Psychology of Addictive Behaviors 2014, Vol. 28, No. 2, 498 –506
© 2013 American Psychological Association 0893-164X/14/$12.00 DOI: 10.1037/a0034706
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Which Facets of Mindfulness Predict the Presence of Substance Use Disorders in an Outpatient Psychiatric Sample? Michael E. Levin
Kristy Dalrymple and Mark Zimmerman
Alpert Medical School of Brown University and Utah State University
Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
There have been inconsistent findings regarding the relationship of mindfulness to substance use disorders, which may be attributable in part to measurement issues and the use of nonclinical samples. The current study examined the relationship between specific facets of mindfulness and substance use disorders (SUD) in a clinical sample. The sample consisted of 867 patients seeking outpatient treatment and who completed diagnostic interviews and self-report assessments. Results indicated that deficits in acting with awareness, being nonjudgmental, and nonreactivity were related to the presence of a current SUD relative to those with no history of SUD, although only acting with awareness and being nonjudgmental were related when all of the facets were included in a logistic regression. Patients with a past history of SUD had greater deficits in acting with awareness relative to those with no history of SUD. Results were similar when examining alcohol use and drug use disorders separately. Current nicotine users had greater deficits in being nonjudgmental, but not on other mindfulness facets. The observing facet was not related to current or past history of SUD. The results of the study and future directions are discussed in relation to research on mindfulness-based treatments for addiction. Keywords: mindfulness, addiction, substance use disorders, mindfulness-based interventions
erally, nonintervention studies have found that deficits in mindfulness are predictive of depression, anxiety, and a variety of other measures of psychological health (Keng et al., 2011). Research with cigarette smokers has similarly found that deficits in mindfulness are related to severity of nicotine dependence and withdrawal symptoms (Vidrine et al., 2009). The research to date examining the relationship between mindfulness and alcohol/illicit drug abuse has been more inconsistent, however, with some studies finding deficits in mindfulness relating to higher rates of substance abuse (Fernandez, Wood, Stein & Rossi, 2010; Murphy & MacKillop, 2012) and other studies finding the opposite such that deficits relate to lower rates of substance abuse (Leigh & Neighbors, 2009; Leigh, Bowen & Marlatt, 2005). One explanation for the inconsistent findings with substance abuse is variations across studies in how mindfulness is measured. Early self-report measures tended to consist of a single factor assessing overall levels of mindfulness (e.g., Mindful Attention Awareness Scale, Brown & Ryan, 2003). More recent research has found that the factor structure of mindfulness self-report items indicates a multifaceted construct (Baer et al., 2006). There are a variety of conceptualizations of mindfulness, but definitions tend to highlight facets including awareness of the present and taking a nonjudgmental, accepting, and nonreactive stance to whatever is observed (Bishop et al., 2004). The current study focused on the mindfulness facets derived from the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006), which consists of observing, describing, acting with awareness, being nonjudgmental, and nonreactivity, and thus provides a means to examine the relation of SUDs to a range of theoretically meaningful facets. When examining specific facets of mindfulness, it appears that higher scores on a measure of mind/body awareness tended to relate with greater
Mindfulness-based methods have been gaining increasing attention as an approach for treating substance abuse and other addictive behaviors (Bowen, Chawla & Marlatt, 2010; Hayes & Levin, 2012; Zgierska et al., 2009). These interventions focus on various techniques such as contemplative meditation to improve one’s awareness of the present moment in a nonjudgmental, nonreactive, and accepting way. There is a growing research base suggesting that mindfulness-based interventions, as well as interventions that incorporate mindfulness technologies within a cognitive– behavioral approach, may be efficacious for treating substance abuse and preventing relapse (Bowen, Witkiewitz & Chawla., 2012; Chiesa & Serretti, 2013; Kelly et al., 2012; Zgierska et al., 2009). Although there have been a number of clinical trials evaluating mindfulness-based interventions with addictions (see Chiesa & Serretti, 2013 for a recent review), there has been limited research regarding whether deficits in mindfulness skills are related to substance use disorders (SUDs) in nonintervention research. Such research could inform the development of a theoretical model for understanding how mindfulness leads to improvements in addiction outcomes, guiding further treatment innovations. More gen-
This article was published Online First November 25, 2013. Michael E. Levin, Department of Psychology, Utah State University; Kristy Dalrymple and Mark Zimmerman, Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University and Department of Psychiatry, Rode Island Hospital, Providence, Rhode Island. Correspondence concerning this article should be addressed to Michael E. Levin, Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT 84322. E-mail: [email protected] 498
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MINDFULNESS AND SUBSTANCE USE DISORDERS
substance use (Leigh et al., 2005; Leigh & Neighbors, 2009), whereas measures assessing being nonreactive and nonjudgmental of one’s experiences, acting with awareness, and describing one’s experiences tend to be related to lower substance use (Fernandez et al., 2010; Leigh & Neighbors, 2009; Murphy & MacKillop, 2012). Theoretically, deficits in each facet of mindfulness may play a role in substance use disorders including alcohol, illicit drug, and nicotine use disorders. Present moment awareness, including observing, describing, and acting with awareness, is important for identifying triggers and high risk situations, which can inform effective coping strategies in the moment and reduce the potential for impulsively or automatically using substances in reaction to triggers (Bowen et al., 2012). In addition, recent research suggests that a greater capacity to describe and differentiate one’s emotions throughout the day can serve to reduce substance abuse, even when experiencing negative affect (Kashdan & Rottenberg, 2010). Negative affect is a key predictor of relapse (e.g., Witkiewitz & Villarroel, 2009), and research indicates that individuals with substance use disorders have difficulty tolerating distress (Leyro, Zvolensky & Bernstein, 2010) and effectively regulating emotions (Aldao, Nolen-Hoeksema & Schweitzer, 2010). The capacity to be nonjudgmental and nonreactive to one’s experiences can serve to reduce emotional reactivity and ineffective coping strategies while providing a foundation to effectively practice tolerating distress and urges to use substances (Bowen et al., 2012). For example, one study found that individuals who were more mindfully accepting were less likely to abuse alcohol despite having implicit biases to do so (Ostafin & Marlatt, 2008). Given the inconsistent findings within research thus far, it is unclear which of these mindfulness facets play a role in substance abuse. Further research is needed to examine whether describing, acting with awareness, being nonjudgmental, and nonreactivity are all functionally important to SUDs or whether particular mindfulness facets are more or less relevant. The current study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project sought to examine which facets of mindfulness, if any, are related to the presence of SUDs among a clinical sample of psychiatric outpatients. Research to date primarily has been conducted with nonclinical samples, which may further explain the inconsistent findings across studies, and it is less clear how mindfulness facets relate to SUDs in clinical samples. Given past research, it was hypothesized that deficits in the describing, acting with awareness, nonreactivity, and nonjudgmental facets of mindfulness would all be related to the presence of SUDs. The observing facet was hypothesized to be unrelated to SUDs or relate in the opposite direction (i.e., greater observing scores related to higher probability of SUD), given past research suggesting this subscale is not predictive of psychopathology (e.g., Bohlmeijer et al., 2011) or predicts greater problems (e.g., Baer et al., 2006) and that heightened mind-body awareness relates to greater substance abuse (Leigh et al., 2005; Leigh & Neighbors, 2009). These results could further inform theoretical models regarding the role of specific mindfulness facets in addictions. In addition, these findings could help guide treatment development by highlighting the qualities of mindfulness that may be particularly important to focus on in SUD interventions.
499 Method
Participants The sample consisted of 867 patients seeking outpatient treatment at the Rhode Island Hospital Department of Psychiatry. The sample was 56.2% female with a median age of 39 (M ⫽ 39.29, SD ⫽ 14.24). The sample was 91.2% White/Caucasian, 3.3% Black/African American, 2.9% Hispanic, 1.6% Asian, and 1.0% other race. In addition, 3.6% of the sample identified as Latino ethnicity. In terms of education, 8.5% of the sample did not graduate high school, 52.3% of the sample graduated high school but not college, 24.5% graduated with a 4-year college degree, and 14.6% received a graduate degree. The percentage of patients with a current SUD diagnosis (excluding nicotine dependence) was 4% (n ⫽ 32) alcohol abuse, 7% (n ⫽ 60) alcohol dependence, 3% (n ⫽ 25) drug abuse, and 7% (n ⫽ 57) drug dependence. The percentage with a past SUD diagnosis was 16% (n ⫽ 134) alcohol abuse, 12% (n ⫽ 102) alcohol dependence, 12% (n ⫽ 100) drug abuse, and 10% (n ⫽ 83) drug dependence. The most common drug use disorders were cannabis abuse (2% with current diagnosis [n ⫽ 21]; 8% past diagnosis [n ⫽ 69]) and cannabis dependence (4% with current diagnosis [n ⫽ 31]; 4% past diagnosis [n ⫽ 32]). In addition, 3% were diagnosed with a current noncannabis drug use disorder and 12% diagnosed with a past noncannabis drug use disorder spanning across a range of illicit drugs. In terms of cigarette smoking prevalence, 23% were current smokers, 28% were past smokers, and 48% had no history of regular smoking (nicotine use disorders were not included as SUDs for reported analyses, but were analyzed separately). The prevalence of other psychological disorders by SUD status is provided in Table 1.
