Using mindfulness in a harm reduction approach to

substance abuse treatment: a literature review.

ADDICTED PEOPLE ARE A vulnerable population. They face manypsychological and emotional
problems which have a negative impact ontheir quality of life. In addition to the psychological and
emotionalproblems, there is also an adverse impact to the health and well-beingof addicted
individuals, which have a significant effect on the socialand economic influence on a global level
(Nooripour, 2014).
The outbreak of the human immunodeficiency virus (HIV), in the early 1980s, rapidly spread from
the homosexual community to the heterosexual population through the shared use of needles and
syringes during intravenous drug use. The result of HIV became Acquired Immunodeficiency
Syndrome (AIDS) and spread throughout the world. Lee, Engstrom, and Petersen (2011) reported
that this pandemic disease gave birth to the idea that in order to decrease the spread of HIV/AIDS,
a new alternative to assist in the treatment of people who suffer from drug use was developed. This
new form of treatment was known as harm reduction (Lee et al., 2011). Harm reduction was an
intervention designed to reduce the problematic effects of addictive behavior (Logan & Marlatt,
2010). In an attempt to reduce the blood-borne diseases associated with HIV and hepatitis, harm
reduction was a supporter of the needle exchange program that provided substance abusers with
new needles, education on safe use, sharing needles, safe injection sites, and allowed them the
ability to inject themselves in the presence of medical personnel (Logan & Marlatt, 2010).
The harm reduction concept
Marlatt's Buddhists beliefs had a profound influence on his research in addictive behavior. Buddha
teaches that enlightenment should be sought by seeking the middle way, which is analogous with
harm reduction. Marlatt believed that a middle path between the extremes of asceticism and
gluttonous self-indulgence led to moderation in behavior. Moderation in behavior became the
principal focus of his research related to the understanding and intervening in addictive
behaviors (Blume, 2012).
The "compassionate pragmatism", as Dr. Marlatt called it, of harm reduction provides an important
public health alternative to moral and disease model of substance abuse (Lee et al., 2011). Lee
et al. argued that harm reduction opened the eyes of public health to multifaceted programs and
policies that reduced harm associated with drug use. Harm reduction focused on meeting people
"where they were at", and identifying client-driven individualized goals. Although open to
abstinence, advocates for harm reduction recognized that (1) this goal may not be the most
appropriate goal for every client, and (2) emphasizing abstinence as a goal may prevent some of the
clients from seeking help or staying in the program (Lee et al., 2011).
Realizing that any and all positive changes regarding substance abuse were valuable, addressing
substance abuse would be just one part of helping clients make positive changes in their lives (Lee
et al., 2011). Programs that were effective in helping people change were needed in order for this
change to take place. Positive indications of effective programs are improved individual, and
community well-being (i.e. reduced needle sharing, discarding needles in public areas, reduction in
deaths from overdoses, increased enrollment in detoxification and treatment centers) (Logan &
Marlatt, 2010). By reducing the harmful effects of substance abuse, communities are able to see a
reduction in the need for medical care due to drug overdoses, reduction in the number of arrests
and court costs, and increase in participation in tax payer contributions, due to an increase in

an employed population Larimer, Malone, Garner, Atkins, Burlingham, Lonezak, ... Marlatt, G. A.
(2009).
Recognizing that substance use had become a problematic coping strategy of disadvantaged
neighborhoods was a step toward helping make a positive change and this would call for an
alternative coping mechanism (Lee et al., 2011). In efforts to reduce harm from substance
abuse, there arose a need for explicit consideration of the way in which social injustices and trauma
contributed to the use of substances. To address this need was another step toward positive change
for substance users. Lee et al. (2011) suggested that if efforts were made to destigmatize substance use and substance users by investing in the "bottoms up" approaches that
emerged from grassroots, such as people empowering approach efforts (Blume, 2012), it would be
particularly beneficial for those who used substances.

