Mindfulness-Oriented Recovery Enhancement (MORE): An Overview

Mindfulness-Oriented Recovery Enhancement (MORE) is a novel social work intervention and mental training program that unites complementary aspects of mindfulness training, “Third Wave” cognitive-behavioral therapy, and positive psychological principles into an integrative treatment strategy. The MORE program is detailed in a treatment manual designed for use by therapists (and patients). C-MIIND Director, Eric Garland, Ph.D., LCSW, developed MORE by translating findings from basic behavioral science and neuroscience into specific strategies designed to ameliorate addictive behavior, stress, and (physical and emotional) pain.

MORE is centered on three key therapeutic processes:
1. MINDFULNESS: MORE strengthens metacognitive control over automatic cognitive biases through mindfulness training – teaching clients to: A) become aware of when their attention has become fixated on addictive cues, stressors, or (physical or emotional) pain; B) shift from affective to sensory processing of craving, stress, or pain sensations; and C) re-orient attention to the breath via the practice of mindful breathing. This technique is also aimed at enhancing self-control over automatic behavioral habits elicited by addictive cues, stressors, and pain. By disrupting negative habit responses, mindfulness may free up cognitive resources to devote to more helpful or healthful ways of thinking, perceiving, and acting in the world.

2. REAPPRAISAL: MORE uses mindfulness practices to potentiate cognitive reappraisal of maladaptive thoughts contributing to negative emotions and addictive behaviors; such “mindful reappraisal” is aimed at fostering adaptive coping in the face of stress. MORE increases psychological flexibility by explicitly teaching mindfulness skills in tandem with cognitive restructuring techniques. Clients are taught to mindfully disengage from negative appraisals of stressful events and restructure them until they abate and positive reappraisals are constructed to promote resilience, meaning in life, and active coping behavior.

3. SAVORING: MORE enhances positive emotion and motivation by instructing clients to mindfully focus attention on and savor naturally rewarding experiences (e.g., a enjoying a beautiful nature scene or the sense of connection with a loved one) while cultivating metacognitive awareness of their own positive emotional responses to such experiences. MORE uses exercises to promote focus on positive daily experiences as a means of restoring dysregulated reward neurocircuitry function associated with addiction, mood disorders, and chronic pain.

MORE is distinct from other mindfulness-based interventions in that it uses mindfulness training as a means of promoting positive psychological processes to improve health and well-being. In this sense, the treatment is truly “integrative,” combining the complementary strengths of different therapeutic techniques into one, synergistic approach. For instance, mindfulness skills are used to help clients to disengage from unhealthy cognitive and behavioral habits, while reappraisal skills are used to develop new, more helpful beliefs and actions. Savoring skills are then used to provide the positive motivational energy and sense of reward needed to drive and sustain behavioral change; this latter feature of MORE is especially innovative, as few (if any) empirically-supported treatments directly aim to strengthen the capacity to extract pleasure from naturally rewarding events and experiences. Unlike other mindfulness-based interventions which eschew a focus on evaluation, narrative processing, and positivity, MORE aims to foster the development of valued ways of seeing and responding in the world – generating a sense of eudaimonic meaning in life. Yet, unlike other third wave CBT approaches which focus on values but do not offer instruction in formal mindfulness meditation, MORE provides mindfulness training as a means of strengthening self-regulatory capacity. This enhanced capacity is then channeled in service of promoting psychosocial flourishing. The tripartite MORE approach is guided by fundamental discoveries from neuroscience about the biobehavioral factors integral to suffering and its alleviation. Indeed, studies indicate that cognitive control of attention (i.e., mindfulness), negative emotion (i.e., reappraisal), and reward processing (i.e., savoring) goes awry in addiction, stress, and chronic pain; these processes are integral to healthy brain and body functioning. Thus, MORE aims to cultivate and leverage these basic human strengths to foster therapeutic change and self-actualization.

 

A conceptual framework of the hypothetical neural mechanisms of MORE is described here.

The original 10 session treatment structure is described here.

MORE’s therapeutic effects have been demonstrated in five randomized controlled trials for a wide array of addictive behaviors, stress-related condition, and their comorbidities, the results of which have been published in numerous scientific journal articles. The MORE research program is currently supported by $15 million in federal research grants from the National Institute on Drug Abuse, the National Center for Complementary and Integrative Health, and the Department of Defense as an intervention for individuals struggling with co-occurring chronic pain and opioid misuse.

