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. Author manuscript; available in PMC: 2021 May 1.
Published in final edited form as: Addict Behav. 2019 Dec 30;104:106283. doi: 10.1016/j.addbeh.2019.106283

Mindfulness as a Predictor of Cognitive-Behavioral Therapy Outcomes in Inner-City Adults with Posttraumatic Stress and Substance Dependence

Anka A Vujanovic 1, Lia J Smith 1, Charles Green 2, Scott D Lane 2, Joy M Schmitz 2
PMCID: PMC7024008  NIHMSID: NIHMS1548719  PMID: 31927220

Abstract

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is highly prevalent and difficult-to-treat. Mindfulness, defined as nonjudgmental attention to and awareness of present-moment experiences, represents a targetable mechanism with potential to predict and improve treatment outcomes for PTSD/SUD populations. We hypothesized that greater self-reported mindfulness at baseline (pre-treatment) would predict (a) lower end-of-treatment PTSD severity and (b) greater longest sustained abstinence during a 12-week cognitive-behavioral treatment program. Participants included 53 inner-city adults meeting at least four symptoms of DSM-5 PTSD and current (DSM-IV) substance dependence (51% women; 75.5% African American; Mage=45.42, SD=9.99). Hierarchical regression analysis results indicated that higher levels of baseline mindfulness predicted lower end-of-treatment PTSD severity but not longest sustained abstinence from the primary substance of choice. Post hoc exploration of end-of-treatment PTSD symptom clusters indicated that higher baseline mindfulness predicted lower intrusion, negative alterations in cognitions and mood, and arousal and reactivity symptoms but not avoidance symptoms. Clinical and research implications are discussed.

Keywords: mindfulness, trauma, PTSD, substance use, addiction, treatment, cognitive behavioral therapy

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur (e.g., McCauley, Killeen, Gros, Brady, & Back, 2012). Such comorbidity is difficult-to-treat and marked by a more costly and chronic clinical course when compared to either disorder alone (e.g., McCauley et al., 2012; Mills, Teesson, Ross, & Peters, 2006; Schafer & Najavits, 2007; Vujanovic & Back, 2019; Vujanovic, Bonn-Miller, & Petry, 2016). Available PTSD/SUD treatments are marked by relatively small effect sizes and high attrition rates (Roberts, Roberts, Jones, & Bisson, 2015), highlighting the clinical utility of identifying predictors of treatment outcome that might be targeted prior to treatment or integrated into early stages of treatment to enhance treatment effectiveness. Cognitive-behavioral therapies for PTSD/SUD are among the most effective interventions presently available (Roberts et al., 2015; Simpson, Lehavot, & Petrakis, 2017; Vujanovic & Back, 2019). Identifying malleable pre-treatment cognitive-affective factors with potential to predict greater PTSD and/or SUD treatment improvement is an important next step toward refining and developing treatment programs for this challenging and prevalent comorbidity.

Mindfulness, defined as intentional regulation of nonjudgmental attention and awareness in the present moment (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Bishop et al., 2004), is one such factor with relevance to both PTSD (e.g., Banks, Newman, & Saleem, 2015; Lang, 2017; Vujanovic, Niles, & Abrams, 2016) and SUD (e.g., Li, Howard, Garland, McGovern, & Lazar, 2017; Zgierska et al., 2009). Recent conceptualizations of mindfulness have purported that the overarching construct includes present-centered awareness, nonjudging of inner experience, as well as nonreactivity to inner experience (Baer et al., 2016), such that individuals with elevated levels of mindfulness are able to be aware of and to non-evaluatively respond to present experiences and to allow thoughts, emotions, and bodily sensations to come and go. Mindfulness is conceptualized as either state, consisting of fluctuations in behaviors, thoughts, or emotions, or trait, a relatively stable personality characteristic that is more long-lasting and less context-dependent (Baer et al., 2006; Brown & Ryan, 2003; Lau et al., 2006). Notably, regardless of one’s level of state or trait mindfulness, the construct is considered to be malleable via intervention (Branstrom, Kvillemo, Brandberg, & Moskowitz, 2010; Kimbrough, Magyari, Langenberg, Chesney, & Berman, 2010; King et al., 2013; Niles et al., 2012; Niles, Vujanovic, Silberbogen, Seligowski, & Potter, 2013).