Logan and Marlatt (2010) reported, that in 2006, alcohol andsubstance abuse was associated with
trauma and emergency room visits.Over one million people screened positive for substance use,
andsubstance-related risky behaviors, abuse, or dependence with no previoussought out substance
abuse treatment. Basically, these people did notrecognize that they had a problem with substance
use, so there was nomotive to seek treatment.
In addition to using substances, many of the people had co-occurring mental disorders (Logan &
Marlatt, 2010). Traditional treatment practitioners usually required substance users to be
abstinent of drugs, before they could be treated for their mental disorders. In some cases, this was
not a feasible treatment plan. Harm reduction allowed the patient /client to reduce the use of drugs
while simultaneously receiving mental health treatment (Logan & Marlatt, 2010).
Harm reduction goals
Instead of viewing abstinence as the only option for intervention for substance use, harm reduction
focuses on reducing the negative consequences of substance use, accepting goals of moderate use
or use in safer conditions (Dimeff, Baer, Kivlahan, & Marlatt, 2003). Harm reduction interventions
target different populations and have three main goals. The first goal is to stay alive. The second
goal is to maintain one's health, and the third goal is to get better. The strengths of harm reduction
include flexibility and the ability to individualize both the goals and the strategy to achieve them.
The differences in these strengths make it difficult for various stakeholders to define, implement,
and assess harm reduction approaches (Lee et al., 2011). Opponents of harm reduction saw the
program as "making peace with genocide", "giving up on people" (Lee et al., 2011, p. 1153) rather
than reducing the harm and minimizing the destruction. In cases where clients are not willing to
stop substance use, abstinence is only a system that is set up for those people to fail. Those who
oppose the use of minimizing the effects of substance use through various interventions, that do not
include abstinence, believe that harm reduction misleads the addict and allows him/her to deny the
seriousness of their problems (Dimeff, Baer, Kivlahan, & Marlatt, 1999).
Buddhist teachings about mindfulness
In addition to Dr. Marlatt's use of mindfulness in his approach of harm reduction in treatment
(Blume, 2012), there have been other psychologists whose practice was based on the principles
of Buddhist teachings of mindfulness. For example, Dr. Jack Apsche (2014) uses mindfulness as
part of Mode Deactivation Therapy (MDT) in his practice with adolescent males to treat Conduct

Disorders (CD), Oppositional Disorders, reactive and proactive aggression, and PTSD. Drs. Jennings
and Apsche (2013) confirmed that mindfulness, along with MDT also proved to be an effective
treatment for sexual abusers. Already in 1969, German-born psychiatrist Fritz Perls realized the
benefits of mindfulness and the therapeutic effects of staying in the present moment (Bayles,
Blossom, & Apsche, 2014).
Because human beings commonly have many negative mental traits, observing the five precepts is
one of the very basic ways to counteract the negative traits. The five precepts are: (1) refrain from
harming self or others, (2) do not steal, (3) do not practice sexual misconduct, (4) speak truthfully,
and (5) do not use drugs/alcohol that cause carelessness and loss of awareness (Faxun, 2011). As
such, the five precepts help guide physical actions, speech, and mental attitude via a systematic
means aimed at actualizing the purification of the body, speech, and mind. The individual will
eventually gain wisdom little by little, and with wisdom, comes awareness of thoughts and
behaviors (Faxun, 2011).
The concept of the five precepts is essential to any mindfulness-based recovery program. The five
precepts are similar to a harm reduction program, and when coupled with mindfulness, they
can become relapse prevention tools. These tools are like a "karmic compass" pointing an individual
away from self-harm and suffering by teaching the individual to develop a good heart and true
happiness (Faxun, 2011). By adopting the five precepts, one adopts the principles of harm
reduction. They learn to cultivate self-respect, self-trust, and eventually learn to move away from
guilt and remorse.
Relapse prevention treatments
Relapse, which is often associated with a medical condition, is the return to a previous set of
behaviors or mental state. It is considered a larger part of an issue that is specifically related to
the individual. Relapse prevention (RP) is related to relapse as a naturally occurring event that is
address through treatment. As such, relapse is not considered bad, rather it is considered to be a
part of the overall treatment process (McGovern, Wrisley, & Drake, 2005). RP in this case, refers to
the re-occurring event of a substance user to return to previous treatment states of substance use.
The relapse prevention model has been well documented, with a large data base to support
it (Hendershot, Witkiewitz, George, & Marlatt, 2011). The benefit of relapse prevention is that it
does not consider a lapse in behavior as a treatment failure. The lapse is considered a normal part
of the recovery process and is a learning experience where the client learns to work through the
lapse and understands the pattern or cues that are associated with the lapse (Hendershot et al.,
2011). One disadvantage of the relapse model is that it is difficult to measure because if
the individual lapses, he or she is very likely to hide the incident out of fear of sanctions (Babor,
Steinberg, Anton, & Del Boca, 2000).
Bowen, Chawla, Collins, Witkiewitz, Hsu, Grow, ... Marlatt (2009) estimated relapse rates following
substance abuse treatment at over 60% and are described as chronic relapsing conditions. Twelvestep programs or mutual support groups are still the most common form of treatment. Mutual
support groups /12-step programs are highly organized groups designed to help those recovering
from substance use by having them be accountable to others in the group. The purpose of the
program is to help the individual refrain from substance use all together. The goal is abstinence
and that should be accomplished at the end of the 12-step process. As mentioned earlier, 12-step
programs are not appropriate for everyone. This program is discussed further later in this article.
By combining skills training with cognitive interventions and a cognitive behavioral treatment that
focuses on response to high-risk situations, RP with a harm reduction approach is an alternative to
the 12-step program that prevents or limits relapse.

