A nuanced examination of human behavior can yield valuable insights into whether a mindfulness-based intervention (MBI) promotes meditation practices and to what degree in various populations. This study aimed to offer a comprehensive analysis of meditation behaviors exhibited by individuals in response to a MBI in the context of an intensive residential treatment program for addiction recovery.
Method
A total of 100 participants enrolled in a residential treatment program participated in an added MBI component to their routine care. We quantified the type, frequency, and duration of meditation practices outside of scheduled MBI sessions and conducted a descriptive analysis to investigate how these practices during the intervention predicted meditation behaviors 7 months later.
Results
All seven common types of mindfulness meditation assessed, except the body scan, were performed an average of once per day during the MBI. The longest average duration of meditation practice was observed in the case of walking meditation, during both the MBI (M=20.30, SD=16.66 min) and 7-month follow-up (M=25.43, SD=20.85 min). Out-of-session meditation frequency (unstandardized beta, B=0.56, p<0.001) and duration (B=0.45, p=0.02) during the MBI significantly predicted subsequent meditation behaviors 7 months later, even after adjusting for treatment site discharge status and other clinical variables.
Conclusions
Most participants in this addiction recovery sample consistently engaged in a variety of meditation practices outside of formal MBI class sessions while in residential living, performing them approximately once a day, with a particularly robust response to walking meditation. The persistence of meditation practice 7 months later suggests that the learned behaviors endure throughout addiction recovery.
Preregistration
This original trial is registered with clinicaltrials.gov (NCT02977988)
Opmerkingen
The original online version of this article was revised to capture the legend key in figure 2.
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Interventions designed to modify behavior often require active participation from individuals, both within formal class sessions and in the application of newly acquired skills in their daily lives. Even interventions supported by empirical evidence may fail to demonstrate improvements if participants do not adhere to prescribed practices or make a concerted effort to cultivate skills (Vermeire et al., 2001). Adherence to an intervention can be defined as the extent to which participants’ responses align with the provided program guidelines and regimen (Martin et al., 2005). Mindfulness-based interventions (MBIs) present a behavioral training context, where participants are tasked with engaging in various meditation practices, both during formal class sessions and as daily outside-of sessions homework (Kabat-Zinn & Hanh, 2009; Segal et al., 2018). Practicing meditation outside of formal classes, especially during intervals between class sessions, is considered essential to deepening one’s meditation.
Adapted versions of MBIs, such as Mindfulness Based Relapse Prevention (MBRP; Bowen et al., 2009) and Moment-by-Moment in Women’s Recovery (MMWR; Vallejo & Amaro, 2009), have been developed to address substance misuse and relapse prevention, aiming to mitigate the underlying mechanisms contributing to the risks of substance use lapses and relapse, including cognitive and emotional arousal states like craving (Witkiewitz et al., 2013). Through meditation practices, these MBIs facilitate a transformation in individuals’ relationships with environmental cues associated with relapse. This transformation enhances their ability to navigate negative emotions by promoting awareness and acceptance of their experiences without reactive responses. A recent systematic review conducted on samples with substance use disorder (SUD) provides some evidence of the efficacy of MBIs in reducing cravings and decreasing the frequency of substance use (Ramadas et al., 2021). However, it is worth noting that the trials included in the review primarily assessed the effects of MBIs through aggregate comparisons based on random assignment to groups which conveys little on levels of meditation performed outside of class sessions. Such aggregated analysis serves as a strategy to establish an overall effect size for trials but lacks the granularity needed to understand individual engagement with meditation during the MBI. A comprehensive analysis of within-subject meditation behavior offers valuable insights into whether MBIs effectively serve as robust stimuli to elicit meditation responses for the dimensions of type, frequency, and duration.
Based on studies that report on participant levels of meditation during a MBI, it is evident that there is a wide variation in reporting results for this variable. In a review of participants’ meditation in relation to study outcomes in a MBI, out of 98 studies, only 24 tested meditation practice in relation to clinical outcome scores (Vettese et al., 2009), and none of these included a sample from a restrictive living environment. Only 5 of the 98 studies (5%) reported measuring meditation at a post-intervention period. There are two studies that report the level of meditation practice in the SUD population (Glasner-Edwards et al., 2017; Grow et al., 2015), although neither represented residential treatment settings. In one study, participants had already completed inpatient or intensive outpatient treatment before enrolling in the MBI (Grow et al., 2015). During the intervention, participants meditated for approximately 100 min per week outside of the formal MBI sessions, which subsequently decreased to around 60 min per week at the 4-month follow-up. In another study involving a stimulant-dependent SUD sample, outside-of-session meditation was scored as an aggregate across all weeks during an 8-week MBI, with the sample averaging about 145 min of meditation during the intervention based on weekly logged minutes (Glasner-Edwards et al., 2017). The sample meditated an average of 18 days across the 8-week period. Meditation levels after the intervention were not reported.
To the best of our knowledge, no study to date has investigated the specific types of meditation practiced within a sample residing in a treatment facility. Moreover, there has been a notable dearth of research concerning the response to MBIs by women in residential recovery. Women in recovery present more complex interpersonal and clinical profiles compared to men (Jiang et al., 2013), yet the majority of information about meditation practice in the aforementioned studies come from samples predominantly consisting of males. This highlights the need to focus on women’s response to a MBI while in residential treatment.