Procedure The MIDAS project (Zimmerman, 2003) is integrated within an outpatient psychiatry practice providing fee-for-service psychiatric treatment, to patients with medical insurance (including Medicare but not Medicaid). The majority of referrals come from primary care physicians (31.6%), therapists in the community (15.8%), and family members or friends (17.5%); this latter group refers more than therapists. Patients seeking treatment at the practice are asked to participate in a comprehensive diagnostic interview prior to meeting with their treating clinician. For those who agree, in-
Table 1 Prevalence of Current and Past Diagnoses by Substance Use Disorder Status Other past or current psychiatric disorders
No SUD (n ⫽ 471)
Current SUD (n ⫽ 149)
Past SUD (n ⫽ 247)
Depressive disorder Anxiety disorder Eating disorder Adjustment disorder Bipolar disorder Impulse-control disorder Somatoform disorder Psychotic disorder Cigarette smoker
187 (40%) 250 (53%) 12 (3%) 50 (11%) 13 (3%) 18 (4%) 31 (7%) 5 (1%) 166 (35%)
59 (40%) 92 (62%) 3 (2%) 8 (5%) 16 (11%) 11 (7%) 12 (8%) 0 (0%) 101 (68%)
110 (45%) 149 (60%) 8 (3%) 10 (4%) 15 (6%) 16 (6%) 19 (8%) 4 (2%) 180 (73%)
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500
LEVIN, DALRYMPLE, AND ZIMMERMAN
formed consent is obtained before administering the diagnostic interview. The study was approved by the Rhode Island Hospital Institutional Review Board. Diagnostic interviews were conducted by doctoral level clinical psychologists and bachelor’s level research assistants. Training for research assistants included observing a psychologist conduct at least 20 interviews, followed by being supervised while conducting 20 interviews. Training for clinical psychologists included observing 5 evaluations, followed by being supervised while conducting 15–20 evaluations. All interviewers then had to demonstrate almost perfect reliability on 5 interviews with senior diagnosticians to complete their training (i.e., agree on the principal diagnosis and demonstrate approximately 80% agreement on diagnoses overall for a given patient). Every interview is reviewed on an item-by-item basis with the senior diagnostician who observed the interview during the course of training. To prevent rater drift, ongoing weekly case conferences are conducted with all members of the team, and item ratings are reviewed by the principal investigator (M.Z.) for every case.
Measures Clinical interviewer assessments. Diagnostic interviewers conducted the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM–IV; SCID; First, Spitzer, Gibbon & Williams, 1995) with each participant to assess DSM–IV Axis I disorders including substance use disorders. Interrater reliability on the SCID was examined for a subsample of patients (n ⫽ 65) using the joint interview method, with results indicating adequate reliability for alcohol use (k ⫽ .64) and drug use disorders (k ⫽ .73; Zimmerman, McGlinchey, Chelminski & Young, 2008). For the current study we combined the alcohol abuse, alcohol dependence, drug abuse, and drug dependence diagnostic categories into a single diagnostic group of substance use disorders (SUD). Cigarette smoking history was also assessed during the clinical interview with the question “Have you ever smoked cigarettes daily for at least one month?” Follow-up questions determined whether patients were currently smoking regularly or only had a past history of cigarette smoking. Additional interviewer items examined in the current study included the psychic and somatic anxiety items from the Schedule for Affective Disorders and Schizophrenia (SADS; Spitzer & Endicott, 1977), which were used to assess severity of anxiety symptoms. The psychic anxiety item asks “how anxious, frightened, scared, or apprehensive have you felt during the past week?” and the somatic anxiety item asks “During the past week have you been bothered by physical symptoms like palpitations, shortness of breath, sweating, headaches, stomach cramps or muscle tension?” For both of these items, patient responses are rated on a 6-point scale ranging from 0, Not at all to 5, Extreme. The interrater reliability for the psychic and somatic anxiety items were ICC ⫽ .88 (p ⬍ .001) and ICC ⫽ .87 (p ⬍ .001), respectively. In addition, the Clinical Global Impression-Severity of depression (CGI-S; Guy, 1976) was used to rate overall depressive symptom severity, with severity rated on a 6-point scale ranging from 0, None to 5,
Extreme. Interrater reliability for the CGI was also high (ICC ⫽ 0.79, p ⬍ .001). Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006). The FFMQ is a 39-item questionnaire designed to assess five facets of mindfulness: observing, describing, acting with awareness, being nonjudgmental, and nonreactivity. The observing subscale assesses one’s attention to present moment experiences (i.e., “I notice the smells and aromas of things”). The describing subscale assesses the ability to label one’s thoughts, feelings, and sensations (i.e., “I’m good at finding the words to describe my feelings”). The acting with awareness subscale assesses the tendency to not attend to present moment experiences while engaging in activities (i.e., “I find myself doing things without paying attention”). The nonjudgmental subscale assesses the tendency to judge one’s thoughts and feelings as bad and to criticize oneself for having negative thoughts and feelings (i.e., “I think some of my emotions are bad or inappropriate and I shouldn’t feel them”). The nonreactivity subscale assesses the capacity to notice thoughts and feelings without acting on or otherwise getting entangled with them (i.e., “I perceive my feelings and emotions without having to react to them”). Each FFMQ item is rated on a 5-point scale ranging from 1 (never or very rarely true) to 5 (very often or always true). Negatively worded items were reverse scored so that for each subscale higher scores indicated greater mindfulness. The FFMQ has been found to be a reliable and valid measure of mindfulness in past research with nonclinical (Baer et al., 2006) and clinical samples (Bohlmeijer et al., 2011). In the current sample, each of the subscales demonstrated adequate internal consistency (Observing Cronbach’s alpha ⫽ .81; Describing Cronbach’s alpha ⫽ .89; Acting with awareness Cronbach’s alpha ⫽ .90; Nonjudgmental Cronbach’s alpha ⫽ .91; and Nonreactivity Cronbach’s alpha ⫽ .81).
Data Analysis The FFMQ subscales were normally distributed as indicated by examining histograms, skewness, and kurtosis for each variable. For each subscale, mean scores were calculated provided a participant answered 85% or more of the items for the given subscale, which has been used in past research (Levin, Lillis & Hayes, 2012). After applying this correction for missing items, between .6% and 1.6% were missing data for each subscale, with complete FFMQ data available for 844 of 867 participants.1 Zero order correlations were conducted to examine the relationship between mindfulness facets and symptoms of depression and anxiety. Analysis of Covariance (ANCOVA) was used to examine differences in scores on mindfulness facets between patients with a current/partial remission SUD, past history of SUD, or no history of SUD. SUD status was based on presence of alcohol and/or illicit drug use disorders. Cigarette smoking was not counted as a SUD (it was analyzed separately). It is important to note that patients without a SUD history were diagnosed with other psychiatric disorders (see Table 1). The CGI depression, somatic anxiety, and 1 Between 2.2% and 8.7% of participants were missing one or more items for each FFMQ subscale. The reported results were similar when only analyzing the sub-sample who completed all items for a given FFMQ subscale.
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MINDFULNESS AND SUBSTANCE USE DISORDERS
psychic anxiety ratings from clinical interviews were entered as covariates to control for the relationship between mindfulness and depression/anxiety symptoms (e.g., Cash & Wittingham, 2010). Post hoc tests were conducted using the Tukey least significant difference test to examine differences in mindfulness facet scores between these three diagnostic groups. A multinomial logistic regression was then conducted to further examine the degree to which facets of mindfulness predict the presence of a current SUD, history of SUD and no history of SUD, when controlling for depression and anxiety variables. The multinomial logistic regression also provided a means of examining the relationship of each mindfulness facet to SUD status while controlling for other facets of mindfulness to better determine their independent relationship to SUDs. Follow-up ANCOVA and multinomial logistic regression analyses were conducted separately with alcohol use disorders and with illicit drug use disorders. Additional analyses examined whether mindfulness facets differed between current smokers, past smokers, and patients with no history of smoking using ANCOVA and regression analyses. SUD status was included as an additional covariate in smoking analyses given the comorbidity between SUDs and cigarette smoking.
Results Zero Order Correlations Analyses were conducted to examine the relationships among the mindfulness facets and between these facets and symptoms of depression and anxiety (see Table 2). The describing, acting with awareness, nonjudgmental, and nonreactivity facets were all significantly correlated in the expected direction (i.e., greater mindfulness in one facet relating to greater mindfulness in another facet) with correlation coefficients ranging from .18 to .40. The observing facet was correlated with each of the other facets, but the correlations with acting with awareness and being nonjudgmental were in the opposite direction (i.e., greater observing related to lower acting with awareness and being nonjudgmental). Depression and anxiety symptoms were significantly correlated with describing, acting with awareness, nonjudgmental, and nonreactivity facets such that greater mindfulness related to lower symptoms, with correlation coefficients ranging from .10 to .40. However, the observing facet was unrelated to depression and correlated in the opposite direction with anxiety symptoms such that higher observing related to greater anxiety.
501
Analyses With Past and Current SUD Diagnoses Analyses were conducted to examine differences in facets of mindfulness by diagnostic groups. Descriptive statistics for each FFMQ subscale by diagnostic group are provided in Table 3. ANCOVA results indicated a significant main effect for SUD status with the FFMQ acting with awareness subscale, F(2, 853) ⫽ 9.71, p ⬍ .001, partial 2 ⫽ .02, nonjudgmental subscale, F(2, 853) ⫽ 4.32, p ⫽ .01, partial 2 ⫽ .01, and nonreactivity subscale, F(2, 845) ⫽ 5.27, p ⫽ .005, partial 2 ⫽ .01. There were no significant main effects for SUD status on the observing or describing subscales (p ⬎ .10). Pairwise comparisons indicated significantly higher scores on acting with awareness among patients with no history of SUD relative to those with current SUD (covariate adjusted mean [Mdiff] ⫽ 2.46, SE ⫽ .61, p ⬍ .001) and relative to those with a past SUD history (Mdiff ⫽ 1.49, SE ⫽ .52, p ⫽ .004). Patients with no history of SUD had significantly higher levels on being nonjudgmental relative to those with current SUD (Mdiff ⫽ 1.82, SE ⫽ .63, p ⫽ .004), but there were no significant differences between patients with a past history of SUD and the other two groups. Patients with current SUD had significantly lower levels of nonreactivity relative to those with no history of SUD (Mdiff ⫽ 1.42, SE ⫽ .46, p ⫽ .002) and relative to patients with a past history of SUD (Mdiff ⫽ 1.41, SE ⫽ .50, p ⫽ .005). A multinomial logistic regression was conducted to further examine which mindfulness facets predicted having a current SUD, past history of SUD, or no history of SUD, when controlling for the other mindfulness facets as well as depression and anxiety symptoms (see Table 4). The overall model significantly predicted SUD status, with post hoc analyses indicating acting with awareness, nonreactivity, and being nonjudgmental as predictors of having a current SUD relative to no history of SUD. Only the acting with awareness subscale significantly predicted having a history of SUD relative to no history of SUD. There was also a statistical trend for depression predicting a history of SUD relative to no history of SUD. In each case lower mindfulness and greater symptom scores were predictive of a greater likelihood of having a SUD diagnosis relative to no history of SUD. No other facets of mindfulness or anxiety symptoms were predictive of SUD status (p ⬎ .10).
