Mindfulness-Oriented Recovery Enhancement: An Overview
Mindfulness-Oriented Recovery Enhancement (MORE) is an evidence-based mental training program, supported by more than 10 clinical trials and over $25 million in federal research grants, that unites complementary aspects of mindfulness training, “Third Wave” cognitive-behavioral therapy, and principles from positive psychology into an integrative therapeutic approach. The MORE program is detailed in a treatment manual designed for use by therapists (and patients). Eric Garland, PhD, LCSW developed MORE by translating fundamental discoveries from neuroscience into therapeutic strategies designed to reduce addictive behavior, emotional distress, and chronic pain, while increasing healthy pleasure, joy, and meaning in life. To learn more about how to be trained in MORE, click here.
MORE is centered on three key therapeutic processes:
1. MINDFULNESS: MORE strengthens metacognitive control over automatic cognitive biases through mindfulness training – teaching clients to: A) become aware of when their attention has become fixated on addictive cues, stressors, or (physical or emotional) pain; B) shift from affective to sensory processing of craving, stress, or pain sensations; and C) re-orient attention to the breath via the practice of mindful breathing. This technique is also aimed at enhancing self-control over automatic behavioral habits elicited by addictive cues, stressors, and pain. By disrupting negative habit responses, mindfulness may free up cognitive resources to devote to more helpful or healthful ways of thinking, perceiving, and acting in the world, including accessing self-transcendence – a deep sense of connection to something greater than the self.
2. REAPPRAISAL: MORE uses mindfulness practices to potentiate cognitive reappraisal of maladaptive thoughts contributing to negative emotions and addictive behaviors; such “mindful reappraisal” is aimed at fostering adaptive coping in the face of stress. MORE increases psychological flexibility by explicitly teaching mindfulness skills in tandem with cognitive restructuring techniques. MORE teaches people to first mindfully disengage from negative appraisals of stressful events and then to reframe them into positive reappraisals to promote resilience and meaning in the face of adversity.
3. SAVORING: MORE enhances positive emotion and motivation by providing instruction in mindful savoring – the practice of focusing attention on and deeply absorbing naturally rewarding experiences (e.g., enjoying the beauty of nature or the sense of connection with a loved one). During savoring, one pays attention to the pleasant sensory features of a positive object or event, while simultaneously noticing and enjoying the pleasurable body sensations, positive emotions, and higher-order affective meaning that arise in response to pleasant life experience. MORE uses exercises to promote focus on positive daily experiences as a means of restoring dysregulated reward neurocircuitry function associated with addiction, mood disorders, and chronic pain, and to increase the healthy sense of pleasure, joy, meaning, and self-transcendence in everyday life.
MORE is distinct from other mindfulness-based interventions in that it uses mindfulness training as a means of promoting positive psychological processes to improve health and well-being. In this sense, the treatment is truly “integrative,” combining the complementary strengths of different therapeutic techniques into one, synergistic approach. For instance, mindfulness skills are used to help clients to disengage from unhealthy cognitive and behavioral habits, while reappraisal skills are used to develop new, more helpful beliefs and actions. Savoring skills are then used to provide the positive motivational energy and sense of reward needed to drive and sustain behavioral change; this latter feature of MORE is especially innovative, as few (if any) empirically-supported treatments directly aim to strengthen the capacity to extract pleasure from naturally rewarding events and experiences. Unlike other mindfulness-based interventions which eschew a focus on evaluation, narrative processing, and positivity, MORE aims to foster the development of valued ways of seeing and responding in the world – generating a sense of eudaimonic meaning in life. Yet, unlike other third wave CBT approaches which focus on values but do not offer instruction in formal mindfulness meditation, MORE provides mindfulness training as a means of strengthening self-regulatory capacity. This enhanced capacity is then channeled in service of promoting psychosocial flourishing. The tripartite MORE approach is guided by fundamental discoveries from neuroscience about the biobehavioral factors integral to suffering and its alleviation. Indeed, studies indicate that cognitive control of attention (i.e., mindfulness), negative emotion (i.e., reappraisal), and reward processing (i.e., savoring) goes awry in addiction, stress, and chronic pain; these processes are integral to healthy brain and body functioning. Thus, MORE aims to cultivate and leverage these basic human strengths to foster therapeutic change and self-actualization.