In research trials, meditation practice is often employed as a covariate or a modifier of treatment effects. Nonetheless, a gap remains in our understanding of the granular aspects of meditation that evolve throughout the course of a MBI and persist after the intervention ends. This knowledge gap is pronounced in populations residing in restrictive living environments, which can perhaps influence levels of meditation outside of class sessions given time and environment constraints on inpatient behavior. To address this gap, our study aims to provide a comprehensive description of the outside-of-session meditation reported by participants during and after a MBI within the context of restricted living residential treatment. Our objective is to offer a detailed account of meditation practices undertaken in response to a MBI adapted for SUD (i.e., MMWR), with a specific focus on the variables of meditation type, frequency, and duration. Furthermore, we test whether levels of meditation during the MBI predict levels of meditation 7 months after the MBI, after adjusting for important clinical covariates. We hypothesize that levels of meditation during the MBI will predict levels of meditation 7 months following the MBI given that meditation behavior found to be reinforcing for an individual during treatment should extend to post-treatment environments.
Method
Participants
The analytic sample was obtained from a parallel-group randomized controlled trial (RCT;NCT02977988) that tested the efficacy of a MBI, MMWR, against a psychoeducational control condition on residential treatment retention and relapse (Amaro & Black, 2017, 2021; Black & Amaro, 2019). Participants were randomly assigned to one of two study conditions in the original trial (MMWR or Neurobiology of Addiction controls; see Figure 1 for the CONSORT diagram). Only the data from the MMWR group is used in this analysis of meditation given our focus on meditation response to the MBI. The control condition did not include meditation. Participants in the MMWR group were instructed to engage in daily meditation practices as homework outside of the scheduled in-person classes during the intervention as they learned new meditation practices from the instructor, and to report on their meditation performed outside of class at four time points during the intervention. The treatment facility did not offer structured mindfulness training services during the study period. All participants still received SUD treatment services as normally provided by the treatment facility while participating in the add-on study interventions.
Fig. 1
CONSORT diagram from original trial. Only the data from the MMWR group is included in the analysis of meditation behavior
×
Individuals eligible to participate in the trial were adult women clinically diagnosed with SUD and admitted to a SUD residential treatment facility located in California (for full protocol, see Amaro & Black, 2017, 2021; Black & Amaro, 2019). The standard admission protocol at treatment entry for the residential clinic required the site’s intake clinician coordinator to stabilize all patients prior to the start of the treatments offered. This consisted of conducting an assessment on all patients for SUDs, mental health disorders, suicidality, and cognitive impairment using the LR-DSM-4 or DSM-5. If the clinician indicated that the patient was not yet stable, they were excluded from the trial; this was an extremely rare event at the site after the first week of residential entry. The same clinician also completed a psychosocial assessment using an in-house form to identify important factors of patient history and needs to inform case management and plan for treatment. The clinic site psychiatrist and clinician coordinator discussed diagnostic assessment, determined final diagnoses, and made record in the patient chart. Participant inclusion criteria included being a client at the study site SUD residential treatment facility, diagnosis of SUD on clinical record, being female, adults aged 18–65 years, being fluent in English, and agreeing to participate in the study. Exclusion criteria included inability to understand or sign informed consent, cognitive impairment, untreated psychotic disorder or severe chronic mental health condition based on clinical intake using LR-DSM-4 or DSM-5 assessments, reported suicidality during the 30 days prior to clinical intake assessment, being a current prisoner, being more than 6 months pregnant, being older than 65 years of age, and not willing to sign a HIPAA form or be audio-recorded during study interview and intervention sessions. A total of 367 participants were assessed for eligibility, of which 225 were randomized; 200 participants were enrolled in the trial and 100 were randomized to the MMWR group. The current analytic sample consisted of all 100 participants from the MMWR group.
Procedure
At the study start, informed consent and HIPAA and baseline interviews were conducted. Post-intervention interviews occurred up to 2 weeks after completion of the last class session of the intervention. A 7-month post-intervention follow-up interview occurred within a 4-week period before and after the anniversary of the intervention completion date. Research staff of the study team served as interviewers and collected data from participants in person or via phone if needed using a computer-assisted interview protocol (Research Electronic Data Capture, REDCap).
Moment-by-Moment in Women’s Recovery
MMWR was delivered twice weekly for 80 min each for a total of 12 group sessions over a 6-week period during residential treatment. The sessions consisted of standardized lesson plans guided by an instructional manual. Study instructors were trained in both MMWR and MBSR (development of MMWR was informed by MBSR) and facilitated all sessions along with an on-site master’s-level clinician with experience in SUDs. Instructors had at least 2 years of experience in the topics they taught. MMWR instructors were experienced mindfulness facilitators. One instructor was in the process of acquiring MBSR instructor certification at the start of the RCT. The first instructor had 5 days of intensive training by an MBSR-certified senior teacher and codeveloper of MMWR. The second facilitator was hired later in the study and trained in MBI delivery; they were trained in MMWR by the first instructor and an MBSR-certified senior teacher and codeveloper of MMWR. Both instructors received ongoing supervision from an MBSR-certified senior teacher and codeveloper of MMWR so that they continue to adhere to the MMWR curriculum.