Follow-Up Analyses With Alcohol Use Disorders Follow up analyses were conducted separately among patients with alcohol use disorders (current diagnosis n ⫽ 94; past diag-
Table 2 Zero Order Correlations Between Mindfulness Facets, Depression Symptoms, and Anxiety Symptoms 1 1. 2. 3. 4. 5. 6. 7. 8. †
Observing Describing Act w/aware Nonjudgmental Nonreactivity Depression Psychic anx. Somatic anx.
p ⬍ .10.
ⴱ
p ⬍ .05.
2
— .18ⴱⴱⴱ ⫺.10ⴱⴱ ⫺.21ⴱⴱⴱ .24ⴱⴱⴱ .05 .06† .07ⴱ ⴱⴱ
p ⬍ .01.
3 ⴱⴱⴱ
.18 — .34ⴱⴱⴱ .21ⴱⴱⴱ .31ⴱⴱⴱ ⫺.21ⴱⴱⴱ ⫺.12ⴱⴱⴱ ⫺.10ⴱⴱ ⴱⴱⴱ
p ⬍ .001.
4 ⴱⴱ
⫺.10 .34ⴱⴱⴱ — .40ⴱⴱⴱ .18ⴱⴱⴱ ⫺.26ⴱⴱⴱ ⫺.28ⴱⴱⴱ ⫺.17ⴱⴱⴱ
5 ⴱⴱⴱ
⫺.21 .21ⴱⴱⴱ .40ⴱⴱⴱ — .24ⴱⴱⴱ ⫺.40ⴱⴱⴱ ⫺.30ⴱⴱⴱ ⫺.27ⴱⴱⴱ
6 ⴱⴱⴱ
.24 .31ⴱⴱⴱ .18ⴱⴱⴱ .24ⴱⴱⴱ — ⫺.20ⴱⴱⴱ ⫺.21ⴱⴱⴱ ⫺.21ⴱⴱⴱ
.05 ⫺.21ⴱⴱⴱ ⫺.26ⴱⴱⴱ ⫺.40ⴱⴱⴱ ⫺.20ⴱⴱⴱ — .38ⴱⴱⴱ .40ⴱⴱⴱ
7
8 †
.06 ⫺.12ⴱⴱⴱ ⫺.28ⴱⴱⴱ ⫺.30ⴱⴱⴱ ⫺.21ⴱⴱⴱ .38ⴱⴱⴱ — .68ⴱⴱⴱ
.07ⴱ ⫺.10ⴱⴱ ⫺.17ⴱⴱⴱ ⫺.27ⴱⴱⴱ ⫺.21ⴱⴱⴱ .40ⴱⴱⴱ .68ⴱⴱⴱ —
LEVIN, DALRYMPLE, AND ZIMMERMAN
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Table 3 Descriptive Statistics for Each Mindfulness Facet by Diagnostic group No history of SUD Current SUD Past history of SUD M (SD) M (SD) M (SD)
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Observing Describing Act w/aware Nonjudgmental Nonreactivity
23.14 (6.54) 26.30 (6.64) 25.30 (7.16) 24.85 (7.52) 19.05 (5.06)
23.23 (6.28) 25.11 (6.81) 22.50 (6.60) 22.51 (7.34) 17.45 (4.71)
23.54 (6.42) 25.18 (6.99) 23.46 (6.33) 23.44 (7.23) 18.85 (4.92)
nosis n ⫽ 234) relative to patients with no SUD history (i.e., no history of alcohol use or drug use disorders; n ⫽ 471). ANCOVA results indicated a significant main effect for alcohol use disorder status with the FFMQ describing, F(2, 793) ⫽ 3.17, p ⫽ .043, partial 2 ⫽ .01, acting with awareness, F(2, 792) ⫽ 9.49, p ⬍ .001, partial 2 ⫽ .02, being nonjudgmental, F(2, 792) ⫽ 5.19, p ⫽ .006, partial 2 ⫽ .01, and nonreactivity subscales, F(2, 785) ⫽ 3.11, p ⫽ .045, partial 2 ⫽ .01. There was no significant main effect for SUD status on the observing subscale (p ⬎ .10). Post hoc pairwise comparisons indicated significantly higher scores on describing among patients with no history of SUD relative to those with a past alcohol disorder history (Mdiff ⫽ 1.32, SE ⫽ .53, p ⫽ .013), but no difference between current alcohol disorder and either past or no SUD history (p ⬎ .10). Patients with no history of SUD had significantly higher scores on acting with awareness relative to those with a current alcohol disorder (Mdiff ⫽ 2.43, SE ⫽ .74, p ⫽ .001) and relative to patients with a past alcohol disorder (Mdiff ⫽ 1.89, SE ⫽ .53, p ⬍ .001). Patients with a current alcohol disorder had significantly lower scores on being nonjudgmental relative to those with no history of SUD (Mdiff ⫽ 2.39, SE ⫽ .76, p ⫽ .002) and relative to patients with a past
alcohol disorder (Mdiff ⫽ 1.63, SE ⫽ .82, p ⫽ .046). Patients with a current alcohol disorder had significantly lower scores on nonreactivity relative to those with no history of SUD (Mdiff ⫽ 1.35, SE ⫽ .54, p ⫽ .013) and a trend relative to patients with a past alcohol disorder (Mdiff ⫽ 1.04, SE ⫽ .59, p ⫽ .076). The overall model was significant for the multinomial logistic regression examining mindfulness facets and depression and anxiety symptoms as predictors of current alcohol disorder, past alcohol disorder or no SUD history (see Table 4). Post hoc analyses indicated that acting with awareness, being nonjudgmental, and nonreactivity predicted having a current alcohol use disorder relative to no history of SUD. Only the acting with awareness subscale significantly predicted having a history of alcohol disorder relative to no history of SUD. In each case lower mindfulness scores were predictive of a greater likelihood of having an alcohol disorder diagnosis relative to no history of SUD. No other facets of mindfulness or depression and anxiety symptoms were predictive of alcohol disorder status (p ⬎ .10).
Follow-Up Analyses With Drug Use Disorders Follow-up analyses were conducted separately among patients with illicit drug use disorders (current diagnosis n ⫽ 77; past diagnosis n ⫽ 152) relative to patients with no SUD history (i.e., no history of alcohol use or drug use disorders; n ⫽ 471). ANCOVA results indicated a significant main effect for drug use disorder status with the FFMQ describing, F(2, 695) ⫽ 3.59, p ⫽ .028, partial 2 ⫽ .01, acting with awareness, F(2, 694) ⫽ 9.29, p ⬍ .001, partial 2 ⫽ .03, being nonjudgmental, F(2, 693) ⫽ 4.30, p ⫽ .014, partial 2 ⫽ .01, and nonreactivity subscales, F(2, 685) ⫽ 3.17, p ⫽ .043, partial 2 ⫽ .01. There was no significant main effect for SUD status on the observing subscale (p ⬎ .10). Post hoc pairwise comparisons indicated significantly higher scores on describing among patients with no history of SUD relative to those with a current drug disorder (Mdiff ⫽ 2.10, SE ⫽ .82, p ⫽ .010), but
Table 4 Multinomial Logistic Regression Results Testing Mindfulness and Depression and Anxiety Symptoms as Predictors of SUD Observe Exp(b)
Describe Exp(b)
Act w/aware Exp(b)
Current SUD vs. no history Past SUD vs. no history Overall model 2 ⫽ 41.88ⴱⴱⴱ, Nagelkerke R2 ⫽ .06
1.00 1.00
1.00 .99
.95ⴱⴱ .97ⴱ
Current AUD vs. no history Past AUD vs. no history Overall model 2 ⫽ 46.79ⴱⴱⴱ, Nagelkerke R2 ⫽ .07
.99 1.00
1.02 .98
Current DUD vs. no history Past DUD vs. no history Overall model 2 ⫽ 36.96ⴱⴱ, Nagelkerke R2 ⫽ .07
1.02 1.01
.97 .99
Current smoker vs. no history Past smoker vs. no history Overall model 2 ⫽ 124.15ⴱⴱⴱ, Nagelkerke R2 ⫽ .16
1.01 1.02
.97† .99
Nonreact Exp(b)
Depression Exp(b)
Psychic anx. Exp(b)
Somatic anx. Exp(b)
SUD status Exp(b)
.97† .99
.95ⴱ 1.01
1.01 1.14†
.95 .96
.98 .98
— —
.95ⴱ .97ⴱ
.96ⴱ .99
.96† 1.00
1.16 1.13
.99 .93
.87 1.04
— —
.95ⴱ .97ⴱ
.97 .98
.95† 1.00
.87 1.08
.84 1.01
1.12 .99
— —
.98† 1.02
1.02 1.00
.92 1.07
1.02 1.02
1.12 1.01
2.49ⴱⴱⴱ 2.23ⴱⴱⴱ
1.01 1.02
Nonjudge Exp(b)
Note. Between 2.2% and 8.7% of participants were missing one or more items for each FFMQ subscale. The reported results were similar when only analyzing the sub-sample who completed all items for a given FFMQ subscale. AUD ⫽ alcohol use disorders; DUD ⫽ illicit drug use disorders. † p ⬍ .10. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
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MINDFULNESS AND SUBSTANCE USE DISORDERS
no difference between past drug disorder and either current or no SUD history (p ⬎ .10). Patients with no history of SUD had significantly higher scores on acting with awareness relative to those with a current drug disorder (Mdiff ⫽ 3.01, SE ⫽ .81, p ⬍ .001) and relative to patients with a past drug disorder (Mdiff ⫽ 1.75, SE ⫽ .62, p ⫽ .005). Patients with no history of SUD had significantly higher scores on being nonjudgmental relative to those with a current drug disorder (Mdiff ⫽ 1.98, SE ⫽ .83, p ⫽ .017) and relative to patients with a past drug disorder (Mdiff ⫽ 1.33, SE ⫽ .63, p ⫽ .036). Patients with a current drug disorder had significantly lower scores on nonreactivity relative to those with no history of SUD (Mdiff ⫽ 1.51, SE ⫽ .60, p ⫽ .012) and relative to patients with a past drug disorder (Mdiff ⫽ 1.35, SE ⫽ .69, p ⫽ .050). The overall model was significant for the multinomial logistic regression examining mindfulness facets and depression and anxiety symptoms as predictors of current drug disorder, past drug disorder, or no SUD history (see Table 4). Post hoc analyses indicated that acting with awareness and nonreactivity predicted having a current drug disorder relative to no history of SUD. Only the acting with awareness subscale significantly predicted having a history of drug disorder relative to no history of SUD. In each case lower mindfulness scores were predictive of a greater likelihood of having a drug disorder diagnosis relative to no history of SUD. No other facets of mindfulness or depression and anxiety symptoms were predictive of drug disorder status (p ⬎ .10).