Longitudinal and cross-sectional studies have demonstrated negative (i.e., inverse) associations between mindfulness and PTSD symptomatology (e.g., Call Pitcock, & Pyne, 2015; Meyer et al., 2019; Smith et al., 2011; Thompson & Waltz, 2010; Wahbeh, Lu, & Oken, 2011) as well as substance use severity (e.g., Bowen & Enkema, 2014; Gallagher, Hudepohl, & Parrott, 2010; Garland, Boettiger, Gaylord, Chanon, & Howard, 2012). Mindfulness-based interventions for PTSD and SUD, respectively, have recently emerged as promising (Banks et al., 2015; Boyd, Lanius, & McKinnon, 2018; Lang, 2017; Li et al., 2017). Mindfulness-based interventions for PTSD have demonstrated clinically meaningful improvement in PTSD symptoms immediately post-treatment (e.g., Jasbi et al., 2018; King et al., 2013; Niles et al., 2012) and sustained reductions in PTSD symptoms post-treatment (Kearney, McDermott, Malte, Martinez, & Simpson, 2012; Kimbrough et al., 2010). Further, mindfulness-based interventions for SUD have shown to be efficacious and safe for the reduction of substance use severity (Zgierska et al., 2009) and to also be feasible and efficacious as relapse prevention programs for SUD (Bowen et al., 2009; Bowen & Enkema, 2014; Bowen et al., 2014). Emerging work has begun to examine reductions of co-occurring PTSD and SUD symptoms following mindfulness-based interventions (e.g., Fortuna, Porche, & Padilla, 2018; Garland, Roberts-Lewis, Tronnier, Graves, & Kelley, 2016; Lyons, Womack, Cantrell, & Kenemore, 2019). This literature is in a nascent stage, but results hold promise despite relatively small though significant effect sizes. This line of inquiry underscores the importance of continuing to explore associations between mindfulness and PTSD and/or SUD treatment outcomes.

Theoretically, mindfulness may predict lower levels of PTSD symptoms and substance use via heightened ability to tolerate present-centered emotions and thus lower tendencies to use substances to escape negative emotional states; indeed, the negative reinforcement model of substance use has been extensively applied to models of PTSD/SUD comorbidity (Breslin, Zack, & McMain, 2002; Brewer, Elwafi, & Davis, 2013; Witkiewitz, Marlatt, & Walker, 2005). This model purports that individuals with PTSD/SUD are likely to maintain PTSD symptoms and substance use due to a strong desire to avoid negative or uncomfortable emotional or physical states associated with trauma and substance withdrawal, including urges and cravings (Saladin, Brady, Dansky, & Kilpatrick, 1995) and/or PTSD symptomatology (Brady, Back, & Coffey, 2004). For example, individuals with PTSD, including subclinical PTSD symptomatology (e.g., Norman, Tate, Anderson, & Brown, 2007), report stronger drug cravings (Coffey et al., 2002; Michael E. Saladin et al., 2003) and withdrawal symptoms (Boden, Babson, Vujanovic, Short, & Bonn-Miller, 2013) as well as a greater tendency to use substances to alleviate negative mood states (e.g., Back, Brady, Jaanimägi, & Jackson, 2006; Chilcoat & Breslau, 1998; Jacobsen, Southwick, & Kosten, 2001). Mindfulness has been shown to partially mediate – or account for – the association between PTSD symptoms and coping motives for substance use (Bonn-Miller, Vujanovic, Twohig, Medina, & Huggins, 2010; Vujanovic, Bonn-Miller, & Marlatt, 2011), demonstrating that heightened mindfulness theoretically may dampen the association between PTSD symptoms and substance use to alleviate negative affect, thereby leading to reduced PTSD and substance use quantity and frequency over time. Individuals with higher levels of mindfulness may be more aware of internal emotional and physiological states associated with PTSD symptomatology and substance use withdrawal (e.g., urges, cravings) and less apt to avoid the uncomfortable emotional and physical states that often trigger substance use and lead to relapse (Enkema & Bowen, 2017; Witkiewitz et al., 2005). Higher levels of mindfulness at treatment outset may therefore predict improved PTSD/SUD treatment outcomes. However, research is needed to test this hypothesis.

The current investigation is the first study to date to examine whether pre-treatment levels of mindfulness are predictive of cognitive-behavioral therapy (CBT) treatment outcomes among adults with SUD and PTSD symptomatology. First, it was hypothesized that higher baseline (pre-treatment) levels of mindfulness would predict lower end-of-treatment (interview-based) PTSD symptom severity. Second, it was hypothesized that higher baseline mindfulness would predict greater ability to abstain from the primary substance of choice (i.e., higher longest sustained abstinence). Post hoc exploratory analyses were conducted to examine the predictive validity of mindfulness in relation to the PTSD symptom clusters of intrusion, avoidance, negative alterations in cognitions and mood, as well as arousal and reactivity. All effects were evaluated after considering theoretically-relevant covariates, including treatment condition, baseline PTSD symptom severity, and baseline number of SUD diagnoses.