Each class session had a central theme and was divided into five segments in the following order: (1) welcome, review of group culture, brief homework practice check-in, objectives, and brief mindfulness meditation or practice; (2) didactic psychoeducational presentation and discussion of lesson content; (3) experiential meditation and mindfulness practices related to the session’s theme; (4) practice of sitting or walking meditation, body scan, and/or standing stretching; and (5) selected reading related to session topic, assignments for the next class, and closing meditation. Study participants were expected to learn and develop skills to help facilitate experiences and stressors using mindfulness principles. Class sessions included lessons on the role of automatic reactivity to stressors and its relation to addiction and relapse; the connections between stress, triggers, and relapse; and how to use mindfulness practices to respond best to related thoughts, emotions, body sensations, and triggers while still avoiding relapse. Instructors taught meditation (audio-guided sitting meditation, sitting meditation without audio, loving kindness meditation, walking meditation, body scan, and mindful stretching) and mindfulness practices that could be used in daily life: stop light technique (used to avert impulsive reactions), triangle of awareness (used to unlink body sensations, thoughts and emotions), mindfulness of breath, mindfulness of emotions, mindfulness of thoughts, mindfulness of body sensations, and mindfulness of cravings. Course instructions included bringing mindful awareness into daily activities and homework to practice meditation daily as possible. At the beginning of the intervention, participants received a MMWR Participant Workbook organized by session with key concepts and practices, as well as homework and practice assignments for each session. Participants were asked to bring their workbook to each session to report on their previous week’s assignment, as well as follow along the instructor’s directions for the current session’s homework and practice assignments. Participants received a MP3 player with meditation audios as a guide for practices introduced in each session.
Measures
Meditation Practice
Participants were asked to report the frequency and average duration of meditation practice for each meditation type that they performed outside of class sessions over the past 7 days at the conclusion of MBI class Sessions 3, 6, 9, and 12; this assessment phase will hereafter be referred to as intervention. At the 7-month follow-up interview, participants were asked to report on their meditation practice over the past 7 months; this period will hereafter be referred to as follow-up. In accordance with terminology commonly used in behavioral sciences, we have established that a session refers to one of the formal MBI in-class meetings; conversely, we define a bout as a single episode of meditation practice, wherein an individual initiates and concludes a meditation session outside of the formal MBI sessions.
Type of Meditation
Participants learned about various meditation types during class sessions and received instructions from the facilitator to practice meditation as daily homework outside of the class sessions. Based on the core training delivered in class, we assessed seven meditation types (i.e., audio-guided sitting meditation, sitting meditation (no audio is provided to guide the meditation), loving-kindness meditation, walking meditation, body scan, mindful stretching, and mindfulness of cravings). The first six types are conventional to MBIs. Using mindfulness to experience cravings without reacting is a specific practice used to help individuals manage the sensory aspects of substance cravings pertinent to people in recovery (Witkiewitz et al., 2013). To quantify participants’ meditation adherence, we operationalized the meditation repertoire as the cumulative performance across these seven meditation types, with a perfect score of 7 indicating full participation in the complete range of meditation practices (over the past week, at four timepoints during the intervention; and over the entire 7-month post-intervention period at follow-up).
Frequency of Meditation
Items that assessed meditation frequency were presented in this format: “How often did you practice [meditation type]?” with reference to the past 7 days. Response options during the intervention phase ranged on a scale of 0–4: 0=0 times, 1=less than once per day, 2=once per day, 3=twice per day, 4=3 or more times per day with a recall window of one week. We used response options at the follow-up interview with a wider recall window of 1 month. Options were as follows: 0=0 times, 1=less than once per month, 2=1–3 times per month, 3=once per week, 4=daily in the past month. We computed a mean score for each participants’ average meditation frequency across the four assessments of 7-day recall periods during the intervention, and separately for the follow-up. Specifically, during the intervention, we summed all frequency scores across the seven meditation types reported at Sessions 3, 6, 9, and 12, then divided that score by the count of responses provided by that participant. As a result of aggregating scores across the weeks for our analyses, we have considered any disproportionate comparisons that may result from different meditation types being introduced in phases throughout the intervention. Sitting and walking meditation, body scan, and mindful stretching were all introduced in the first MBI session; loving-kindness was introduced at Session 2; and mindfulness of cravings was introduced at Session 3. Participants reported on their meditation practices for the first time at the end of Session 3.
Duration of Meditation Bouts
Each meditation frequency item was followed by the question “How many minutes did you usually spend on this?” Participants reported the number of minutes that they meditated, on average, per meditation bout. We computed means to indicate participants’ average duration of meditation bouts across the four assessed 7-day recall periods during the intervention, and for the follow-up period. Specifically, we summed all meditation duration responses (in min) for six meditation types (“using mindfulness to experience cravings without reacting” was not assessed with this level of detail and thus was not included) to create a sum score for each participant, then divided that score by the count of responses provided by that participant. To compute a conservative score of meditation duration, all meditation durations that were reported by participants as a range (e.g., 20–40 min) were coded as the reported lower bound of the range (e.g., 20–40 min would be recoded as 20 min). Three participants reported outlier responses for average meditation duration. After examining the specific participants’ meditation data, we excluded the outlier responses based on typos in two cases (i.e., 480, 1440) and lack of interpretability in one case (i.e., every 3 hr).
MBI Completer Status
Attendance sign-in sheets were provided to each participant for each of the 12 sessions. The sign-in sheets indicated the session number, session date, participants’ first name and last name initial, and a designated space for participants to sign. The sign-in sheets were collected at the end of each session and reviewed for signatures by a study staff member. Attendance records were checked for accuracy at the completion of Session 11, at the end of the cohort, and again at the conclusion of the intervention. In the original study, participants were considered completers of the MBI intervention if they completed at least 9 of 12 sessions. In the current study, MBI completion is coded as a binary variable based on attendance of nine or more MBI sessions (0=did not complete MBI (attended <9 sessions), 1=completed MBI (attended 9+ sessions)).