Although RP has empirical evidence of promising advancement in treatment, significant problems

remain. Firstly, relapse is difficult to define as it varies according to the treatment approach, and to
measure as it is largely a self-reported condition. Relapse rates also vary significantly depending on
the specific approach and treatment goals. Bowen et al. (2009) reported a 44% to 70% relapse rate
of standard RP approaches, i.e. without integration of further efficacious treatment components
such as mindfulness and acceptance. Furthermore, with the exception of a few long-term studies
such as that of American psychiatrist, Harvard professor, and trustee of Alcoholics
Anonymous (AA), George Vaillant (2003), hardly any long-term follow-up relapse data is available.
Besides, as the AA, the main champion of the 12-step program for substance abuse, places a high
premium on anonymity and privacy of its members, conducting research is not easy nor
encouraged. At this time, it is interesting to add that Vaillant's study found that just as many
treated alcoholics are abusing alcohol at the end of a two-year follow-up period as are the untreated
sample through spontaneous remission. Similarly, another comparative study by
Brandsma, Maultsby, and Welsh (1980) concluded that abstinence approaches such as the 12-step
program had the highest drop-out rate, 68% at the 6-month follow-up compared to an average of
42% for the other methods. Almost none of the subjects remained totally abstinent after treatment,
and neither were there significant differences between groups on this variable. Here, a meaningful
pattern seems to emerge. Abstinence is not reasonably achievable as a substance abuse treatment
goal. Therefore, scientific and evidence-based harm reduction models with integrated cognitive and
mindfulness elements have become viable alternatives, despite the continued controversy of the
appropriateness of harm reduction goals by controlled substance use compared with abstinenceonly treatment scenarios of the disease model.
Using mindfulness in the treatment of substance abuse
Mindfulness is considered to be awareness in the present moment, which is approached in a nonjudgmental manner in the treatment of substance abuse. This form of treatment is gaining more
attention in scientific literature. Mindfulness is an added element that is sometimes used in third
wave treatment programs, and has been used by many therapeutic orientations, such as Cognitive
Behavioral Therapy (CBT), Mindfulness-Based Stress Reduction (MBSR), Acceptance and
Commitment (ACT), Mindfulness-Based Cognitive Therapy (MBCT), and Mode Deactivation Therapy
(MDT) (Bowen et al., 2009; Jennings, Apsche, Blossom, & Bayles, 2013). By combining mindfulness
with traditional cognitive-behavioral relapse prevention (CBRP), research suggest that mindfulness
may help develop a detached and decentered relationship to thoughts and feelings, preventing
escalation of thought patterns that may lead to relapse (Bowen et al., 2009).
Although mindfulness has existed in practice for centuries, it was never applied as a stand-alone
therapy until psychiatrist and psychotherapist Fritz Perls used it in an attempt to unify mind,
body, and spirit with Gestalt Therapy. Using what he learned from Zen Buddhism, Perls emphasized
the principle of enhanced awareness in the present moment. He recognized and understood that all
forms of immediate awareness--sensation, perception, emotion, thought, behavior, and
bodily feelings, were the natural therapeutic effects of staying in the here and now experience
(Jennings, Apsche, Blossom, & Bayles, 2012). Jennings and Apsche (2013) described mindfulness as
"being fully aware of your immediate present experience and accepting yourself as you are in this
moment without judgment" (p. 17).
While cognitive behavioral therapy (CBT) has become the most common standard approach among
psychotherapies, the explicit effort to integrate mindfulness and acceptance into traditional CBT
therapies has revolutionized the field of psychology (Jennings, Apsche, Blossom & Bayles, 2013).
Traditional CBT uses four main strategies to change thinking and behavior: skills training, exposure
therapy, cognitive therapy, and consistency management. Exposure therapy is the equivalent of