Follow-Up Analyses With Smoking Status A series of analyses were conducted to examine potential deficits in mindfulness facets among patients who reported currently smoking cigarettes (n ⫽ 202), a past history of regularly smoking (n ⫽ 245), or no history of regularly smoking (n ⫽ 419). ANCOVA analyses controlling for depression and anxiety symptoms as well as SUD status indicated a significant main effect for smoking status with the FFMQ nonjudgmental subscale, F(2, 850) ⫽ 5.06, p ⫽ .007, partial 2 ⫽ .01. There was no significant main effect for smoking status on the observing, describing, acting with awareness, or nonreactivity subscales (p ⬎ .10). Post hoc pairwise comparisons indicated significantly lower scores on being nonjudgmental among current smokers relative to past smokers (Mdiff ⫽ 2.04, SE ⫽ .64, p ⫽ .002), and a trend for lower scores among current smokers relative to patients with no history of smoking (Mdiff ⫽ 1.18, SE ⫽ .61, p ⫽ .052). The overall model was significant for the multinomial logistic regression examining mindfulness facets, depression and anxiety symptoms, and SUD status as predictors of current smoking, past smoking, or no smoking history (see Table 4). Post hoc analyses indicated a trend for describing and being nonjudgmental predicting being a current smoker relative to no history of smoking. SUD status predicted being a current smoker relative to no history as well as being a past smoker relative to no history. In each case lower mindfulness scores and history of SUD were predictive of a greater likelihood of being a smoker relative to no history.
Discussion The current study sought to examine the relationship between facets of mindfulness and SUDs in a clinical sample. Results indicated that deficits in acting with awareness, being nonjudg-
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mental, and nonreactivity were related to the presence of a current SUD relative to no history of SUD. In addition, patients with a past history of SUD had deficits in acting with awareness relative to those with no history of SUD. When controlling for other mindfulness facets in a multinomial logistic regression, only the acting with awareness and nonreactivity subscales significantly predicted presence of a current SUD relative to no history of SUD. A similar pattern of results was found when examining alcohol use and drug use disorders separately, except that describing was also related to SUD status. Current cigarette smokers demonstrated deficits in being nonjudgmental relative to past smokers and those with no history of smoking, but did not differ on other mindfulness facets. The observing facet was not related to current or past history of SUD in any analyses. These results add to the existing literature suggesting that specific facets of mindfulness are related to SUDs, particularly deficits in acting with awareness, being nonjudgmental, and nonreactivity (Fernandez et al., 2010; Leigh & Neighbors, 2009; Murphy & MacKillop, 2012). In addition, the results suggest that patients who smoke may have elevated deficits in being nonjudgmental of their emotions, which adds to research indicating the role of mindfulness and emotional acceptance in nicotine dependence (e.g., Gifford et al., 2011; Vidrine et al., 2009). This is the first study we are aware of that has examined these relationships in nonintervention research using a clinical sample of psychiatric patients, suggesting that similar findings generalize to clinical populations. Theoretically, the tendency to act without awareness could contribute to habitually engaging in addictive behaviors as well as failing to recognize and thus effectively cope with triggers and high risk situations that lead to relapse. The tendency to judge and be reactive to difficult emotions, thoughts, and urges may also elicit maladaptive avoidant behavior including further substance use, which is consistent with research indicating the relationship of distress tolerance and emotion regulation to SUDs (Aldao et al., 2010; Leyro et al., 2010). Experimental research is needed to further explore the role of these mindfulness facets in SUDs. Consistent with past research, deficits in the observing facet was not related to SUD status. However, the study also did not find a positive relationship between heightened observation of the present moment and increased substance abuse, which has been found in some past research (Leigh et al., 2005; Leigh & Neighbors, 2009). Theoretically, heightened observation could be a protective or risk factor depending on skills in other mindfulness facets. For example, if one was highly judgmental and reactive to one’s experiences, heightened observation could be indicative of hyperarousal and problematic self-monitoring. Alternatively, heightened observation in the context of being nonjudgmental and nonreactive could reflect an enhanced mindful attention to the present. Consistent with this, a recent study found a significant interaction between mindful observation and nonreactivity in predicting substance use, such that individuals who were high in observation and nonreactivity were less likely to use substances, whereas those high in observation and low in nonreactivity were more likely to use substances (Eisenlohr-Moul et al., 2012). Although these results do not indicate whether increasing mindfulness would be beneficial for addiction problems, they are consistent with other research which suggests that targeting
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present moment awareness and the capacity to notice experiences without judging or impulsively reacting to them may reduce substance use problems. For example, a recent study found that a mindfulness-based intervention for substance abuse reduced the occurrence of cravings in reaction to feeling depressed, and that this effect predicted lower rates of substance abuse (Witkiewitz & Bowen, 2010). Another study found that a mindfulness-based intervention for substance abuse reduced the tendency to try to suppress thoughts, which was related to better addiction outcomes (Bowen, Witkiewitz, Dilworth & Marlatt, 2007). These findings suggest that increasing one’s ability to mindfully notice one’s experiences in the present moment, without judging them or reacting to them, may be a promising mechanism for treating addictions. Yet, it is important to note that reviews of the literature indicate methodological weaknesses with existing research on mindfulness-based interventions for SUDs and the need for more research (Chiesa & Serretti, 2013). There are a few key limitations with the current study. First, the study used a cross sectional design so the temporal relationship between mindfulness deficits and SUD status is unclear. Although it is possible that mindfulness deficits may lead to substance abuse, chronic substance abuse may also reduce one’s present moment awareness and increase reactivity to difficult thoughts and feelings. Future research would benefit from longitudinal designs that can more clearly determine whether mindfulness deficits are risk factors for the development and exacerbation of SUDs. Given the services provided at the outpatient treatment program where the MIDAS Project is conducted, only 17% of the patients with a current or past SUD had a SUD diagnosis alone. There is a high prevalence of comorbid psychiatric diagnoses among SUD populations (Conway, Compton, Stinson & Grant, 2006; Kessler, 2004), which lends to the generalizability of the current findings. Nonetheless, it is unclear whether the observed deficits in mindfulness facets are attributable to the presence of a SUD in general or unique to features regarding having a comorbid SUD in addition to other psychiatric disorders. However, we statistically controlled for depression and anxiety symptoms, reducing the potential that mindfulness deficits were attributable to these comorbid symptoms. Individuals with comorbid psychiatric diagnoses and SUDs tend to be more severe and difficult to treat (Hawkins, 2009; Kessler, 2004), and mindfulness-based interventions have been found to be efficacious for a broad range of psychological problems (Hayes, Villatte, Levin & Hildebrandt, 2011). Mindfulness-based interventions may be applicable to individuals with comorbid SUD and other psychiatric diagnoses, which is a population particularly in need of innovative treatments (O’Brien et al., 2004). To better understand the relationship of mindfulness deficits to SUD and comorbid populations, further research would benefit from examining whether similar mindfulness deficits are observed among individuals with SUD alone relative to those with other psychiatric diagnoses without SUD as well as comorbid SUD and psychiatric diagnoses. The current study also did not include measures assessing related constructs that may better account for SUDs or the relationship between SUDs and mindfulness. For example, a recent study found that the relationship between mindfulness and SUDs was fully accounted for by impulsivity (Murphy & MacKillop, 2012). It is unclear whether mindfulness provides unique predictive utility over and above other established con-
structs such as impulsivity (Murphy & MacKillop, 2012), distress tolerance (Leyro et al., 2010), and emotion regulation (Gratz & Roemer, 2004). Continuing to examine the unique role of mindfulness facets in relation to these other variables could help to better understand risk factors and potential mechanisms of change for SUDs. The FFMQ limited the facets of mindfulness that were examined in relation to SUDs. It may be the case that other mindfulness facets, such as the acceptance subscale from the Philadelphia Mindfulness Scale (Cardaciotto et al., 2008), would have demonstrated different relationships with SUDs. In addition, previous research has indicated that the observing subscale of the FFMQ tends to relate to greater distress (e.g., Baer et al., 2006), and it is unclear whether a similar relationship would be found with another present moment awareness mindfulness subscale. Future research should include a more comprehensive range of mindfulness measures in addition to related constructs. The current study combined substance abuse and dependence diagnostic groups. Although this served to increase statistical power to detect differences in mindfulness facets, it also may raise questions regarding heterogeneity within the SUD groups. However, previous research has found minimal value in distinguishing the abuse and dependence diagnostic groups and has led to combining these two categories in the DSM-5 (Hasin, 2012; O’Brien, 2011). It is important to note, however, that the effect sizes for differences in mindfulness facets across groups were small with partial eta squared values of .01 to .02. This may be attributable in part to the use of a multifaceted measure in which the variance between groups in mindfulness may have been partitioned across multiple subscales, thus indicating small effect sizes for each variable. In addition, the comparison group of psychiatric patients was likely to already have deficits in mindfulness facets given the relationship between mindfulness and psychological symptoms (e.g., Cash & Wittingham, 2010), which may have further reduced effect sizes. Future research would benefit from examining whether these findings replicate and whether larger effect sizes may be observed relative to nonclinical control groups. This study adds to a growing body of literature suggesting the potential role of specific mindfulness facets in addictions (Eisenlohr-Moul et al., 2012; Fernandez et al., 2010). Given the multifaceted nature of mindfulness, future research would benefit from continuing to identify which facets, if any, are functionally important in addictions and what intervention methods can best target these processes. This research may eventually serve to inform more efficient, effective, and focused interventions targeting specific facets of mindfulness.