Discharge Status from the SUD Residential Treatment Facility
Discharge status from the SUD residential treatment facility represents a participant’s discharge status from the residential site after the first treatment episode from the facility. Discharge status was determined on a case-by-case basis by the SUD residential treatment team, which included a licensed SUD counselor certified in drug and alcohol treatment, clinician therapist registered with the Board of Behavioral Sciences (BBS), and team supervisor certified in SUD treatment and registered with the BBS, after a discussion of whether the participant developed the necessary skills to complete the residential treatment, as well as progress made toward their treatment goals (there was not a standard set of goals for the participants; most formulated goals at treatment entry and sometimes in discussion with treatment team members). If there was disagreement between team members, the supervisor made the final decision.
Based on their clinical progress, participants were designated one of three possible categories (completer, non-completer with satisfactory progress, and non-completer with unsatisfactory progress) on their patient chart at the time of discharge. A completer is defined as a patient who completed the course of treatment, met treatment goals, and were sufficiently stable to transition to step-down care; i.e., they developed sufficient coping skills, attended group sessions, followed rules/requirements on the days they were away from the facility including having called in, returned on time, and a negative drug screen result. A non-completer with satisfactory progress was defined as a patient who left treatment before completion of the treatment plan and before achieving all treatment goals but made significant progress toward treatment goals and improved stability as determined by the clinical team. A non-completer with unsatisfactory progress was defined as a patient who left treatment before completion of the treatment plan and made little to no progress toward achieving treatment goals, such as having left treatment early without receiving many of the services, being discharged from facility due to multiple instances of relapse (e.g., indicated by a positive drug screen, participant admitted to using substances, multiple other participants reported about one participant having a relapse or giving them drugs) and not changing behavior, and having continually violated facility’s rules (e.g., brought drugs on site). The three SUD residential treatment discharge status categories were coded as follows: 0=non-completer with unsatisfactory progress, 1= non-completer with satisfactory progress, 2=completer.
Demographic and Clinical Variables
Bivariate correlations, tests of mean differences, and prediction models included demographic and clinical variables. Race/ethnicity was coded 1=non-Hispanic White, 2=non-Hispanic Black, 3=Hispanic/Latina, and 4=Other. SUD diagnosis at residential entry was coded 1=alcohol use disorder (AUD), 2=drug use disorder (DUD), and 3=DUD+AUD. Number of mental health diagnoses other than SUD was coded 0=none, 1=one, and 2=two or more. SUD residential treatment assignment was coded 0=mandated, 1=not mandated. Age, drug addiction severity at baseline (ranged from 0–1), and alcohol addiction severity at baseline (ranged from 0–1) were all on a continuous scale.
Alcohol and drug addiction severity at baseline scores were based on a questionnaire, Addiction Severity Index, Lite version (ASI-Lite; Cacciola et al., 2007). The ASI-Lite is a semi-structured instrument that involves a timeline followback component conducted by clinicians at baseline to gather information on the type(s) of substance(s) used and the number of days they were each used in the past 30 days. Participants also reported on how troubled or bothered they had been by problems with alcohol/drugs (0=not at all, 1=slightly, 2=moderately, 3=considerably, 4=extremely), how important treatment for these problems was to them (0=not at all, 1=slightly, 2=moderately, 3=considerably, 4=extremely), and how many days they experienced problems with alcohol/drugs (number of days). All responses were inputted to a formula to compute a final drug addiction severity score and alcohol addiction severity score (see McGahan et al., 1986 for the formula).
Data Analyses
Analyses were conducted in SPSS version 28 software (SPSS Inc, Chicago, IL). Statistical tests were selected after examining data distributions. Based on the Shapiro-Wilk’s test of normality, meditation frequency (skewness 0.84; kurtosis 0.26) and average duration of meditation bouts during intervention (skewness 0.95; kurtosis 0.57) and meditation frequency during follow-up (skewness −0.27; kurtosis −0.77) were normally distributed. Average duration of meditation bouts during follow-up was not normally distributed (skewness 4.15; kurtosis 25.43). Bivariate tests were conducted using Spearman’s rank correlation coefficient. One-way ANOVAs were conducted to assess differences in meditation frequency and average duration of meditation bouts during intervention among categories for race/ethnicity, SUD diagnosis at residential entry, and number of mental health diagnoses other than SUD. All assumptions of an ANOVA were tested and met. The Mann-Whitney U test was used to assess variability in meditation frequency and average duration of meditation bouts during intervention among those who were mandated to SUD residential treatment vs. those who were not mandated. Two separate generalized linear models with a linear response profile analysis of meditation frequency or average duration of meditation bouts during follow-up and the identity link function were conducted to examine meditation frequency or average duration of meditation bouts during intervention as predictors. Both models controlled for age, drug addiction severity at baseline, alcohol addiction severity at baseline, SUD diagnosis at residential entry, and discharge status from the SUD residential treatment facility, and either meditation frequency or average duration of meditation bouts during intervention. The Mann-Whitney U test was used to assess variability in meditation frequency and average duration of meditation bouts during intervention and follow-up among MBI completers vs. non-completers. A one-way ANOVA was conducted to assess differences in meditation frequency and average duration of meditation bouts during intervention among the SUD residential treatment discharge status categories. All assumptions of an ANOVA were tested and met.
There were missing data for meditation frequency and duration due to attrition of participants who did not respond to follow-up prompting, though we had very low attrition for this complex sample at this time interval. Missing data were considered for all computed mean scores and values of meditation frequency and duration. Mean scores and values were computed with a denominator that represented non-missing cases only (i.e., the denominator represented the count of total responses that participants reported, rather than a standard value indicating the total count of possible responses). Thus, missing responses were not assumed 0 for computing average meditation frequency or average duration of bouts.
