Mindfulness-Oriented Recovery Enhancement: An Overview
Mindfulness-Oriented Recovery Enhancement (MORE) is a mental training program that unites complementary aspects of mindfulness training, “Third Wave” cognitive-behavioral therapy, and positive psychological principles into an integrative treatment strategy. The MORE program is detailed in a treatment manual designed for use by therapists (and patients). Eric Garland, Ph.D., LCSW developed MORE by translating findings from basic behavioral science and neuroscience into specific strategies designed to ameliorate addictive behavior, stress, and (physical and emotional) pain. 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.
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. Clients are taught to mindfully disengage from negative appraisals of stressful events and restructure them until they abate and positive reappraisals are constructed to promote resilience, meaning in life, and active coping behavior.
3. SAVORING: MORE enhances positive emotion and motivation by instructing clients to mindfully focus attention on and savor naturally rewarding experiences (e.g., a enjoying a beautiful nature scene or the sense of connection with a loved one) while cultivating metacognitive awareness of their own positive emotional responses to such experiences. 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.
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.
Research Evidence on MORE
MORE has been tested through a more than $25 million treatment development research program. Dr. Garland originally developed and tested MORE during his NIH-funded pre-doctoral fellowship in a Stage 1 randomized controlled trial (RCT) for alcohol dependence that demonstrated MORE could significantly improve physiological recovery from stress and drinking-related triggers (Garland et al., 2010). Later, MORE was adapted to address substance dependence, in general, and was shown in a SAMHSA-funded Stage 3 RCT to outperform CBT in reducing craving and PTSD symptoms in a sample of 180 formerly homeless individuals with co-occurring substance use and psychiatric disorders (Garland et al., 2016). In a Stage 2 RCT funded by the National Institute on Drug Abuse, MORE was shown to significantly reduce pain symptoms and prescription opioid misuse (Garland et al., 2014); a second Stage 2 RCT replicated the therapeutic effects of MORE on pain and opioid misuse (Garland et al., 2019); thus, MORE appears to be an efficacious treatment for opioid misuse. MORE has also been shown to produce therapeutic effects in people with video game addiction (Li et al., 2017), nicotine addiction (Froeliger et al., 2017), and binge eating (Thomas et al., 2019). Recently, MORE was piloted in a NIH-funded Stage 1 RCT as an adjunct to medication assisted treatment for opioid use disorder (OUD), and was found to significantly decrease number of days of illicit drug use and reduce the likelihood of relapse to cocaine (Cooperman et al., 2019). Five large, multi-million dollar Stage 3 and 4 RCTs funded by the NIH, the Department of Defense, and the Patients Centered Outcomes Research Institute are underway to study the effects of MORE as a treatment for opioid misuse and chronic pain. Two new NIH-funded studies will be using fMRI to examine the effects of MORE on the brain mechanisms of addiction recovery.
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., 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. (in press). 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.