A conceptual framework of the hypothetical neural mechanisms of MORE is described here.
The original 10 session treatment structure is described here.
History of MORE
To learn about the history of MORE, listen to this Mind and Life Podcast interview with Dr. Garland.
Implementing MORE in Health Care
Eric L. Garland, Ph.D., LCSW has trained individual clinicians (e.g., social workers, psychologists, physicians, nurses, counselors, physical therapists, etc.) and health care systems to implement MORE as an intervention for people with complex, chronic, and overlapping health and mental health conditions. To date, Dr. Garland has provided training in MORE to over 350 clinicians from a range of settings (e.g., private practice, academic health systems, community-based clinics, the military health system), including Johns Hopkins Medical School (Maryland), Mt. Sinai Hospital (New York), Intermountain Healthcare (Utah), Southwest Care Center (New Mexico), New Roads Behavioral Health (Utah), Medical University of South Carolina (South Carolina), University of Utah Health (Utah), Philadelphia Veterans Affairs Medical Center (Pennsylvania), Ralph H. Johnson Veterans Affairs Medical Center (South Carolina), Kaiser Permanente (Washington), Neuroscience Associates of New York (New York), Triangle Options for Substance Abusers (North Carolina), Saint Luke’s Cancer Institute & Koontz Center for Advanced Breast Cancer (Kansas), Brooke Army Medical Center (Texas), Darnall Army Medical Center (Texas), Madigan Army Medical Center (Washington), Wilford Hall Hospital (Texas), the University of Zurich (Switzerland), and the University of Fribourg (Switzerland), among others.
In January 2021, Essentia Health, a large integrated healthcare organization serving over 670,000 patients across three states (MN, WI, ND), began implementing MORE as an insurance-reimbursable service through group medical visits delivered by primary care providers – a signal moment in the dissemination of MORE. In other health systems, MORE has also been delivered as an insurance-reimbursable service via group and individual psychotherapy formats, as well as through Health Behavior Assessment and Intervention (HBAI) procedure codes. Pioneers like Essentia are paving the way for other large scale health systems to integrate this highly efficacious, evidence-based practice into standard medical care and reach the greatest number of people in need.
Research Evidence on MORE
Over the past decade, MORE’s therapeutic outcomes and mechanisms have been studied in multiple Stage 1, Stage 2, and Stage 3 trials supported by $25+ million treatment development research program funded by the National Institutes of Health and the Department of Defense.
In the first Stage 1 randomized controlled trial (RCT) of MORE was conducted with alcohol use disorder (AUD) patients in a long-term therapeutic community. Results from this pilot RCT (N=53) demonstrated MORE’s effects on addiction mechanisms including alcohol attentional bias and autonomic recovery (i.e., heart rate variability) from alcohol cue-exposure (Garland et al., 2010). Having demonstrated promise as an addictions treatment, MORE was then tested in a 5-year Stage 3 RCT (N=180) at the same therapeutic community in a sample of formerly homeless men with co-occurring SUDs and psychiatric disorders. MORE outperformed cognitive-behavioral therapy (CBT) and treatment-as-usual (TAU) in reducing craving and PTSD symptoms (Garland et al., 2016). Next, MORE was modified as a treatment for prescription opioid misuse among chronic pain patients and tested in a Stage 2 RCT (N=115). After treatment, long-term prescription opioid users receiving MORE were significantly less likely than participants in an active control group to exhibit opioid misuse symptoms pathognomonic with opioid use disorder (OUD) (Garland et al., 2014). In this trial, MORE was also found to significantly reduce chronic pain severity and functional interference, decrease momentary craving (Garland, Bryan, et al., 2017), and restructure reward related mechanisms, as indicated by decreased opioid attentional bias (Garland et al., 2017), reduced opioid cue-reactivity (Garland, Froeliger, et al., 2014), and increased autonomic and neurophysiological responses to natural reward stimuli (Garland, Howard, et al., 2017; Garland et al., 2015). Shortly thereafter, a Stage 1 pilot neuroimaging trial (N=13) of MORE as a treatment for smoking cessation found similar evidence of restructuring reward processing via fMRI measures of brain reward system function (Froeliger et al., 2017). Later, two additional Stage 1 RCTs of MORE were completed that suggest that the effects of MORE may be extended into treatment for behavioral addictions. In a pilot RCT (N=30), MORE was shown to significantly reduce symptoms of internet gaming disorder (Li, Garland, et al., 2017). In another pilot RCT (N=51) of MORE as an intervention for obesity among cancer survivors, MORE significantly improved facets of interoceptive awareness and decreased food attentional bias, the latter of which was associated with increased physiological responsiveness to natural reward cues (Thomas et al., 2019).