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Received January 31, 2013 Revision received June 11, 2013 Accepted August 28, 2013 䡲
© 2013 American Psychological Association 0893-164X/14/$12.00 DOI: 10.1037/a0034706
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Which Facets of Mindfulness Predict the Presence of Substance Use Disorders in an Outpatient Psychiatric Sample? Michael E. Levin
Kristy Dalrymple and Mark Zimmerman
Alpert Medical School of Brown University and Utah State University
Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island
There have been inconsistent findings regarding the relationship of mindfulness to substance use disorders, which may be attributable in part to measurement issues and the use of nonclinical samples. The current study examined the relationship between specific facets of mindfulness and substance use disorders (SUD) in a clinical sample. The sample consisted of 867 patients seeking outpatient treatment and who completed diagnostic interviews and self-report assessments. Results indicated that deficits in acting with awareness, being nonjudgmental, and nonreactivity were related to the presence of a current SUD relative to those with no history of SUD, although only acting with awareness and being nonjudgmental were related when all of the facets were included in a logistic regression. Patients with a past history of SUD had greater deficits in acting with awareness relative to those with no history of SUD. Results were similar when examining alcohol use and drug use disorders separately. Current nicotine users had greater deficits in being nonjudgmental, but not on other mindfulness facets. The observing facet was not related to current or past history of SUD. The results of the study and future directions are discussed in relation to research on mindfulness-based treatments for addiction. Keywords: mindfulness, addiction, substance use disorders, mindfulness-based interventions
erally, nonintervention studies have found that deficits in mindfulness are predictive of depression, anxiety, and a variety of other measures of psychological health (Keng et al., 2011). Research with cigarette smokers has similarly found that deficits in mindfulness are related to severity of nicotine dependence and withdrawal symptoms (Vidrine et al., 2009). The research to date examining the relationship between mindfulness and alcohol/illicit drug abuse has been more inconsistent, however, with some studies finding deficits in mindfulness relating to higher rates of substance abuse (Fernandez, Wood, Stein & Rossi, 2010; Murphy & MacKillop, 2012) and other studies finding the opposite such that deficits relate to lower rates of substance abuse (Leigh & Neighbors, 2009; Leigh, Bowen & Marlatt, 2005). One explanation for the inconsistent findings with substance abuse is variations across studies in how mindfulness is measured. Early self-report measures tended to consist of a single factor assessing overall levels of mindfulness (e.g., Mindful Attention Awareness Scale, Brown & Ryan, 2003). More recent research has found that the factor structure of mindfulness self-report items indicates a multifaceted construct (Baer et al., 2006). There are a variety of conceptualizations of mindfulness, but definitions tend to highlight facets including awareness of the present and taking a nonjudgmental, accepting, and nonreactive stance to whatever is observed (Bishop et al., 2004). The current study focused on the mindfulness facets derived from the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006), which consists of observing, describing, acting with awareness, being nonjudgmental, and nonreactivity, and thus provides a means to examine the relation of SUDs to a range of theoretically meaningful facets. When examining specific facets of mindfulness, it appears that higher scores on a measure of mind/body awareness tended to relate with greater
Mindfulness-based methods have been gaining increasing attention as an approach for treating substance abuse and other addictive behaviors (Bowen, Chawla & Marlatt, 2010; Hayes & Levin, 2012; Zgierska et al., 2009). These interventions focus on various techniques such as contemplative meditation to improve one’s awareness of the present moment in a nonjudgmental, nonreactive, and accepting way. There is a growing research base suggesting that mindfulness-based interventions, as well as interventions that incorporate mindfulness technologies within a cognitive– behavioral approach, may be efficacious for treating substance abuse and preventing relapse (Bowen, Witkiewitz & Chawla., 2012; Chiesa & Serretti, 2013; Kelly et al., 2012; Zgierska et al., 2009). Although there have been a number of clinical trials evaluating mindfulness-based interventions with addictions (see Chiesa & Serretti, 2013 for a recent review), there has been limited research regarding whether deficits in mindfulness skills are related to substance use disorders (SUDs) in nonintervention research. Such research could inform the development of a theoretical model for understanding how mindfulness leads to improvements in addiction outcomes, guiding further treatment innovations. More gen-
This article was published Online First November 25, 2013. Michael E. Levin, Department of Psychology, Utah State University; Kristy Dalrymple and Mark Zimmerman, Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University and Department of Psychiatry, Rode Island Hospital, Providence, Rhode Island. Correspondence concerning this article should be addressed to Michael E. Levin, Utah State University, Department of Psychology, 2810 Old Main Hill, Logan, UT 84322. E-mail: [email protected] 498
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MINDFULNESS AND SUBSTANCE USE DISORDERS
substance use (Leigh et al., 2005; Leigh & Neighbors, 2009), whereas measures assessing being nonreactive and nonjudgmental of one’s experiences, acting with awareness, and describing one’s experiences tend to be related to lower substance use (Fernandez et al., 2010; Leigh & Neighbors, 2009; Murphy & MacKillop, 2012). Theoretically, deficits in each facet of mindfulness may play a role in substance use disorders including alcohol, illicit drug, and nicotine use disorders. Present moment awareness, including observing, describing, and acting with awareness, is important for identifying triggers and high risk situations, which can inform effective coping strategies in the moment and reduce the potential for impulsively or automatically using substances in reaction to triggers (Bowen et al., 2012). In addition, recent research suggests that a greater capacity to describe and differentiate one’s emotions throughout the day can serve to reduce substance abuse, even when experiencing negative affect (Kashdan & Rottenberg, 2010). Negative affect is a key predictor of relapse (e.g., Witkiewitz & Villarroel, 2009), and research indicates that individuals with substance use disorders have difficulty tolerating distress (Leyro, Zvolensky & Bernstein, 2010) and effectively regulating emotions (Aldao, Nolen-Hoeksema & Schweitzer, 2010). The capacity to be nonjudgmental and nonreactive to one’s experiences can serve to reduce emotional reactivity and ineffective coping strategies while providing a foundation to effectively practice tolerating distress and urges to use substances (Bowen et al., 2012). For example, one study found that individuals who were more mindfully accepting were less likely to abuse alcohol despite having implicit biases to do so (Ostafin & Marlatt, 2008). Given the inconsistent findings within research thus far, it is unclear which of these mindfulness facets play a role in substance abuse. Further research is needed to examine whether describing, acting with awareness, being nonjudgmental, and nonreactivity are all functionally important to SUDs or whether particular mindfulness facets are more or less relevant. The current study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project sought to examine which facets of mindfulness, if any, are related to the presence of SUDs among a clinical sample of psychiatric outpatients. Research to date primarily has been conducted with nonclinical samples, which may further explain the inconsistent findings across studies, and it is less clear how mindfulness facets relate to SUDs in clinical samples. Given past research, it was hypothesized that deficits in the describing, acting with awareness, nonreactivity, and nonjudgmental facets of mindfulness would all be related to the presence of SUDs. The observing facet was hypothesized to be unrelated to SUDs or relate in the opposite direction (i.e., greater observing scores related to higher probability of SUD), given past research suggesting this subscale is not predictive of psychopathology (e.g., Bohlmeijer et al., 2011) or predicts greater problems (e.g., Baer et al., 2006) and that heightened mind-body awareness relates to greater substance abuse (Leigh et al., 2005; Leigh & Neighbors, 2009). These results could further inform theoretical models regarding the role of specific mindfulness facets in addictions. In addition, these findings could help guide treatment development by highlighting the qualities of mindfulness that may be particularly important to focus on in SUD interventions.
499 Method
Participants The sample consisted of 867 patients seeking outpatient treatment at the Rhode Island Hospital Department of Psychiatry. The sample was 56.2% female with a median age of 39 (M ⫽ 39.29, SD ⫽ 14.24). The sample was 91.2% White/Caucasian, 3.3% Black/African American, 2.9% Hispanic, 1.6% Asian, and 1.0% other race. In addition, 3.6% of the sample identified as Latino ethnicity. In terms of education, 8.5% of the sample did not graduate high school, 52.3% of the sample graduated high school but not college, 24.5% graduated with a 4-year college degree, and 14.6% received a graduate degree. The percentage of patients with a current SUD diagnosis (excluding nicotine dependence) was 4% (n ⫽ 32) alcohol abuse, 7% (n ⫽ 60) alcohol dependence, 3% (n ⫽ 25) drug abuse, and 7% (n ⫽ 57) drug dependence. The percentage with a past SUD diagnosis was 16% (n ⫽ 134) alcohol abuse, 12% (n ⫽ 102) alcohol dependence, 12% (n ⫽ 100) drug abuse, and 10% (n ⫽ 83) drug dependence. The most common drug use disorders were cannabis abuse (2% with current diagnosis [n ⫽ 21]; 8% past diagnosis [n ⫽ 69]) and cannabis dependence (4% with current diagnosis [n ⫽ 31]; 4% past diagnosis [n ⫽ 32]). In addition, 3% were diagnosed with a current noncannabis drug use disorder and 12% diagnosed with a past noncannabis drug use disorder spanning across a range of illicit drugs. In terms of cigarette smoking prevalence, 23% were current smokers, 28% were past smokers, and 48% had no history of regular smoking (nicotine use disorders were not included as SUDs for reported analyses, but were analyzed separately). The prevalence of other psychological disorders by SUD status is provided in Table 1.