Method

The sample was comprised of 53 adults (51% women; Mage = 45.42, SD = 9.99) with substance dependence (67.9% [n = 36] were cocaine dependent) and at least four symptoms of PTSD per the DSM-5 (APA, 2013). Please see Table 1 for sample characteristics. Inclusionary criteria consisted of: being between the ages of 18–65, being proficient in English, meeting criteria for current (past month) DSM-IV substance dependence (APA, 2000), endorsing history of trauma exposure per DSM-5 PTSD Criterion A and at least four current (past month) DSM-5 PTSD symptoms, and seeking treatment for substance dependence. Exclusionary criteria included: exclusive (only) nicotine dependence, alcohol or opioid dependence requiring detoxification, current or past bipolar I disorder or major psychotic disorder, active (past 6 months) psychotic spectrum symptoms, major unstable medical conditions, current (past month) suicidal or homicidal ideation with intent or plan, pregnancy, or inability to provide verbal and written consent.

Table 1.

Participant Characteristics

Variable Mean(SD) or %
(n) (N=53)		 Completers
(n=41)^ 		Non-completers
(n=12)^ 		p
Race/Ethnicity1
 Black/African American 75.5% (40) 73.2% (30) 83.3% (10) ns
 White 20.8% (11) 24.4% (10) 8.3% (1) ns
 Hispanic 3.8% (2) 2.4% (1) 8.3% (1) ns
Age (years) 45.4 (9.9) 47.3 (9.6) 39.0 (9.0) <.01
Marital Status1
 Single 62.3% (33) 61.0% (25) 66.7% (8) ns
 Married 18.9% (10) 19.5% (8) 16.7% (2) ns
 Other 18.9% (10) 19.5% (8) 16.6% (2) ns
Socioeconomic Status1
 Less Than High School 5.7% (3) 2.4% (1) 16.7% (2) ns
 High School/GED 35.9% (19) 36.6% (15) 33.4% (4) ns
 Some College 41.5% (22) 39.0% (16) 50.0% (6) ns
 College Degree or above 13.2% (7) 17.1% (7) 0% (0) ns
 Not reported 3.8% (2) 4.9% (2) 0.0% (0) ns
 Number of days with paid work (past 30 days)1 7.1 (10.1) 6.3 (10.1) 9.9 (9.9) ns
 Monthly income (past 30 days) $749.5 (766.0) $699.0 (737.4) $921.9 (868.7) ns
Trauma Event Exposures2
 Number of Traumatic Event Exposures Types 7.1 (3.5) 6.8 (3.4) 8.3 (3.4) ns
 Assault with a weapon 73.6% (39) 75.6% (31) 66.7% (8) ns
 Physical assault 75.5% (40) 73.2% (30) 83.3% (10) ns
 Natural disaster 58.5% (31) 61.0% (25) 50.0% (6) ns
 Transportation accident 71.7% (38) 65.9% (26) 91.7% (11) ns
 Sexual assault 64.2% (34) 63.4% (26) 66.7% (8) ns
 Toxic substance exposure 15.1% (8) 12.2% (5) 25.0% (3) ns
 Life threatening illness or injury 50.9% (27) 46.3% (19) 66.7% (8) ns
 Fire or explosion 34.0% (18) 34.1% (14) 33.3% (4) ns
 Human suffering 24.5% (13) 24.4% (10) 25.0% (3) ns
 Serious accident 43.4% (23) 43.9% (18) 41.7% (5) ns
 Sudden violent death 35.8% (19) 29.3% (12) 58.3% (7) ns
 Sudden accidental death 24.5% (13) 24.4% (10) 25.0% (3) ns
 Unwanted sexual experiences 47.2% (25) 43.9% (18) 58.3% (7) ns
 Other stressful event or experience 37.7% (20) 34.1% (14) 50.0% (6) ns
 Captivity 22.6% (12) 17.1% (7) 41.7% (5) ns
 Causing serious injury to someone else 18.9% (10) 14.6% (6) 33.3% (4) ns
 Combat war-zone exposure 13.2% (7) 12.2% (5) 16.7% (2) ns
Axis I Diagnoses (DSM-IV)3
 Mean Number of Diagnoses (overall) 3.0 (1.2) 2.9 (1.2) 3.3 (1.4) ns
 Cocaine Dependence 67.9% (36) 73.2% (30) 50.0% (6) ns
 PTSD4 79.2% (42) 75.6% (31) 91.7% (11) ns
 Alcohol Abuse/Dependence 45.3% (24) 46.3% (19) 41.7% (5) ns
 Cannabis Dependence 37.7% (20) 29.3% (12) 66.7% (8) ns
 Major Depressive Disorder 30.2% (16) 26.8% (11) 41.7% (5) ns
 Substance Induced Mood Disorder 7.5% (4) 9.8% (4) 0.0% (0) ns
 Sedative Dependence 5.7% (3) 4.9% (2) 8.3% (1) ns
 Stimulus Dependence 3.8% (2) 4.9% (2) 0.0% (0) ns
 Opioid Dependence 5.7% (3) 4.9% (2) 8.3% (1) ns
 Hallucinogen/PCP Dependence 3.8% (2) 2.4% (1) 8.3% (1) ns
 Other substance Dependence 3.8% (2) 4.9% (2) 0% (0) ns
 Panic Disorder 7.5% (4) 7.3% (3) 8.3% (1) ns
 Obsessive Compulsive Disorder 1.9% (1) 0% (0) 8.3% (1) ns
 Eating Disorder 3.8% (2) 4.9% (2) 0% (0) ns
 Psychosis 1.9% (1) 2.4% (1) 0% (0) ns
Substance Use1
 Cannabis Use, Past Month (yes/no) 10.4 (13.5) 9.0 (13.2) 15.5 (13.8) ns
 Alcohol Use Days, Past Month 10.1 (10.3) 10.2 (10.6) 9.8 (9.7) ns
 Drug Use Problem Days, Past Month 16.2 (11.9) 16.1 (11.7) 16.5 (13.2) ns
PTSD S everity (DSM-5)4
 Total Score 36.7 (12.2) 36.1 (13.0) 38.8 (8.8) ns
 Intrusion Symptoms (B) 9.3 (3.3) 9.2 (3.5) 9.5 (2.5) ns
 Avoidance Symptoms (C) 5.0 (2.1) 4.9 (2.0) 5.3 (2.5) ns
 Negative Cognitions and Mood Symptoms (D) 13.2 (6.1) 13.0 (6.5) 14.3 (4.9) ns
 Arousal and Reactivity Symptoms (E) 9.2 (4.1) 9.1 (4.2) 9.8 (3.7) ns
Treatment Condition5
 CBT for SUD6 60.4% (32) 65.9% (27) 41.7% (5) ns
 TIPSS7 39.6% (21) 34.1% (14) 58.3% (7) ns
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Note.