More recently, a second Stage 2 RCT (N=95) of MORE for opioid-treated chronic pain patients found that MORE significantly reduced opioid misuse behaviors and pain severity by increasing a range of positive psychological factors, including positive affect, savoring, meaning in life, and self-transcendence (Garland, Hanley, Riquino, et al., 2019). In this trial, MORE was also shown to significantly decrease opioid dose, which was predicted by increasing heart rate variability during mindfulness meditation (Garland et al., 2020). A Stage 1 RCT (N=30) of MORE as an adjunct to methadone maintenance treatment of OUD found MORE to significantly reduce days of heroin and other illicit drug use (Cooperman et al., 2020) and to decrease momentary craving while enhancing self-control over craving (Garland, Hanley, Kline, et al., 2019). In another Stage 1 RCT (N=51), MORE was shown to significantly reduce opioid craving and psychological distress among pregnant women receiving medications for OUD (MOUD) (Reese, 2020).
To augment these clinical findings, Dr. Garland conducted a series of randomized experiments which were published in the high impact journal Science Advances, showing that MORE reduced neurophysiological indices of drug cue-reactivity and enhanced natural reward responsiveness in the human brain (Garland et al., 2019). These findings provide strong support for the hypothesis that MORE can restructure reward responses underpinning addiction.
Finally, Dr. Garland completed a NIH R01-funded full-scale RCT of MORE as a treatment for opioid misuse among people with chronic pain. In this trial, 250 opioid misusing chronic pain patients were treated with MORE or a supportive psychotherapy control condition in a primary care setting. Nine months after the end of treatment, the MORE group evidenced a 46% reduction in opioid misuse, and 36% of patients were able to reduce their opioid dose by half or greater (with a mean opioid dose reduction of 76 morphine milligram equivalents). In addition, the MORE group showed a 25% reduction in chronic pain-related functional interference, lower pain severity, and reduced depression, emotional distress, and PTSD through the 9-month follow-up. Also, participants in MORE reported significant increases in positive emotions, meaning in life, and the sense of self-transcendence, coupled with enhanced autonomic responsiveness to natural rewards and improved self-regulation of opioid cue-reactivity. Finally, MORE increased frontal midline theta EEG activation which in turn mediated the effect of MORE on opioid misuse, indicating that MORE reduces addictive behavior by strengthening cognitive control and restructuring reward processing in the brain.
Across these 11 RCTs, 868 participants have been randomized to MORE or various control conditions including supportive group psychotherapy, CBT, exercise and nutrition counseling, medications for opioid use disorder (MOUD), and treatment-as-usual.
Furthermore, multiple additional RCTs are now underway in the United States and Europe to test the efficacy and mechanisms of MORE as a intervention for: a) opioid misuse in veterans, b) illicit opioid use disorder, c) chronic low back pain in civilians and active duty military personnel, d) chronic knee pain in active duty military personnel undergoing knee replacement surgery; e) fibromyalgia, and f) smoking cessation. These studies include full-scale efficacy trials and later stage comparative effectiveness trials that will help to advance the implementation and dissemination of MORE as an empirically-supported intervention.
Research Conflict of Interest Disclosure
Eric Garland, PhD, LCSW is the Director of the Center on Mindfulness and Integrative Health Intervention Development. The Center provides Mindfulness-Oriented Recovery Enhancement (MORE), mindfulness-based therapy, and cognitive behavioral therapy in the context of research trials for no cost to research participants; however, Dr. Garland has received honoraria and payment for delivering seminars, lectures, and teaching engagements (related to training clinicians in MORE and mindfulness) sponsored by institutions of higher education, government agencies, academic teaching hospitals, and medical centers. Dr. Garland also receives royalties from the sale of books related to MORE.