immediate awareness because it contains the essential elements of intense focus on immediate
awareness by including mental, physical, and emotional experiences that produce acceptance of the
immediate discomfort and irrationality (Jennings, et al., 2013). Through the process of identifying
and challenging the validity of cognitions, the process of CBT can be seen as a degree of
mindfulness that systematically and repeatedly exposes the client to his or her disturbing and
dysfunctional thoughts, emotions, and behaviors. It is hopeful the client will increasingly be able to
tolerate and accept disturbing cognitions without negative self-judgment (Jennings, et al., 2013).
However, this was considered a shortcoming upon which third wave approaches such as Acceptance
and Commitment Therapy (act), Dialectical Behavior Therapy (DBT), and Mode Deactivation
Therapy (MDT) were conceptualized.
Beck's (1996) development of the concept of Modes or core beliefs impacted psychological functions
when he posited that people learned from unconscious experiential components and
cognitive structural processing components (Bayles, Blossom, & Apsche, 2014). Harmful behaviors
are maladaptive due to dysfunctional modes or schemas and in order to change a person's behavior,
the experiential components have to be restructured. Once the dysfunctional behaviors
and habitual responses have been removed, they are replaced with self-awareness, acceptance, and
regulatory skills (Bayles, Blossom, & Apsche, 2014). Non-judgmental acceptance is the key to the
process of challenging negative cognitions (Jennings, et al., 2013). Since the intent of harm
reduction is to reduce the negative consequences of substance abuse, the goal is to accept
moderate use and use in safer conditions as an alternative therapy for substance abuse (Dimeff,
Baer, Kivlahan, & Marlatt, 1999).
Mindfulness is just beginning to be introduced into the treatment of substance abuse. Research in
the use of mindfulness in substance use programs is finding its way into scientific literature (Bowen
et al., 2009). Mindfulness is achieved through a series of awareness and observation exercises that
helps develop trust, reduces anxiety, and increases commitment to treatment. Mindfulness has
become a key factor in overcoming limitations of traditional CBT (Bayles, Blossom, & Apsche,
2014). CBT is limited in the area of validation. Where CBT challenges the validity of the individual's
core belief, Mindfulness and MDT validates the individual's belief as having a grain of truth. Once
the belief is validated, clarification of what the individual perceives as truth, is clarified in order to
understand the belief system. The perceived views of the individual is redirected to an alternative
possibility that the individual currently holds. Validation, Clarification, and Redirection (vcr) uses
unconditional acceptance and validation of the individual's unconscious learning experience (Bayles
et al., 2014). Avoidance of openness and honesty in interactions with others is another major
problem with interpersonal relationships; mindfulness-individuals are encouraged to be open and
honest with others, thus overcoming avoidance (Bayles et al., 2014).
Other uses of mindfulness
Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) has
been used to treat depression (Bowen et al., 2009). Mindfulness-Based Relapse Prevention (MBRP)
is an aftercare approach that integrates RP with practices from MBSR and MBCT. The
core principle of the treatment is to recognize and identify high-risk situations. By recognizing the
early warning signs of relapse, this increased awareness of internal (emotional and cognitive) and
external (situational) cues, previously associated with substance use, allows the individual to
develop effective coping skills, and improve self-efficacy (Bowen et al., 2009). The pilot efficacy trial
study, conducted by Bowen et al., showed significant decrease in the number of days
substances were used by the participants, while cravings, awareness and acceptance also
improved.