Procedure The MIDAS project (Zimmerman, 2003) is integrated within an outpatient psychiatry practice providing fee-for-service psychiatric treatment, to patients with medical insurance (including Medicare but not Medicaid). The majority of referrals come from primary care physicians (31.6%), therapists in the community (15.8%), and family members or friends (17.5%); this latter group refers more than therapists. Patients seeking treatment at the practice are asked to participate in a comprehensive diagnostic interview prior to meeting with their treating clinician. For those who agree, in-
Table 1 Prevalence of Current and Past Diagnoses by Substance Use Disorder Status Other past or current psychiatric disorders
No SUD (n ⫽ 471)
Current SUD (n ⫽ 149)
Past SUD (n ⫽ 247)
Depressive disorder Anxiety disorder Eating disorder Adjustment disorder Bipolar disorder Impulse-control disorder Somatoform disorder Psychotic disorder Cigarette smoker
187 (40%) 250 (53%) 12 (3%) 50 (11%) 13 (3%) 18 (4%) 31 (7%) 5 (1%) 166 (35%)
59 (40%) 92 (62%) 3 (2%) 8 (5%) 16 (11%) 11 (7%) 12 (8%) 0 (0%) 101 (68%)
110 (45%) 149 (60%) 8 (3%) 10 (4%) 15 (6%) 16 (6%) 19 (8%) 4 (2%) 180 (73%)
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formed consent is obtained before administering the diagnostic interview. The study was approved by the Rhode Island Hospital Institutional Review Board. Diagnostic interviews were conducted by doctoral level clinical psychologists and bachelor’s level research assistants. Training for research assistants included observing a psychologist conduct at least 20 interviews, followed by being supervised while conducting 20 interviews. Training for clinical psychologists included observing 5 evaluations, followed by being supervised while conducting 15–20 evaluations. All interviewers then had to demonstrate almost perfect reliability on 5 interviews with senior diagnosticians to complete their training (i.e., agree on the principal diagnosis and demonstrate approximately 80% agreement on diagnoses overall for a given patient). Every interview is reviewed on an item-by-item basis with the senior diagnostician who observed the interview during the course of training. To prevent rater drift, ongoing weekly case conferences are conducted with all members of the team, and item ratings are reviewed by the principal investigator (M.Z.) for every case.
Measures Clinical interviewer assessments. Diagnostic interviewers conducted the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM–IV; SCID; First, Spitzer, Gibbon & Williams, 1995) with each participant to assess DSM–IV Axis I disorders including substance use disorders. Interrater reliability on the SCID was examined for a subsample of patients (n ⫽ 65) using the joint interview method, with results indicating adequate reliability for alcohol use (k ⫽ .64) and drug use disorders (k ⫽ .73; Zimmerman, McGlinchey, Chelminski & Young, 2008). For the current study we combined the alcohol abuse, alcohol dependence, drug abuse, and drug dependence diagnostic categories into a single diagnostic group of substance use disorders (SUD). Cigarette smoking history was also assessed during the clinical interview with the question “Have you ever smoked cigarettes daily for at least one month?” Follow-up questions determined whether patients were currently smoking regularly or only had a past history of cigarette smoking. Additional interviewer items examined in the current study included the psychic and somatic anxiety items from the Schedule for Affective Disorders and Schizophrenia (SADS; Spitzer & Endicott, 1977), which were used to assess severity of anxiety symptoms. The psychic anxiety item asks “how anxious, frightened, scared, or apprehensive have you felt during the past week?” and the somatic anxiety item asks “During the past week have you been bothered by physical symptoms like palpitations, shortness of breath, sweating, headaches, stomach cramps or muscle tension?” For both of these items, patient responses are rated on a 6-point scale ranging from 0, Not at all to 5, Extreme. The interrater reliability for the psychic and somatic anxiety items were ICC ⫽ .88 (p ⬍ .001) and ICC ⫽ .87 (p ⬍ .001), respectively. In addition, the Clinical Global Impression-Severity of depression (CGI-S; Guy, 1976) was used to rate overall depressive symptom severity, with severity rated on a 6-point scale ranging from 0, None to 5,
Extreme. Interrater reliability for the CGI was also high (ICC ⫽ 0.79, p ⬍ .001). Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006). The FFMQ is a 39-item questionnaire designed to assess five facets of mindfulness: observing, describing, acting with awareness, being nonjudgmental, and nonreactivity. The observing subscale assesses one’s attention to present moment experiences (i.e., “I notice the smells and aromas of things”). The describing subscale assesses the ability to label one’s thoughts, feelings, and sensations (i.e., “I’m good at finding the words to describe my feelings”). The acting with awareness subscale assesses the tendency to not attend to present moment experiences while engaging in activities (i.e., “I find myself doing things without paying attention”). The nonjudgmental subscale assesses the tendency to judge one’s thoughts and feelings as bad and to criticize oneself for having negative thoughts and feelings (i.e., “I think some of my emotions are bad or inappropriate and I shouldn’t feel them”). The nonreactivity subscale assesses the capacity to notice thoughts and feelings without acting on or otherwise getting entangled with them (i.e., “I perceive my feelings and emotions without having to react to them”). Each FFMQ item is rated on a 5-point scale ranging from 1 (never or very rarely true) to 5 (very often or always true). Negatively worded items were reverse scored so that for each subscale higher scores indicated greater mindfulness. The FFMQ has been found to be a reliable and valid measure of mindfulness in past research with nonclinical (Baer et al., 2006) and clinical samples (Bohlmeijer et al., 2011). In the current sample, each of the subscales demonstrated adequate internal consistency (Observing Cronbach’s alpha ⫽ .81; Describing Cronbach’s alpha ⫽ .89; Acting with awareness Cronbach’s alpha ⫽ .90; Nonjudgmental Cronbach’s alpha ⫽ .91; and Nonreactivity Cronbach’s alpha ⫽ .81).
Data Analysis The FFMQ subscales were normally distributed as indicated by examining histograms, skewness, and kurtosis for each variable. For each subscale, mean scores were calculated provided a participant answered 85% or more of the items for the given subscale, which has been used in past research (Levin, Lillis & Hayes, 2012). After applying this correction for missing items, between .6% and 1.6% were missing data for each subscale, with complete FFMQ data available for 844 of 867 participants.1 Zero order correlations were conducted to examine the relationship between mindfulness facets and symptoms of depression and anxiety. Analysis of Covariance (ANCOVA) was used to examine differences in scores on mindfulness facets between patients with a current/partial remission SUD, past history of SUD, or no history of SUD. SUD status was based on presence of alcohol and/or illicit drug use disorders. Cigarette smoking was not counted as a SUD (it was analyzed separately). It is important to note that patients without a SUD history were diagnosed with other psychiatric disorders (see Table 1). The CGI depression, somatic anxiety, and 1 Between 2.2% and 8.7% of participants were missing one or more items for each FFMQ subscale. The reported results were similar when only analyzing the sub-sample who completed all items for a given FFMQ subscale.
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MINDFULNESS AND SUBSTANCE USE DISORDERS
psychic anxiety ratings from clinical interviews were entered as covariates to control for the relationship between mindfulness and depression/anxiety symptoms (e.g., Cash & Wittingham, 2010). Post hoc tests were conducted using the Tukey least significant difference test to examine differences in mindfulness facet scores between these three diagnostic groups. A multinomial logistic regression was then conducted to further examine the degree to which facets of mindfulness predict the presence of a current SUD, history of SUD and no history of SUD, when controlling for depression and anxiety variables. The multinomial logistic regression also provided a means of examining the relationship of each mindfulness facet to SUD status while controlling for other facets of mindfulness to better determine their independent relationship to SUDs. Follow-up ANCOVA and multinomial logistic regression analyses were conducted separately with alcohol use disorders and with illicit drug use disorders. Additional analyses examined whether mindfulness facets differed between current smokers, past smokers, and patients with no history of smoking using ANCOVA and regression analyses. SUD status was included as an additional covariate in smoking analyses given the comorbidity between SUDs and cigarette smoking.
Results Zero Order Correlations Analyses were conducted to examine the relationships among the mindfulness facets and between these facets and symptoms of depression and anxiety (see Table 2). The describing, acting with awareness, nonjudgmental, and nonreactivity facets were all significantly correlated in the expected direction (i.e., greater mindfulness in one facet relating to greater mindfulness in another facet) with correlation coefficients ranging from .18 to .40. The observing facet was correlated with each of the other facets, but the correlations with acting with awareness and being nonjudgmental were in the opposite direction (i.e., greater observing related to lower acting with awareness and being nonjudgmental). Depression and anxiety symptoms were significantly correlated with describing, acting with awareness, nonjudgmental, and nonreactivity facets such that greater mindfulness related to lower symptoms, with correlation coefficients ranging from .10 to .40. However, the observing facet was unrelated to depression and correlated in the opposite direction with anxiety symptoms such that higher observing related to greater anxiety.
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Analyses With Past and Current SUD Diagnoses Analyses were conducted to examine differences in facets of mindfulness by diagnostic groups. Descriptive statistics for each FFMQ subscale by diagnostic group are provided in Table 3. ANCOVA results indicated a significant main effect for SUD status with the FFMQ acting with awareness subscale, F(2, 853) ⫽ 9.71, p ⬍ .001, partial 2 ⫽ .02, nonjudgmental subscale, F(2, 853) ⫽ 4.32, p ⫽ .01, partial 2 ⫽ .01, and nonreactivity subscale, F(2, 845) ⫽ 5.27, p ⫽ .005, partial 2 ⫽ .01. There were no significant main effects for SUD status on the observing or describing subscales (p ⬎ .10). Pairwise comparisons indicated significantly higher scores on acting with awareness among patients with no history of SUD relative to those with current SUD (covariate adjusted mean [Mdiff] ⫽ 2.46, SE ⫽ .61, p ⬍ .001) and relative to those with a past SUD history (Mdiff ⫽ 1.49, SE ⫽ .52, p ⫽ .004). Patients with no history of SUD had significantly higher levels on being nonjudgmental relative to those with current SUD (Mdiff ⫽ 1.82, SE ⫽ .63, p ⫽ .004), but there were no significant differences between patients with a past history of SUD and the other two groups. Patients with current SUD had significantly lower levels of nonreactivity relative to those with no history of SUD (Mdiff ⫽ 1.42, SE ⫽ .46, p ⫽ .002) and relative to patients with a past history of SUD (Mdiff ⫽ 1.41, SE ⫽ .50, p ⫽ .005). A multinomial logistic regression was conducted to further examine which mindfulness facets predicted having a current SUD, past history of SUD, or no history of SUD, when controlling for the other mindfulness facets as well as depression and anxiety symptoms (see Table 4). The overall model significantly predicted SUD status, with post hoc analyses indicating acting with awareness, nonreactivity, and being nonjudgmental as predictors of having a current SUD relative to no history of SUD. Only the acting with awareness subscale significantly predicted having a history of SUD relative to no history of SUD. There was also a statistical trend for depression predicting a history of SUD relative to no history of SUD. In each case lower mindfulness and greater symptom scores were predictive of a greater likelihood of having a SUD diagnosis relative to no history of SUD. No other facets of mindfulness or anxiety symptoms were predictive of SUD status (p ⬎ .10).