Publications on MORE
- Garland, E.L., Hudak, J., Hanley, A.W., & Nakamura, Y. (2020). Mindfulness-Oriented Recovery Enhancement reduces opioid dose in primary care by strengthening autonomic regulation during meditation. American Psychologist, 75(6), 840-852.
- Hudak, J., Hanley, A.W., Marchand, W.R., Nakamura, Y., Yabko, B., Garland, E.L. (2020). Endogenous theta stimulation during meditation predicts reduced opioid dosing following treatment with Mindfulness-Oriented Recovery Enhancement. Neuropsychopharmacology.
- Hanley, A.W., & Garland, E.L. (2020). Salivary measurement and mindfulness-based modulation of prescription opioid cue-reactivity. Drug and Alcohol Dependence, 217(1).
- Hanley, A.W., & Garland, E.L. (2020). The Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM): Development and validation of a new tool to assess therapist adherence and competence. Journal of Evidence-Based Social Work.
- Garland, E.L., Atchley, R.M., Hanley, A.W., Zubieta, J.K., & Froeliger, B. (2019). Mindfulness-Oriented Recovery Enhancement remediates hedonic dysregulation in opioid users: Neural and affective evidence of target engagement. Science Advances, 5(10), eaax1569.
- Garland, E.L., Hanley, A.W., Kline, A., & Cooperman, N.A. (2019). Mindfulness-Oriented Recovery Enhancement reduces opioid craving among individuals with opioid use disorder and chronic pain in medication assisted treatment: Ecological momentary assessments from a stage 1 randomized controlled trial. Drug and Alcohol Dependence, 201(1), 61-65.
- Garland, E.L., Hanley, A.W., Riquino, M.R., Reese, S.E., Baker, A.K., Salas, K., Yack, B.P., Bedford, C.E., Bryan, M.A., Atchley, R.M., Nakamura, Y., Froeliger, B., & Howard, M.O. (2019). Mindfulness-Oriented Recovery Enhancement reduces opioid misuse risk via analgesic and positive psychological mechanisms: A randomized controlled trial. Journal of Consulting and Clinical Psychology.
- Thomas, E.A., Mijangos, J., Walker, D., Reimers, C., Beck, A., Hansen, P., & Garland, E.L. (in press). Mindfulness-Oriented Recovery Enhancement restructures reward processing and promotes interoceptive awareness in overweight cancer survivors: Mechanistic results from a stage 1 RCT. Integrative Cancer Therapies
- Garland E.L., Bryan, M.A., Priddy, S.E., Riquino, M.R., Froeliger, B., & Howard, M.O. (2018). Effects of Mindfulness-Oriented Recovery Enhancement versus social support on negative affective interference during inhibitory control among opioid-treated chronic pain patients: A pilot mechanistic study. Annals of Behavioral Medicine.
- Garland, E.L. & Howard, M.O. (2018). Enhancing natural reward responsiveness among opioid users predicts relief from chronic pain: An analysis of EEG data from a trial of Mindfulness-Oriented Recovery Enhancement. Journal of the Society for Social Work and Research, 9(2), 2334-2315.
- Li, W., Garland, E.L., & Howard, M.O. (2018). Therapeutic mechanisms of Mindfulness-Oriented Recovery Enhancement for internet gaming disorder: Reducing craving and addictive behavior by targeting cognitive processes. Journal of Addictive Diseases.
- Garland, E.L., Howard, M.O., Zubieta, J., & Froeliger, B. (2017). Restructuring hedonic dysregulation in chronic pain and prescription opioid misuse: Effects of Mindfulness-Oriented Recovery Enhancement on responsiveness to drug cues and natural rewards. Psychotherapy and Psychosomatics, 86(2), 111-112.
- Garland, E.L., Baker, A.K., & Howard, M.O. (2017). Mindfulness-Oriented Recovery Enhancement reduces opioid attentional bias among prescription opioid-treated chronic pain patients. Journal of the Society for Social Work and Research.
- Garland, E.L., Bryan, C.J., Finan, P., Thomas, E.A., Priddy, S.E., Riquino, M., & Howard, M.O. (2017). Pain, hedonic regulation, and opioid misuse: Modulation of momentary experience by Mindfulness-Oriented Recovery Enhancement in opioid-treated chronic pain patients. Drug and Alcohol Dependence, 173, S65-S72.