The mindfulness part of MBRP aims to raise awareness of the triggers, monitor internal reactions,
and foster more skillful behavioral choices by focusing on increased awareness, acceptance
and tolerance of positive and negative physical, emotional, and cognitive states (e.g. cravings), in
the present moment, thereby decreasing the need to engage in substance use (Bowen et al., 2009).
It is evidenced that cravings is a significant predictor for substance use, substance use disorder
(SUD), and relapse following substance use disorder treatment (Witkiewitz, Bowen, Douglas, & Hsu,
2013). By using mindfulness to increase awareness of regulation and tolerance of potential events
that cause relapse, the substance user may improve the ability to cope with relapse triggers by
interrupting the previous cycle of automatic substance use behaviors (Bowen et al., 2009). From
a mindfulness perspective, cravings may be effectively reduced by increasing awareness and
acceptance of the triggers that lead to relapse, while helping the individual recognize and minimize
the blame and/or guilt and the negative thinking that increases the risk of relapse (Bowen et al.,
2009; Witkiewitz et al., 2013).
Mindfulness-based relapse prevention vs. treatment as usual
Bowen et al. (2009) conducted a randomized controlled trial (RCT) to compare the feasibility and
initial efficacy of MBRP with the 12-step treatment as usual (TAU) among individuals with substance
use disorders. The effect of treatment outcomes, as well as key secondary processes (cravings,
mindfulness, and acceptance) were assessed. Bowen, et al. hypothesized that those treated with
MBRP would realize greater reductions in substance use and increased awareness associated
with mindfulness and acceptance than those receiving TAU. The reduction in substance use that
was realized with MBRP was due primarily to the mindfulness approach since the participants,
through increased awareness, were cognizant of the cues that led to substance use. They were
accepting of their behavior, non-judgmentally. Through harm reduction, they learned to use
moderately and in safer conditions, thereby reducing the need to abuse the substances.
MBRP is conducted using an 8-week, 2-hour group sessions following protocol in the MBRP
treatment manual. There are usually 6 to 10 clients and two therapists participating in the group
sessions. Each session has a central theme with meditation practices and related RP discussions
and exercises (Bowen et al., 2009). Some of the themes included in the sessions are automatic pilot
and its relationship to relapse, recognizing thoughts and emotions in relationship to
triggers, integrating mindfulness practices into daily life, practicing the skills in high-risk
situations, and the role of thoughts in relapse (Bowen et al., 2009). Sessions begin with a 20 to 30
minute guided meditation involving experiential exercises and intermittent discussions on the role
of mindfulness in relapse prevention. Participants are given daily exercises to do between sessions
and a meditation CD to use for practice outside the group. During the sessions, homework that the
group has worked on throughout the week is reviewed (Bowen et al., 2009).
The TAU group remained in the 12-step program designed to maintain abstinence. The TAU groups
met weekly and their themes included rational thinking skills, grief and loss, assertiveness, selfesteem, goal setting, and effects of alcohol and other drugs on interpersonal relationships and
experiences (Bowen et al., 2009). Some of the groups included the RP skills, based on the disease
model of addiction. The TAU group did not have regularly scheduled homework assignments, met
once or twice a week (depending on the clinical need) and the meetings lasted 1.5 hours.
Therapists facilitating the MBRP groups held master's degrees in psychology or social work while
therapists facilitating the TAU groups were licensed Chemical Dependency Counselors with
varying levels of experience in outpatient clinical aftercare services (Bowen et al., 2009).
When comparing why the outcomes of TAU and mindfulness/harm reduction programs differ in
outcome, it is clear that mindfulness works much better with harm reduction than with TAU for the