 

 

Publications on MORE

Garland, E.L., Howard, M.O., Zubieta, J., & Froeliger, B. (2017). Restructuring hedonic dysregulation in chronic pain and prescription opioid misuse: Effects of Mindfulness-Oriented Recovery Enhancement on responsiveness to drug cues and natural rewards. Psychotherapy and Psychosomatics, 86(2), 111-112.

Garland, E.L., Bryan, C.J., Finan, P., Thomas, E.A., Priddy, S.E., Riquino, M., & Howard, M.O. (2017). Pain, hedonic regulation, and opioid misuse: Modulation of momentary experience by Mindfulness-Oriented Recovery Enhancement in opioid-treated chronic pain patients. Drug and Alcohol Dependence, 173, S65-S72.

Li, W., Garland, E.L., McGovern, P., O’Brien, J.E., Tronnier, C., & Howard, M.O. (2017). Mindfulness-Oriented Recovery Enhancement for internet gaming disorder in U.S. adults: A stage 1 randomized controlled trial. Psychology of Addictive Behaviors, 31, 393-402.

Garland, E.L., Baker, A.K., & Howard, M.O. (in press). Mindfulness-Oriented Recovery Enhancement reduces opioid attentional bias among prescription opioid-treated chronic pain patients. Journal of the Society for Social Work and Research.

Garland, E.L. (2016). Targeting hedonic dysregulation with Mindfulness-Oriented Recovery Enhancement: Restructuring reward mechanisms in addiction, stress, and pain. Annals of the New York Academy of Sciences, 1373, 25-37.

Garland, E.L., Manusov, E.G., Froeliger, B., Kelly, A., Williams, J.M., & Howard, M.O. (2014). Mindfulness-Oriented Recovery Enhancement for chronic pain and prescription opioid misuse: Results from an early stage randomized controlled trial. Journal of Consulting and Clinical Psychology, 82(3), 448-459.

Garland, E.L., Froeliger, B., & Howard, M.O. (2014). Effects of Mindfulness-Oriented Recovery Enhancement on reward responsiveness and opioid cue-reactivity. Psychopharmacology, 231(16), 3229-3238.

Garland, E.L., Froeliger, B.E., & Howard, M.O. (in press). Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: Exploratory ERP findings from a pilot RCT. Journal of Behavioral Medicine.

Kelly, A., & Garland, E.L. (2014). Treatment of depression and coping with chronic pain through Mindfulness-Oriented Recovery Enhancement. In C.W. LeCrory (ed.), Case Studies in Social Work Practice. Wiley: New York.

Garland, E.L. (2013). Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain. NASW Press: Washington, DC. http://www.naswpress.org/publications/clinical/mindfulness-oriented-recovery.html

Garland, E.L., Thomas, E.A., & Howard, M.O. (in press). Mindfulness-Oriented Recovery Enhancement ameliorates the impact of pain on self-reported psychological and physical function among opioid-using chronic pain patients. Journal of Pain and Symptom Management.

Garland, E. L. (in press). Disrupting the downward spiral of chronic pain and opioid addiction with Mindfulness-Oriented Recovery Enhancement: A review of clinical outcomes and neurocognitive targets. Journal of Pain and Palliative Care Pharmacotherapy.

Garland, E.L., & Howard, M.O. (2013). Mindfulness-Oriented Recovery Enhancement reduces pain attentional bias in chronic pain patients. Psychotherapy and Psychosomatics, 82(5), 311-318.

Garland, E.L., Schwarz, N., Kelly, A., Whitt, A., & Howard, M.O. (2012). Mindfulness-Oriented Recovery Enhancement for alcohol dependence: Therapeutic mechanisms and intervention acceptability. Journal of Social Work Practice in the Addictions, 12, 242-263.

Garland, E.L., Franken, I.H., & Howard, M.O. (2012). Cue-elicited heart rate variability and attentional bias predict alcohol relapse following treatment. Psychopharmacology, 222, 17-26.

Garland, E.L., Gaylord, S.A., Boettiger, C.A., & Howard, M.O. (2010). Mindfulness training modifies cognitive, affective, and physiological mechanisms implicated in alcohol dependence: Results from a randomized controlled pilot trial. Journal of Psychoactive Drugs, 42(2), 177-192.

 

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