 2009) have argued that mindfulness affords that mental shifting function – allowing one to decenter from a given thought about one’s life, into the openly observing, metacognitive mode of awareness. Once the mind has stepped back from the stress appraisal into this state of mindfulness, attention broadens to encompass previously unattended details about one’s life circumstance – you begin to notice things about yourself and your situation that you had overlooked or ignored because you were so stressed and upset. For example, bad feedback from a boss might lead you to think, “I always screw up and my boss hates me.” However, if you were to engage mindfulness, you might be able to step back from this thought and then begin to notice the ways in which you have been successful at work and the recent times when your boss has given you praise. After which you might think, “Well, that’s not really true. Usually I do a good job at work and that’s why my boss is giving me this critical feedback – she believes that I can take my career to the next level!” This positive reappraisal might then motivate you to take constructive action at work. Thus, the metacognitive aspect of mindfulness allows us to see that our thoughts are not necessarily facts. By becoming aware of awareness, we come to realize that who we are is much bigger than any one thought, feeling, or stressful life event, and that ultimately, we are free to choose the meaning of our lives.

In these ways, mindfulness helps us to disrupt habits of negative thinking, allowing the mind to naturally expand to consider new possibilities and novel ways of seeing the world. When, through mindfulness, we suspend our preconceived notions and assumptions about the difficult aspects of our lives, we are able to bring increased awareness to the richly woven tapestry of life that unfolds all around us, allowing us to draw out innumerable golden threads. The smiling face of a passerby, the song of a bird perched in a nearby tree, the trill of insects on a warm summer evening, a tiny flower blossoming from a crack in a sidewalk, the laughter of children, or even the ever-constant companion of one’s own breath can become sources of wonder and delight to savor, in spite of and perhaps because of the stressors and challenges we face. Facing bitter hardship and adversity can help us to truly taste and appreciate the moments of sweetness that surround us. Through mindfulness and reappraisal we can learn to widen the scope of our awareness to encompass more of the meaningful and beautiful experiences in life, making the painful and dissatisfying ones smaller by comparison.

drericgarland Addiction, Chronic Pain, Mental Health, MORE, Research

Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain

I am pleased to annoMOREcvrspreadunce the publication of my new book, Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain, by NASW Press. This book is a treatment manual that describes the step-by-step implementation of Mindfulness-Oriented Recovery Enhancement (MORE), as well as the theoretical framework and growing evidence base underlying this new form of therapy.

From the press release:

“Human existence can be beset by a variety of negative mental states such that life seems devoid of meaning, but it can also be liberated—a meaningful life reclaimed and savored through cultivation of a higher kind of mind. This quality, mindfulness, refers to both a set of contemplative practices and certain distinct psychological states and traits, and it can be cultivated through intentional effort and training.

In Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain, Eric L. Garland presents an innovative program of intervention that can be put into practice by therapists working with people struggling with addiction and the conditions that underlie it. Unlike other substance abuse treatment modalities, which focus largely on relapse prevention, Mindfulness-Oriented Recovery Enhancement (MORE) concentrates on helping people to recover a sense of meaning and fulfillment in everyday life, embracing its pleasures and pain without avoiding challenges by turning to substance use.

Along with chapters on the bipsychosocial model underlying MORE and the current state of research on mindfulness, this book includes a complete treatment manual laying out for clinicians, step by step, how to run MORE groups—including adaptations to address chronic pain and prescription opioid misuse—and enhance the holistic recovery process for people striving to overcome addiction.

With addiction a widespread and growing problem in our society, Mindfulness-Oriented Recovery Enhancement could not be more timely or needed. It integrates the latest research on addiction, cognitive neuroscience, positive psychology, and mindfulness into a practice that has garnered empirical support and holds the promise of release and fulfillment for those who suffer from addiction.”

For more information or to purchase the book, go to http://www.naswpress.org/publications/clinical/mindfulness-oriented-recovery.html

Testimonials

“In this work, Dr. Garland lays out a novel and timely behavioral approach for the treatment of substance abuse disorders. This treatment Mindfulness-Oriented Recovery Enhancement (MORE), is grounded in ancient philosophy and the most up-to-date, empirically driven models of drug addiction that stem from the social and neurobiological sciences. Dr. Garland successfully tackles the task of synthesizing the principles of these diverse fields, provides empirical support for MORE’s effectiveness, and delivers a concise and clear message that will surely appeal to clinicians, researchers, students, and the general public. Anyone who holds an interest in the dilemma of drug addiction and its treatment will benefit from reading Mindfulness-Oriented Recovery Enhancement for Addiction, Stress and Pain.”

Brett Froeliger, PhD

Department of Neurosciences
Medical University of South Carolina

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“Eric L. Garland’s exciting book, Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain is a ground-breaking new contribution to addiction treatment literature. Dr. Garland, a licensed clinical social worker with more than a decade of experience in delivering evidence-based interventions based on contemporary cognitive—affective neuroscience, offers a clearly articulated 10-session model for intervening with substance dependent clients. The treatment approach presented in Garland’s book is inexpensive, research based, broadly applicable to substance-dependent people of all types, and readily adopted by student and experienced practitioners. Although mindfulness interventions are rooted in ancient Buddhist traditions, psychophysiological and clinical assessments suggest that they are among the most efficacious treatments currently available for a range of modern-day maladies. I strongly encourage clinicians and therapists working with substance-dependent clients to read Mindfulness-Oriented Recovery Enhancement.”

Matthew Owen Howard, PhD

School of Social Work
University of North Carolina at Chapel Hill

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“Mindfulness-Oriented Recovery Enhancement for Addiction, Stress and Pain is a wonderful addition to the growing array of treatment manuals that are clinically informed, research—based, and focused on helping individuals who abuse substances to achieve long-term sobriety and improvements in overall life functioning. This book is written by an experienced psychotherapist who has developed and empirically evaluated the MORE model during the past decade. Dr. Eric L. Garland skillfully integrates mainstream cognitive–behavioral therapies with the much older spiritual traditions of meditative mindfulness to create a comprehensive treatment manual describing a semi-structured, 10–session approach to helping substance abusers. A later section of this book contains an eight-session protocol for using the MORE approach with patients experiencing chronic pain. Like the treatment model for substance abusers, the chronic pain protocol is thoroughly based in solid research findings, including clinical outcome studies. The book concludes with an array of client handouts for data collection and providing information. I highly recommend this treatment manual for therapists looking to learn more about the empirically-grounded research findings pertaining to mindfulness meditation and how they can be effectively used to help clients.”

Bruce A. Thyer, PhD, LCSW, BCBA-D

College of Social Work
Florida State University