- Garland, E.L., Baker, A.K., Riquino, M.R., & Priddy, S.E. (2017). Mindfulness-Oriented Recovery Enhancement: A review of its theoretical underpinnings, clinical application, and biobehavioral mechanisms. In Ivtzan, I. (ed.), Handbook of Mindfulness-Based Programs: Every Established Intervention, from Medicine to Education. Routledge Press.
- Li, W., Garland, E.L., McGovern, P., O’Brien, J.E., Tronnier, C., & Howard, M.O. (2017). Mindfulness-Oriented Recovery Enhancement for internet gaming disorder in U.S. adults: A stage 1 randomized controlled trial. Psychology of Addictive Behaviors, 31, 393-402.
- Froeliger, B., Mathew, A., McConnell, P., Eichberg, C., Saladin, M.E., Carpenter, M.J., & Garland, E.L. (in press). Restructuring reward mechanisms in nicotine addiction: A pilot fMRI study of Mindfulness-Oriented Recovery Enhancement for cigarette smokers. Evidence-Based Complementary and Alternative Medicine.
- Li, W., Garland, E. L., O’Brien, J.E., Tronnier, C., McGovern, P., Howard, M. O. (2017). Mindfulness-Oriented Recovery Enhancement for video game addiction in emerging adults: Preliminary findings from case reports. International Journal of Mental Health and Addiction.
- Garland, E.L. (2016). Targeting hedonic dysregulation with Mindfulness-Oriented Recovery Enhancement: Restructuring reward mechanisms in addiction, stress, and pain. Annals of the New York Academy of Sciences, 1373, 25-37.
- Garland, E.L., Roberts-Lewis, A., Tronnier, C., Kelley, K., & Graves, R. (2016). Mindfulness-Oriented Recovery Enhancement versus CBT for co-occurring substance dependence, traumatic stress, and psychiatric disorders: Proximal outcomes from a pragmatic randomized trial. Behaviour Research and Therapy, 77, 7-16.
- Garland, E.L., Froeliger, B.E., & Howard, M.O. (2015). Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: Exploratory ERP findings from a pilot RCT. Journal of Behavioral Medicine, 38(2), 327-336.
- Garland, E.L., Froeliger, B., & Howard, M.O. (2014). Effects of Mindfulness-Oriented Recovery Enhancement on reward responsiveness and opioid cue-reactivity. Psychopharmacology, 231(16), 3229-3238.
- Garland, E.L., Manusov, E.G., Froeliger, B., Kelly, A., Williams, J., & Howard, M.O. (2014). Mindfulness-Oriented Recovery Enhancement for chronic pain and prescription opioid misuse: Results from an early stage randomized controlled trial. Journal of Consulting and Clinical Psychology, 82(3), 448-459.
- Garland, E.L., Thomas, E.A., & Howard, M.O. (2014). Mindfulness-Oriented Recovery Enhancement ameliorates the impact of pain on self-reported psychological and physical function among opioid-using chronic pain patients. Journal of Pain and Symptom Management, 48(6), 1091-1099.
- Garland, E.L., & Howard, M.O. (2013). Mindfulness-Oriented Recovery Enhancement reduces pain attentional bias in chronic pain patients. Psychotherapy and Psychosomatics, 82, 311-318.
- Kelly, A., & Garland, E.L. (2014). Treatment of depression and coping with chronic pain through Mindfulness-Oriented Recovery Enhancement. In C.W. LeCrory (ed.), Case Studies in Social Work Practice. Wiley: New York.
- Garland, E.L., Schwarz, N., Kelly, A., Whitt, A., & Howard, M.O. (2012). Mindfulness-Oriented Recovery Enhancement for alcohol dependence: Therapeutic mechanisms and intervention acceptability. Journal of Social Work Practice in the Addictions, 12, 242-263.
- Garland, E.L., Gaylord, S.A., Boettiger, C.A., & Howard, M.O. (2010). Mindfulness training modifies cognitive, affective, and physiological mechanisms implicated in alcohol dependence: Results from a randomized controlled pilot trial. Journal of Psychoactive Drugs, 42(2), 177-192.