Results
Sample characteristics
Table 1 provides descriptive baseline characteristics of the study sample (n=100). Mean age was 32.43 (SD=9.84) years; the majority were Hispanic/Latina (60%), incarcerated in the 8 months before residential entry (59%), and had a DUD at residential entry (74%), and nearly half had less than a high school education (47%). Substance use in the 8 months before residential entry was mainly methamphetamine/amphetamine (74%), followed by alcohol use to intoxication (51%), and cannabis (50%). About 24% were homeless before residential entry, and 49% had one mental health diagnosis other than SUD. The majority (83%) of participants were mandated to SUD residential treatment. Table 2 provides the study sample descriptive statistics for the main study variables. Figure 2 shows a detailed illustration of each participant’s meditation measures.
Table 1
Baseline characteristics of women in residential treatment for SUD
n=100
Age in years, M (SD)
32.43 (9.84)
Race and ethnicity
Hispanic or Latina
60
Non-Hispanic Black
18
Non-Hispanic White
20
Other
2
Education
Less than high school
47
Completed high school
31
Some education after high school
22
Homeless prior to residential entry
24
Incarcerated in 8 months before to residential entry
59
Number of mental health diagnoses other than SUD
None
37
1
49
2 or more
11
Used substance during 8 months before residential entry
Methamphetamine/amphetamine
73
Cannabis
50
Alcohol to intoxication (≥5 drinks in one sitting)
51
Cocaine and/or crack
14
Other sedatives/hypnotics/tranquilizers
7
Hallucinogens
6
Heroin
5
Opiates/analgesics
7
Methadone, non-prescribed
2
Days in residential prior to study intervention start, M (SD)
38.42 (15.91)
SUD residential assignment
Not mandated
17
Mandated
83
SUD diagnosis at residential entry
Alcohol use disorder only
9
Drug use disorder only
74
Both DUD and AUD
14
Table 2
Descriptive statistics for meditation performed outside of MBI sessions
n (%)
Meditation frequency during intervention (n=93)
0 times
8 (9%)
Less than once per day
31 (33%)
Once per day
44 (47%)
Twice per day
9 (10%)
3 or more times per day
1 (1%)
Average duration of meditation bouts during MBI (n=80)
1 ≤ 10 min
34 (42.50%)
10 < × ≤ 20 min
23 (28.75%)
20 < × ≤ 30 min
18 (22.50%)
30 < × ≤ 40 min
3 (3.75%)
40 < × ≤ 50 min
2 (2.50%)
Meditation frequency during follow-up (n=87)
0 times
22 (25%)
Less than once per month
32 (37%)
1–3 times per month
29 (33%)
Once per week
4 (5%)
Daily
0 (0%)
Average duration of meditation bouts during follow-up (n=76)
1 ≤ 10 minutes
24 (32%)
10 < × ≤ 20 min
28 (37%)
20 < × ≤ 30 min
17 (22%)
30 < × ≤ 40 min
3 (4%)
40 < × ≤ 50 min
4 (5%)
MBI completer status (n=100)
Non-completer (attended fewer than 9 of 12 sessions)
27 (27%)
Completer (attended 9 or more of 12 sessions)
73 (73%)
Table 3
Meditation frequency and duration by type from 7-day recall periods reported at MBI sessions
Session 3
Session 6
Session 9
Session 12
Meditation frequency, in times per day
Audio-guided sitting meditation
1.73 (1.21)
1.92 (1.13)
2.00 (1.28)
2.37 (1.28)
Sitting meditation
1.86 (1.36)
1.89 (1.12)
2.14 (1.17)
2.54 (1.18)
Loving-kindness meditation
2.02 (1.33)
2.02 (1.17)
2.40 (1.25)
2.46 (1.24)
Walking meditation
1.94 (1.38)
2.18 (1.31)
2.62 (1.29)
2.57 (1.10)
Body scan
1.28 (1.24)
1.63 (1.18)
1.91 (1.22)
2.25 (1.23)
Mindful stretching
1.81 (1.14)
2.13 (1.18)
2.28 (1.22)
2.66 (1.10)
Using mindfulness to experience cravings without reacting
1.84 (1.41)
1.88 (1.36)
2.36 (1.36)
2.56 (1.24)
Average duration of meditation bouts, in minutes
Audio-guided sitting meditation
14.91 (14.75)
17.07 (17.89)
16.77 (14.59)
17.10 (14.34)
Sitting meditation
16.26 (13.09)
15.56 (19.60)
17.54 (16.84)
14.73 (11.71)
Loving-kindness meditation
13.83 (11.91)
16.92 (28.23)
14.02 (13.27)
13.65 (11.88)
Walking meditation
27.68 (23.10)
23.33 (29.57)
18.02 (15.24)
17.80 (15.97)
Body scan
11.47 (12.02)
12.11 (11.27)
11.96 (10.91)
10.39 (8.55)
Mindful stretching
10.95 (9.97)
14.19 (11.92)
13.57 (9.86)
12.52 (8.26)
The mean (SD) of the frequency and average duration of meditation bouts performed outside of MBI sessions during the 7-day periods at MBI class Sessions 3, 6, 9, and 12 are reported. Meditation frequency is scored on a scale of 0–4: 0=0 times, 1=less than once per day, 2=once per day, 3=twice per day, 4=3 or more times per day. Average duration of meditation bouts represents the average number of minutes spent per meditation bout across the 7-day recall period
Fig. 2