Follow-Up Analyses With Alcohol Use Disorders Follow up analyses were conducted separately among patients with alcohol use disorders (current diagnosis n ⫽ 94; past diag-
Table 2 Zero Order Correlations Between Mindfulness Facets, Depression Symptoms, and Anxiety Symptoms 1 1. 2. 3. 4. 5. 6. 7. 8. †
Observing Describing Act w/aware Nonjudgmental Nonreactivity Depression Psychic anx. Somatic anx.
p ⬍ .10.
ⴱ
p ⬍ .05.
2
— .18ⴱⴱⴱ ⫺.10ⴱⴱ ⫺.21ⴱⴱⴱ .24ⴱⴱⴱ .05 .06† .07ⴱ ⴱⴱ
p ⬍ .01.
3 ⴱⴱⴱ
.18 — .34ⴱⴱⴱ .21ⴱⴱⴱ .31ⴱⴱⴱ ⫺.21ⴱⴱⴱ ⫺.12ⴱⴱⴱ ⫺.10ⴱⴱ ⴱⴱⴱ
p ⬍ .001.
4 ⴱⴱ
⫺.10 .34ⴱⴱⴱ — .40ⴱⴱⴱ .18ⴱⴱⴱ ⫺.26ⴱⴱⴱ ⫺.28ⴱⴱⴱ ⫺.17ⴱⴱⴱ
5 ⴱⴱⴱ
⫺.21 .21ⴱⴱⴱ .40ⴱⴱⴱ — .24ⴱⴱⴱ ⫺.40ⴱⴱⴱ ⫺.30ⴱⴱⴱ ⫺.27ⴱⴱⴱ
6 ⴱⴱⴱ
.24 .31ⴱⴱⴱ .18ⴱⴱⴱ .24ⴱⴱⴱ — ⫺.20ⴱⴱⴱ ⫺.21ⴱⴱⴱ ⫺.21ⴱⴱⴱ
.05 ⫺.21ⴱⴱⴱ ⫺.26ⴱⴱⴱ ⫺.40ⴱⴱⴱ ⫺.20ⴱⴱⴱ — .38ⴱⴱⴱ .40ⴱⴱⴱ
7
8 †
.06 ⫺.12ⴱⴱⴱ ⫺.28ⴱⴱⴱ ⫺.30ⴱⴱⴱ ⫺.21ⴱⴱⴱ .38ⴱⴱⴱ — .68ⴱⴱⴱ
.07ⴱ ⫺.10ⴱⴱ ⫺.17ⴱⴱⴱ ⫺.27ⴱⴱⴱ ⫺.21ⴱⴱⴱ .40ⴱⴱⴱ .68ⴱⴱⴱ —
LEVIN, DALRYMPLE, AND ZIMMERMAN
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Table 3 Descriptive Statistics for Each Mindfulness Facet by Diagnostic group No history of SUD Current SUD Past history of SUD M (SD) M (SD) M (SD)
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Observing Describing Act w/aware Nonjudgmental Nonreactivity
23.14 (6.54) 26.30 (6.64) 25.30 (7.16) 24.85 (7.52) 19.05 (5.06)
23.23 (6.28) 25.11 (6.81) 22.50 (6.60) 22.51 (7.34) 17.45 (4.71)
23.54 (6.42) 25.18 (6.99) 23.46 (6.33) 23.44 (7.23) 18.85 (4.92)
nosis n ⫽ 234) relative to patients with no SUD history (i.e., no history of alcohol use or drug use disorders; n ⫽ 471). ANCOVA results indicated a significant main effect for alcohol use disorder status with the FFMQ describing, F(2, 793) ⫽ 3.17, p ⫽ .043, partial 2 ⫽ .01, acting with awareness, F(2, 792) ⫽ 9.49, p ⬍ .001, partial 2 ⫽ .02, being nonjudgmental, F(2, 792) ⫽ 5.19, p ⫽ .006, partial 2 ⫽ .01, and nonreactivity subscales, F(2, 785) ⫽ 3.11, p ⫽ .045, partial 2 ⫽ .01. There was no significant main effect for SUD status on the observing subscale (p ⬎ .10). Post hoc pairwise comparisons indicated significantly higher scores on describing among patients with no history of SUD relative to those with a past alcohol disorder history (Mdiff ⫽ 1.32, SE ⫽ .53, p ⫽ .013), but no difference between current alcohol disorder and either past or no SUD history (p ⬎ .10). Patients with no history of SUD had significantly higher scores on acting with awareness relative to those with a current alcohol disorder (Mdiff ⫽ 2.43, SE ⫽ .74, p ⫽ .001) and relative to patients with a past alcohol disorder (Mdiff ⫽ 1.89, SE ⫽ .53, p ⬍ .001). Patients with a current alcohol disorder had significantly lower scores on being nonjudgmental relative to those with no history of SUD (Mdiff ⫽ 2.39, SE ⫽ .76, p ⫽ .002) and relative to patients with a past
alcohol disorder (Mdiff ⫽ 1.63, SE ⫽ .82, p ⫽ .046). Patients with a current alcohol disorder had significantly lower scores on nonreactivity relative to those with no history of SUD (Mdiff ⫽ 1.35, SE ⫽ .54, p ⫽ .013) and a trend relative to patients with a past alcohol disorder (Mdiff ⫽ 1.04, SE ⫽ .59, p ⫽ .076). The overall model was significant for the multinomial logistic regression examining mindfulness facets and depression and anxiety symptoms as predictors of current alcohol disorder, past alcohol disorder or no SUD history (see Table 4). Post hoc analyses indicated that acting with awareness, being nonjudgmental, and nonreactivity predicted having a current alcohol use disorder relative to no history of SUD. Only the acting with awareness subscale significantly predicted having a history of alcohol disorder relative to no history of SUD. In each case lower mindfulness scores were predictive of a greater likelihood of having an alcohol disorder diagnosis relative to no history of SUD. No other facets of mindfulness or depression and anxiety symptoms were predictive of alcohol disorder status (p ⬎ .10).
Follow-Up Analyses With Drug Use Disorders Follow-up analyses were conducted separately among patients with illicit drug use disorders (current diagnosis n ⫽ 77; past diagnosis n ⫽ 152) relative to patients with no SUD history (i.e., no history of alcohol use or drug use disorders; n ⫽ 471). ANCOVA results indicated a significant main effect for drug use disorder status with the FFMQ describing, F(2, 695) ⫽ 3.59, p ⫽ .028, partial 2 ⫽ .01, acting with awareness, F(2, 694) ⫽ 9.29, p ⬍ .001, partial 2 ⫽ .03, being nonjudgmental, F(2, 693) ⫽ 4.30, p ⫽ .014, partial 2 ⫽ .01, and nonreactivity subscales, F(2, 685) ⫽ 3.17, p ⫽ .043, partial 2 ⫽ .01. There was no significant main effect for SUD status on the observing subscale (p ⬎ .10). Post hoc pairwise comparisons indicated significantly higher scores on describing among patients with no history of SUD relative to those with a current drug disorder (Mdiff ⫽ 2.10, SE ⫽ .82, p ⫽ .010), but
Table 4 Multinomial Logistic Regression Results Testing Mindfulness and Depression and Anxiety Symptoms as Predictors of SUD Observe Exp(b)
Describe Exp(b)
Act w/aware Exp(b)
Current SUD vs. no history Past SUD vs. no history Overall model 2 ⫽ 41.88ⴱⴱⴱ, Nagelkerke R2 ⫽ .06
1.00 1.00
1.00 .99
.95ⴱⴱ .97ⴱ
Current AUD vs. no history Past AUD vs. no history Overall model 2 ⫽ 46.79ⴱⴱⴱ, Nagelkerke R2 ⫽ .07
.99 1.00
1.02 .98
Current DUD vs. no history Past DUD vs. no history Overall model 2 ⫽ 36.96ⴱⴱ, Nagelkerke R2 ⫽ .07
1.02 1.01
.97 .99
Current smoker vs. no history Past smoker vs. no history Overall model 2 ⫽ 124.15ⴱⴱⴱ, Nagelkerke R2 ⫽ .16
1.01 1.02
.97† .99
Nonreact Exp(b)
Depression Exp(b)
Psychic anx. Exp(b)
Somatic anx. Exp(b)
SUD status Exp(b)
.97† .99
.95ⴱ 1.01
1.01 1.14†
.95 .96
.98 .98
— —
.95ⴱ .97ⴱ
.96ⴱ .99
.96† 1.00
1.16 1.13
.99 .93
.87 1.04
— —
.95ⴱ .97ⴱ
.97 .98
.95† 1.00
.87 1.08
.84 1.01
1.12 .99
— —
.98† 1.02
1.02 1.00
.92 1.07
1.02 1.02
1.12 1.01
2.49ⴱⴱⴱ 2.23ⴱⴱⴱ
1.01 1.02
Nonjudge Exp(b)
Note. Between 2.2% and 8.7% of participants were missing one or more items for each FFMQ subscale. The reported results were similar when only analyzing the sub-sample who completed all items for a given FFMQ subscale. AUD ⫽ alcohol use disorders; DUD ⫽ illicit drug use disorders. † p ⬍ .10. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
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MINDFULNESS AND SUBSTANCE USE DISORDERS
no difference between past drug disorder and either current or no SUD history (p ⬎ .10). Patients with no history of SUD had significantly higher scores on acting with awareness relative to those with a current drug disorder (Mdiff ⫽ 3.01, SE ⫽ .81, p ⬍ .001) and relative to patients with a past drug disorder (Mdiff ⫽ 1.75, SE ⫽ .62, p ⫽ .005). Patients with no history of SUD had significantly higher scores on being nonjudgmental relative to those with a current drug disorder (Mdiff ⫽ 1.98, SE ⫽ .83, p ⫽ .017) and relative to patients with a past drug disorder (Mdiff ⫽ 1.33, SE ⫽ .63, p ⫽ .036). Patients with a current drug disorder had significantly lower scores on nonreactivity relative to those with no history of SUD (Mdiff ⫽ 1.51, SE ⫽ .60, p ⫽ .012) and relative to patients with a past drug disorder (Mdiff ⫽ 1.35, SE ⫽ .69, p ⫽ .050). The overall model was significant for the multinomial logistic regression examining mindfulness facets and depression and anxiety symptoms as predictors of current drug disorder, past drug disorder, or no SUD history (see Table 4). Post hoc analyses indicated that acting with awareness and nonreactivity predicted having a current drug disorder relative to no history of SUD. Only the acting with awareness subscale significantly predicted having a history of drug disorder relative to no history of SUD. In each case lower mindfulness scores were predictive of a greater likelihood of having a drug disorder diagnosis relative to no history of SUD. No other facets of mindfulness or depression and anxiety symptoms were predictive of drug disorder status (p ⬎ .10).