fact that TAU lacks acceptance of the substance abuse behavior. TAU teaches the substance user
grief and loss techniques (Bowen et al., 2009), where mindfulness therapy teaches acceptance of
one's behavior without judgment (Jennings, Apsche, Blossom, & Bayles, 2013; Bayles, Blossom, &
Apsche, 2014). Harm reduction allows moderate use of substances while the individual is in
treatment while TAU insists on abstinence with no tolerance. If the individual relapses and uses
a substance one time, the treatment is considered a failure (Logan & Marlatt, 2010). Harm
reduction considers relapse as a part of therapy and a learning experience to increase awareness
(Hendershot, Wikiewitz, George, & Marlatt, 2011). Mindfulness therapy provides
regularly scheduled homework assignments for the substance user to continue with while he or she
is not in a therapy session, where TAU does not provide regularly scheduled homework
assignments. Training for mindfulness programs/harm https://www.linkedin.com/pub/ritascribner/103/6b5/473 reduction programs differ from the training for TAU. Therapists facilitating
mindfulness therapies hold Master's Degrees in Psychology while therapists facilitating TAU
therapies are licensed as Chemical Dependency Counselors with various levels of experience
in outpatient clinical aftercare services (Bowen, 2009). Further research would need to be
conducted to determine whether the difference in training may be factor in the different outcomes
of the programs, however, the difference in overall structure ofboth programs has a definite impact
on the outcome of the treatment. All in all, mindfulness will not work as well with the 12-step
program because the outcome goals of the mindfulness/harm reduction programs (moderate use of
substances) are in opposition of the 12-step programs to obtain abstinence.
The overall results of the study supported the author's hypothesis. Evidence was provided that the
feasibility and initial efficacy of MBRP was supported as an alternative to the standard 12step based related care programs. Outcome scores suggested significant improvement in the
number of days of substance use, awareness, acceptance, and judgment mediated the relationship
between those receiving MBRP and self-reported cravings (Bowen et al., 2009; Witkiewitz et al.,
2013).
More recently, Kelly, Stout, and Slaymaker (2012) conducted a study consisting of 303 emerging
adults. The participants consisted of 26% females, 95% white, and 51% presented with comorbid
Axis I disorders, ages 18-24. The study was conducted at a residential treatment center for
effectiveness of a 12-step program for Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).
Effectiveness was assessed on intake, 3, 6, and 12 months on 12-step attendance, involvement, and
outcomes for percent of days of abstinence and percent of days of heavy drinking. The authors
conducted a lagged hierarchical linear model (HLM) to determine whether attendance and
involvement played a beneficial part in recovery.
Kelly et al. (2012) discovered that at the 3-month time period, attendance rose 36% to reach its
highest at 89% and maintained at 82% for 6 months. By the end of the 12-month period, attendance
and involvement declined to 76%. During the initial phase (3 months) meetings were attended 3
times a week, but declined to once weekly by the 12th month. In conclusion, a comparison of the
study conducted by Kelly, Stout, and Slaymaker (2012), against the study conducted by Bowen et
al. (2009), measuring TAU against mindfulness-based treatment programs, it can be concluded that
mindfulness-based treatment performed at a level that assured its place in society as an
acceptable alternative treatment program to 12-step programs (Kelly et al., 2012).
Conclusions
As we have illustrated, the broad adoption of relapse approaches in the various treatment contexts
challenges standard definitions, measurements, and consistent findings of comparative outcomes.
However, it is apparent that there are strategies that are integral to substance abuse interventions

that have proven to be more effective in terms of achieving progress when measured by treatment
perseverance, frequency and amount of usage, and associated societal costs compared
to traditional 12-step programs.
In particular, it is argued that mindfulness-based cognitive behavioral therapies is appropriate and
effective as a Behavioral Self-Control Training (BSCT) method. By promoting awareness
and acceptance rather than disputing core beliefs and shaming the client, a stronger therapeutic
alliance is possible to support behavioral goals and commitment. According to Saladin and Santa
Ana (2004), the literature on BSCT, old and new, is unequivocal with regard to its efficacy, and it is
argued that the principles of mindfulness cultivate and enhance the positive potential of cognitivebehavioral approaches that are focused on harm reduction rather than a disease model perspective
on substance abuse treatment.
References