Meditation levels by participant during the MBI and at follow-up. MBI, mindfulness-based intervention; SUD, substance use disorder; ID, study ID; SA, audio-guided sitting meditation; S, sitting meditation; LK, loving-kindness meditation; W, walking meditation; BS, body scan; MS, mindful stretching; MC, using mindfulness to experience cravings without reacting; avg freq, average meditation frequency across all seven meditation types outside of class sessions across four 7-day periods during the MBI as reported at class Sessions 3, 6, 9, and 12 and during the 7-month follow-up as reported at a follow-up interview; avg dur, average duration of meditation bouts across six meditation types outside of class sessions across four 7-day periods during the MBI as reported at class Sessions 3, 6, 9, and 12 and during the 7-month follow-up as reported at a follow-up interview; class attend, MBI sessions attended as reported by signed attendance records
×
A small positive correlation was found between average duration of meditation bouts during intervention and alcohol addiction severity at baseline (r(77)=0.22, p=0.05). No other significant correlations were found between meditation frequency or average duration of meditation bouts during intervention and age (r(91)=0.18, p=0.09 and r(77)=−0.05, p=0.69, respectively), drug addiction severity at baseline (r(91)= −0.16, p=0.13 and r(77)=0.09, p=0.43, respectively), or alcohol addiction severity at baseline (r(91)=0.04, p=0.68). We found no differences in means for meditation frequency or average duration of meditation bouts during intervention across categories of race/ethnicity (F(3,89)=0.89, p=0.45 and F(3,75)=0.60, p=0.62, respectively), SUD diagnosis at residential entry (F(2,87)=0.95, p=0.39 and F(2,73)=0.95, p=0.39, respectively), number of mental health diagnoses other than SUD (F(2,87)=1.67, p=0.19 and F(2,73)=0.41, p=0.66, respectively), or SUD residential treatment assignment (U=482.50, p=0.17 and U=339.00, p=0.39, respectively).
Frequency and Duration of Meditation During the MBI
Table 3 displays the sample’s average frequency and duration of bouts for each meditation type during each of four 7-day periods before MBI Session 3, 6, 9, and 12. During the MBI, 7 participants were missing all meditation frequency data, and 20 participants were missing all meditation duration data. Average meditation frequency during intervention was once per day (M=2.05, SD=0.75), with average duration of meditation bouts being 14.46 min (SD=9.86). A gradual increase was observed in average meditation frequency during intervention from less than once per day during the 7-day period before Session 3 (M=1.79, SD=0.84) and Session 6 (M=1.95, SD=0.84), to once per day during the 7-day period before Session 9 (M=2.23, SD=0.93) and session 12 (M=2.48, SD=0.90). A gradual decrease was observed in average duration of meditation from 15.47 min (SD=10.55) to 14.20 min (SD=9.14) over the course of the intervention. The correlation between frequency and average duration of meditation bouts was not significant (r(78)=0.19, p=0.09).
Participants practiced all meditation types except body scan on average once per day during intervention: walking meditation (M=2.29, SD=1.05), loving-kindness meditation (M=2.18, SD=1.00), mindful stretching (M=2.14, SD=0.96), practicing mindfulness to experience cravings without reacting (M=2.08, SD=1.08), sitting meditation (M=2.04, SD=1.00), audio-guided sitting meditation (M=2.00, SD=0.96). Body scan was practiced on average less than once per day (M=1.69, SD=1.02). Walking meditation was practiced on average for the longest duration per meditation bout (M=20.30, SD=16.66 min), followed by sitting meditation (M=15.58, SD=13.50 min), audio-guided sitting meditation (M=14.95, SD=12.96 min), loving-kindness meditation (M=13.96, SD=12.89 min), mindful stretching (M=12.15, SD=8.38 min), and then body scan (M=11.41, SD=10.44 min).
Frequency and Duration of Meditation at Follow-up
For the follow-up period, thirteen participants were missing all meditation frequency data, and 24 participants were missing all meditation duration data. Average meditation frequency during follow-up was less than once per month (M=1.58, SD=0.91), with average duration of meditation bouts being 18.18 min (SD=15.26). The correlation between meditation frequency and duration during follow-up was not significant (r(74)=0.19, p=0.10). Participants performed walking meditation most frequently, on average 1–3 times per month at follow-up. All other meditation types were performed on average less than once per month: loving-kindness meditation (M=1.76, SD=1.39), sitting meditation (M=1.74, SD=1.38), mindful stretching (M=1.61, SD=1.57), practicing mindfulness to experience cravings without reacting (M=1.51, SD=1.55), audio-guided sitting meditation (M=1.14, SD=1.25), body scan (M=1.13, SD=1.32). Walking meditation was performed on average for the longest duration per meditation bout (M=25.43, SD=20.85 min), followed by audio-guided sitting meditation (M=18.72, SD=12.56 min), sitting meditation (M=16.84, SD=13.37 min), loving-kindness meditation (M=16.48, SD=14.50 min), mindful stretching (M=12.13, SD=9.58 min), and then body scan (M=11.24, SD=10.66 min).