Follow-Up Analyses With Smoking Status A series of analyses were conducted to examine potential deficits in mindfulness facets among patients who reported currently smoking cigarettes (n ⫽ 202), a past history of regularly smoking (n ⫽ 245), or no history of regularly smoking (n ⫽ 419). ANCOVA analyses controlling for depression and anxiety symptoms as well as SUD status indicated a significant main effect for smoking status with the FFMQ nonjudgmental subscale, F(2, 850) ⫽ 5.06, p ⫽ .007, partial 2 ⫽ .01. There was no significant main effect for smoking status on the observing, describing, acting with awareness, or nonreactivity subscales (p ⬎ .10). Post hoc pairwise comparisons indicated significantly lower scores on being nonjudgmental among current smokers relative to past smokers (Mdiff ⫽ 2.04, SE ⫽ .64, p ⫽ .002), and a trend for lower scores among current smokers relative to patients with no history of smoking (Mdiff ⫽ 1.18, SE ⫽ .61, p ⫽ .052). The overall model was significant for the multinomial logistic regression examining mindfulness facets, depression and anxiety symptoms, and SUD status as predictors of current smoking, past smoking, or no smoking history (see Table 4). Post hoc analyses indicated a trend for describing and being nonjudgmental predicting being a current smoker relative to no history of smoking. SUD status predicted being a current smoker relative to no history as well as being a past smoker relative to no history. In each case lower mindfulness scores and history of SUD were predictive of a greater likelihood of being a smoker relative to no history.
Discussion The current study sought to examine the relationship between facets of mindfulness and SUDs in a clinical sample. Results indicated that deficits in acting with awareness, being nonjudg-
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mental, and nonreactivity were related to the presence of a current SUD relative to no history of SUD. In addition, patients with a past history of SUD had deficits in acting with awareness relative to those with no history of SUD. When controlling for other mindfulness facets in a multinomial logistic regression, only the acting with awareness and nonreactivity subscales significantly predicted presence of a current SUD relative to no history of SUD. A similar pattern of results was found when examining alcohol use and drug use disorders separately, except that describing was also related to SUD status. Current cigarette smokers demonstrated deficits in being nonjudgmental relative to past smokers and those with no history of smoking, but did not differ on other mindfulness facets. The observing facet was not related to current or past history of SUD in any analyses. These results add to the existing literature suggesting that specific facets of mindfulness are related to SUDs, particularly deficits in acting with awareness, being nonjudgmental, and nonreactivity (Fernandez et al., 2010; Leigh & Neighbors, 2009; Murphy & MacKillop, 2012). In addition, the results suggest that patients who smoke may have elevated deficits in being nonjudgmental of their emotions, which adds to research indicating the role of mindfulness and emotional acceptance in nicotine dependence (e.g., Gifford et al., 2011; Vidrine et al., 2009). This is the first study we are aware of that has examined these relationships in nonintervention research using a clinical sample of psychiatric patients, suggesting that similar findings generalize to clinical populations. Theoretically, the tendency to act without awareness could contribute to habitually engaging in addictive behaviors as well as failing to recognize and thus effectively cope with triggers and high risk situations that lead to relapse. The tendency to judge and be reactive to difficult emotions, thoughts, and urges may also elicit maladaptive avoidant behavior including further substance use, which is consistent with research indicating the relationship of distress tolerance and emotion regulation to SUDs (Aldao et al., 2010; Leyro et al., 2010). Experimental research is needed to further explore the role of these mindfulness facets in SUDs. Consistent with past research, deficits in the observing facet was not related to SUD status. However, the study also did not find a positive relationship between heightened observation of the present moment and increased substance abuse, which has been found in some past research (Leigh et al., 2005; Leigh & Neighbors, 2009). Theoretically, heightened observation could be a protective or risk factor depending on skills in other mindfulness facets. For example, if one was highly judgmental and reactive to one’s experiences, heightened observation could be indicative of hyperarousal and problematic self-monitoring. Alternatively, heightened observation in the context of being nonjudgmental and nonreactive could reflect an enhanced mindful attention to the present. Consistent with this, a recent study found a significant interaction between mindful observation and nonreactivity in predicting substance use, such that individuals who were high in observation and nonreactivity were less likely to use substances, whereas those high in observation and low in nonreactivity were more likely to use substances (Eisenlohr-Moul et al., 2012). Although these results do not indicate whether increasing mindfulness would be beneficial for addiction problems, they are consistent with other research which suggests that targeting
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present moment awareness and the capacity to notice experiences without judging or impulsively reacting to them may reduce substance use problems. For example, a recent study found that a mindfulness-based intervention for substance abuse reduced the occurrence of cravings in reaction to feeling depressed, and that this effect predicted lower rates of substance abuse (Witkiewitz & Bowen, 2010). Another study found that a mindfulness-based intervention for substance abuse reduced the tendency to try to suppress thoughts, which was related to better addiction outcomes (Bowen, Witkiewitz, Dilworth & Marlatt, 2007). These findings suggest that increasing one’s ability to mindfully notice one’s experiences in the present moment, without judging them or reacting to them, may be a promising mechanism for treating addictions. Yet, it is important to note that reviews of the literature indicate methodological weaknesses with existing research on mindfulness-based interventions for SUDs and the need for more research (Chiesa & Serretti, 2013). There are a few key limitations with the current study. First, the study used a cross sectional design so the temporal relationship between mindfulness deficits and SUD status is unclear. Although it is possible that mindfulness deficits may lead to substance abuse, chronic substance abuse may also reduce one’s present moment awareness and increase reactivity to difficult thoughts and feelings. Future research would benefit from longitudinal designs that can more clearly determine whether mindfulness deficits are risk factors for the development and exacerbation of SUDs. Given the services provided at the outpatient treatment program where the MIDAS Project is conducted, only 17% of the patients with a current or past SUD had a SUD diagnosis alone. There is a high prevalence of comorbid psychiatric diagnoses among SUD populations (Conway, Compton, Stinson & Grant, 2006; Kessler, 2004), which lends to the generalizability of the current findings. Nonetheless, it is unclear whether the observed deficits in mindfulness facets are attributable to the presence of a SUD in general or unique to features regarding having a comorbid SUD in addition to other psychiatric disorders. However, we statistically controlled for depression and anxiety symptoms, reducing the potential that mindfulness deficits were attributable to these comorbid symptoms. Individuals with comorbid psychiatric diagnoses and SUDs tend to be more severe and difficult to treat (Hawkins, 2009; Kessler, 2004), and mindfulness-based interventions have been found to be efficacious for a broad range of psychological problems (Hayes, Villatte, Levin & Hildebrandt, 2011). Mindfulness-based interventions may be applicable to individuals with comorbid SUD and other psychiatric diagnoses, which is a population particularly in need of innovative treatments (O’Brien et al., 2004). To better understand the relationship of mindfulness deficits to SUD and comorbid populations, further research would benefit from examining whether similar mindfulness deficits are observed among individuals with SUD alone relative to those with other psychiatric diagnoses without SUD as well as comorbid SUD and psychiatric diagnoses. The current study also did not include measures assessing related constructs that may better account for SUDs or the relationship between SUDs and mindfulness. For example, a recent study found that the relationship between mindfulness and SUDs was fully accounted for by impulsivity (Murphy & MacKillop, 2012). It is unclear whether mindfulness provides unique predictive utility over and above other established con-
structs such as impulsivity (Murphy & MacKillop, 2012), distress tolerance (Leyro et al., 2010), and emotion regulation (Gratz & Roemer, 2004). Continuing to examine the unique role of mindfulness facets in relation to these other variables could help to better understand risk factors and potential mechanisms of change for SUDs. The FFMQ limited the facets of mindfulness that were examined in relation to SUDs. It may be the case that other mindfulness facets, such as the acceptance subscale from the Philadelphia Mindfulness Scale (Cardaciotto et al., 2008), would have demonstrated different relationships with SUDs. In addition, previous research has indicated that the observing subscale of the FFMQ tends to relate to greater distress (e.g., Baer et al., 2006), and it is unclear whether a similar relationship would be found with another present moment awareness mindfulness subscale. Future research should include a more comprehensive range of mindfulness measures in addition to related constructs. The current study combined substance abuse and dependence diagnostic groups. Although this served to increase statistical power to detect differences in mindfulness facets, it also may raise questions regarding heterogeneity within the SUD groups. However, previous research has found minimal value in distinguishing the abuse and dependence diagnostic groups and has led to combining these two categories in the DSM-5 (Hasin, 2012; O’Brien, 2011). It is important to note, however, that the effect sizes for differences in mindfulness facets across groups were small with partial eta squared values of .01 to .02. This may be attributable in part to the use of a multifaceted measure in which the variance between groups in mindfulness may have been partitioned across multiple subscales, thus indicating small effect sizes for each variable. In addition, the comparison group of psychiatric patients was likely to already have deficits in mindfulness facets given the relationship between mindfulness and psychological symptoms (e.g., Cash & Wittingham, 2010), which may have further reduced effect sizes. Future research would benefit from examining whether these findings replicate and whether larger effect sizes may be observed relative to nonclinical control groups. This study adds to a growing body of literature suggesting the potential role of specific mindfulness facets in addictions (Eisenlohr-Moul et al., 2012; Fernandez et al., 2010). Given the multifaceted nature of mindfulness, future research would benefit from continuing to identify which facets, if any, are functionally important in addictions and what intervention methods can best target these processes. This research may eventually serve to inform more efficient, effective, and focused interventions targeting specific facets of mindfulness.
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Received January 31, 2013 Revision received June 11, 2013 Accepted August 28, 2013 䡲