Bayles, C., Blossom, P, Apsche, J. (2014). A brief review and update of mode deactivation therapy.
International Journal of Behavioral and Consultation Therapy. 9(1), 46-48.
Blume, A. W., (2012). Seeking the middle way: G. Alan Marlatt and harm reduction. Addiction
Research and Theory 20(3), 218-226. DOI: 10.3109/16066359.2012.657281
Babor, T. F., Steinberg, K., Anton, R., & Del Boca, F. (2000). Talk is cheap: Measuring drinking
outcomes in clinical trials. Journal of Studies on Alcohol and Drugs, 61(1), 55-63.
Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J. ... Marlatt, A. (2009).
Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance
Abuse, 30(4), DOI: 10.1080/08897070903250084
Brandsma, J. M., Maultsby, M. C., & Welsh, R. J. (1980). Outpatient treatment of alcoholism: A
review and comparative study. Baltimore, MD: University Park Press.
Dimeff, L. A., Baer, J. S., Kivlahan, D. R., & Marlatt, G. A. (1999). Brief alcohol screening and
intervention for college students (BASICS): A harm reduction approach. New York, NY: The Guilford
Press.
Faxun, V. (2011). One life, five precepts: Buddhist ethics for modern living. Singapore: Shi Faxun.
Hendershot, C. S., Witkiewitz, K., George, W. H., & Marlatt, G. A. (2011). Relapse prevention for
addictive behaviors. Substance Abuse Treatment, Prevention, and Policy, 6, 1-17. DOI:
10.1186/1747-597X-6-17
Kelly, J. F., Stout, R. L., & Slaymaker, V. (2012). Emerging adults' treatment outcomes in relation to
12-step mutual-help attendance and active involvement. Drug and Alcohol Dependence, 129(1-2),
151-157. DOI: 10.1016/j.drugalcdep.2012.10.005
Larimer, M. E., Malone, D. K., Garner, M. D., Atkins, D. C., Burlingham, B., Lonezak, H. S. ...
Marlatt, G. A. (2009). Health care and public service use and costs before and after provision of
housing for chronically homeless persons with severe alcohol problems. The Journal of the
American Medical Association, 301(13), 1349-1357. DOI: 10.1001/jama.2009.414

Lee, H. S., Engstrom, M., & Petersen, S.R. (2011). Harm reduction and 12 steps: Complementary,
oppositional, or something in-between. Substance Use and Misuse, 46(9), 1151-1161.
DOI: 10.3109/10826084.2010.548435
McGovern, M. P, Wrisley, B. R., & Drake, R. E. (2005). Relapse of Substance Use Disorder and its
prevention among persons with co-occurring disorders. Psychiatric Services, 56(10), 1270-1273.
Nooripour, R., De Velasco, B. P, ZadeMohammadi, A., Ventegod, S., Bayles, C., Blossom, P, &
Apsche, J. (2014). Effectiveness of quality of life therapy on sexual self-efficacy and quality of life
in addicted couples. International Journal of Behavioral and Consultation Therapy 9(1), 43-45.
Saladin, M. E., & Santa Ana, E. J. (2004). Controlled drinking: More than just a controversy. Current
Opinion in Psychiatry, 17(3), 175-187.
Vallaint, G. E. (2003). A 60-year follow-up of alcoholic men. Addiction, 98(8), 1043-1051. DOI:
10.1046/j.1360-0443.2003.00422.x
Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, SH. (2013). Mindfulness-based relapse prevention.
Addictive Behaviors, 38(2), 15631571. DOI: 10.1016/j.addbeh.2012.04.001
Corliss Bayles
Walden University
http://www.thefreelibrary.com/Using+mindfulness+in+a+harm+reduction+approach+to+substanc
e+abuse...-a0387059384