Meditation During Intervention Predicts Meditation at the 7-Month Follow-up
After controlling for average duration of meditation bouts during intervention, age, drug addiction severity at baseline, alcohol addiction severity at baseline, SUD diagnosis at residential entry, and discharge status from the SUD residential treatment facility, meditation frequency during intervention significantly predicted meditation frequency at the 7-month follow-up period (unstandardized beta, B=0.56, SE=0.12, p<0.001; Table 4). After controlling for meditation frequency during intervention, age, drug addiction severity at baseline, alcohol addiction severity at baseline, SUD diagnosis at residential entry, and discharge status from the SUD residential treatment facility, average duration of meditation bouts during intervention significantly predicted average duration of meditation bouts at the follow-up period (B=0.45, SE=0.20, p=0.02).
Table 4
Prediction of meditation variables at 7-month follow-up
Predictor variables
Meditation frequency
Meditation duration
B
SE
p-value
B
SE
p-value
Meditation frequency during MBI
0.56
0.12
<0.001
−1.10
2.69
0.68
Average duration of meditation bouts during MBI
−0.00
0.01
0.82
0.45
0.20
0.02
Covariates
Age
0.00
0.01
0.92
0.24
0.19
0.21
ASI drug
−0.60
1.01
0.55
−29.35
21.47
0.17
ASI alcohol
0.01
0.61
0.98
35.66
12.83
0.01
Discharge status from the SUD residential treatment site
Non-completer with unsatisfactory progress
−0.22
0.233
0.34
11.41
4.84
0.02
Non-completer with satisfactory progress
−0.12
0.262
0.66
4.38
6.20
0.48
Completer
–
–
–
–
–
–
SUD diagnosis at residential entry
Alcohol use disorder
0.62
0.356
0.08
−18.35
7.61
0.02
Drug use disorder
0.55
0.230
0.02
−8.14
5.19
0.12
Both alcohol and drug use disorder
–
–
–
–
–
–
The Addiction Severity Index, Lite version was used to compute drug and alcohol addiction severity scores at baseline
MBI Course Completion and Meditation
Most participants completed the MBI (73% of participants completed nine or more in-class sessions). Correlations between MBI completion and meditation frequency (r(91)=0.19, p=0.07) or duration of meditation bouts (r(78)=0.03, p=0.78) during the intervention were not significant. A significant positive correlation was found between MBI completion and meditation frequency (r(85)=0.29, p=0.01) at follow-up. No significant difference was observed in meditation frequency (U=533.50, p=0.07) or duration of meditation bouts (U=439.50, p=0.78) during intervention by MBI completion status. Meditation frequency during follow-up was significantly greater among those who completed the MBI compared to those who did not (U=382.00, p=0.01). Duration of meditation bouts at follow-up did not significantly differ based on MBI completion status (U=359.00, p=0.49). A positive correlation was found between MBI completion and discharge status from the SUD residential treatment facility (r(98)=0.45, p<0.001).
Residential Site Discharge Status and Meditation Performance
Most participants discharged from the SUD residential treatment facility as a residential treatment site completer (n=54), followed by non-completer with unsatisfactory progress (n=27), and then non-completer with satisfactory progress (n=19). Average meditation frequency during intervention was less than once per day for both the non-completer with unsatisfactory progress group (M=1.90, SD=0.83; n=22) and non-completer with satisfactory progress group (M=1.90, SD=0.74; n=17), while the completer group practiced on average once per day (M=2.18, SD=0.77; n=54). Average duration of meditation bouts was 11.91 min for the non-completer with unsatisfactory progress group (SD=7.96; n=17), 12.22 min (SD=8.16; n=13) for the non-completer with satisfactory progress group, and 16.26 min (SD=10.80; n=50) for the completer group. No significant correlation was found between discharge status from the SUD residential treatment facility and meditation frequency (r(91)=0.15, p=0.16) or duration of meditation bouts (r(78)=0.18, p=0.11) during intervention. No significant differences were found in meditation frequency (F(2,90)=1.49, p=0.23) or average duration of meditation bouts (F(2,77)=1.70, p=0.19) during intervention by SUD residential treatment discharge status.
Discussion
Our objective in conducting this analysis was to provide a comprehensive examination of the meditation practices outside scheduled MBI class sessions, focusing on the type, frequency, and duration of meditations among racially/ethnically diverse individuals housed in residential treatment for SUD. Additionally, we aimed to assess these meditation patterns during the MBI course and at a 7-month follow-up interview. We subsequently investigated whether the frequency and average duration of meditation bouts during the MBI course predicted the frequency and average duration of meditation practiced during a 7-month post-intervention period. We also controlled for important clinical variables, such as addiction severity at baseline, SUD diagnosis, and discharge status from the residential treatment site. Our findings reveal that individuals with SUD respond to a MBI program by engaging in a variety of meditation types and frequently during the intervention. Although meditation was not frequent during follow-up, some participants continued their meditation practice for at least 7 months after the intervention, indicating a sustained maintenance of the behavior learned. Moreover, in line with our hypothesis, meditation frequency and duration during intervention predicted meditation practice during a 7-month follow-up period suggesting that adherence to MBI homework assignments may lead to more meditation long-term while in the context of recovery. This is an important finding given the complex and shifting environments involved in SUD recovery and relapse. Our findings add to the limited body of research that examines meditation levels outside of scheduled MBI sessions (e.g., Glasner-Edwards et al., 2017).
During the MBI course, the frequency of meditation bouts outside of class sessions averaged once per day, but during the follow-up, it dropped to approximately once per month. Only 5% of the sample practiced at least once per week during the follow-up period. The average duration of meditation bouts remained consistent at about 15 min for both the intervention and follow-up phases. While meditating during the MBI course predicted future meditation behavior in our sample, that behavior was not frequently practiced during the follow-up period. This declining frequency aligns with the findings of Grow et al. (2015), who reported a decrease in meditation from about 100 min per week during the intervention to about 60 min per week at the 2- and 4-month follow-up assessments. Interestingly, walking meditation emerged as the most frequently practiced and longest-lasting meditation type during both the intervention and follow-up phases. One potential explanation for this observation is that walking is a commonplace physical activity that people engage in multiple times each day. Participants might have seamlessly integrated walking with meditation or may have mistakenly combined walking itself with the concept of walking meditation when recalling their meditation; that is, reporting the frequency or duration that they walked (and did not meditate) as the frequency or duration that they performed walking meditation. In contrast, the body scan was the least frequently practiced meditation type. Traditional body scan meditation typically takes around 45 min and demands a deliberate, sequential focus on various parts of the body, noting any discomfort, pain, or negative sensations that arise (Dreeben et al., 2013). Previous research, conducted on a sample of undergraduate students, indicated that the body scan meditation was less effective at promoting a non-evaluative stance toward observed stimuli when compared to sitting meditation. Furthermore, it was found to be less effective at reducing difficulties with emotion regulation when compared to both sitting meditation and mindful yoga types (Sauer-Zavala et al., 2013). Given the time commitment required and these comparative findings, it is possible that our sample of women in recovery practiced body scan meditation the least frequently such that it was more aversive than other types of meditation.
The frequency and duration of specific meditation types practiced by our sample may be attributed to various factors. One factor could be the emphasis placed on certain meditation types during in-class sessions and homework assignments within a given recall window during the MBI. Alternatively, participants may have opted for meditation types they found least challenging or most reinforcing compared to others to manage symptoms and elevate mood. Notably, there is limited research on individual differences in the type of meditation preferred. Prior studies have often aggregated meditation types into a general practice of mindfulness meditation, a common approach taken in the field (e.g., Zgierska et al., 2009). Our study stands out as one of the few to identify a potential preference for a particular meditation type among women in recovery. This discovery could have practical implications, suggesting that a focus on walking meditation in this cohort might be advantageous if the goal is to increase the frequency and duration of meditation within a MBI adapted for addiction recovery.
In ancillary descriptive analyses, we observed that outside-of-session meditation levels during the MBI showed no associations with baseline demographic and clinical variables (i.e., age, race/ethnicity, SUD diagnosis at residential entry, drug and alcohol addiction severity at baseline, SUD residential treatment assignment, number of mental health diagnoses other than SUD, and discharge status from the SUD treatment facility). Meditation levels were similar across non-Hispanic White, non-Hispanic Black, Hispanic/Latina, and Other race/ethnicity groups; DUD-, AUD-, and DUD+AUD-diagnosed groups; those who were mandated vs. not mandated to SUD residential treatment; those who had 0, 1, or 2 or more other mental health diagnoses other than SUD; and non-completers of the SUD residential treatment with unsatisfactory progress, non-completers with satisfactory progress, and completers. This finding is informative about MMWR generality in the sense that individuals from a variety of demographic and clinical risk categories meditate to a similar level when experiencing the same MBI adapted for addiction recovery.
Limitations and Future Research
This study has certain limitations, primarily stemming from the use of self-report data on meditation, which can introduce reporting bias and recall errors, potentially affecting the accuracy of our measurements, particularly the retrospective assessment of meditation 7 months following the intervention. To mitigate some of these issues, we implemented a short recall period during the intervention, where participants reported their meditation activities for the past week during the 6-week intervention. Additionally, the use of a self-administered survey completed in private was aimed at minimizing the Hawthorne effect. Future research can benefit from incorporating objective measures of meditation, such as using body-worn feedback device. Secondly, we examined the frequency and duration of meditation practice separately due to the structure of the questionnaires and data collection method employed in the original study. Responses for the frequency of meditation performed were reported on a scale ranging from 0 to 4 (0 times to 3 or more times per day during the intervention). The average duration of a meditation bout in a given week was reported separately in response to a different question, where participants reported the average number of minutes they spent in meditation. Consequently, we were not able to calculate the precise cumulative amount of meditation performed, such as the total number of minutes per day or week during the intervention. Future studies may consider assessing frequency and duration of practice together to provide a more comprehensive picture of cumulative meditation performance. Thirdly, frequency of meditation was not a continuous variable, and the response options for frequency of meditation during follow-up were on an uneven scale (0 times, less than once per month, 1–3 times per month, once per week, daily), which affects the interpretation of the results. Lastly, the variable indicating MBI course completion rates in our study showed high levels of completion, so it is possible that the elevated meditation behaviors observed in this group are more reflective of general conscientiousness and task completion in a sample motivated to complete residential treatment.
In summary, our analysis reveals that women with SUD exhibit a diverse range of meditation practices in response to a MBI administered within a residential setting. We found that those who meditated more during the intervention were more likely to meditate 7 months later. Specifically, our data suggest that women in residential treatment tend to favor walking meditation over other meditation types. This insight can inform future research, such that a MBI tailored for women with SUD may benefit from emphasizing and integrating walking meditation. For instance, it could involve leading the MBI curriculum with walking meditation then transitioning across the course to more static behavior such as sitting meditation and body scan. This tailored approach may optimize the effect of MBIs for women in recovery.
Declarations
Ethics
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. IRB approval was obtained from the University of Southern California.
Informed Consent
Informed consent was obtained from all individual participants included in the study. This article does not contain any studies with animals performed by any of the authors.
Use of Artificial Intelligence
Artificial intelligence was not used.
Conflict of Interest
The authors declare no completing interests.
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