^

Completers: Participants who completed treatment; Non-completers: Participants who did not complete treatment.

1

Data derived from Addiction Severity Index-Lite at baseline;

2

Data derived from Life Events Checklist at baseline;

3

Data derived from Structured Clinical Interview for DSM-IV Axis I Disorder for current disorders at baseline;

4

Data derived from the Clinician Administered PTSD Scale for DSM-5 at baseline;

5

Treatment type that participants were assigned to during the trial;

6

Cognitive-behavioral therapy for SUD;

7

Treatment of Integrated Posttraumatic Stress and Substance Use.

Measures

Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1996).

The SCID-I is a well-established structured diagnostic interview designed to assess major DSM-IV Axis I disorders. The SCID-I was administered at baseline by M.A.-level counselors or psychology doctoral students; all administrations were audio-recorded. A random sample (20%) of the SCID-I interviews was reviewed by the first author and no cases of disagreement were noted. For purposes of the present study, the SCID-I was used to assess baseline current (past month) psychiatric diagnoses in order to establish study inclusionary/exclusionary criteria, as noted above.

Clinician Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013a).

The CAPS-5 is a well-established, “gold standard”, 30-item structured interview for the assessment of DSM-5 PTSD diagnosis and severity. The CAPS-5 assesses the 20 DSM-5 PTSD symptoms, rated on a 5-point Likert-style scale (0 = absent to 4 = extreme/incapacitating), as well as the duration of symptoms, subjective distress, and relevant impairments in functioning. Administration requires identification of an index traumatic life event, assessed via the Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013b). In the current study, the CAPS-5 was administered by M.A.-level counselors or psychology doctoral students. All administrations were audio-recorded and all were reviewed by the first author, who was blind to treatment condition, for standardized administration and procedural adherence. The CAPS-5 was administered at baseline and at the final treatment session (session 12). Each CAPS-5 administration queried the past-month time-frame; internal consistencies of the CAPS-5 at baseline and final sessions were good (α’s = .89 and .82, respectively).

Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006).

The FFMQ is a 39-item self-report measure of mindfulness. Items are rated on a 5-point Likert-type scale (1 = never or very rarely true to 5 = very often or always true). The FFMQ measures five facets of mindfulness including observing (i.e., attention to internal and external experiences), describing (i.e., ability to label internal experiences), acting with awareness (i.e., attention to activities in the moment), nonjudging of experience (i.e., ability to remain nonevaluative about internal experiences), and nonreactivity to inner experience (i.e., ability to allow internal experiences to come and go) (Baer et al., 2006). The FFMQ has good construct validity and reliability (Baer et al., 2008), and the internal consistency of the FFMQ total score in the current study was good (α = .85). The FFMQ was administered at baseline, and the total score was used as a global mindfulness index in the current study, as consistent with past work in PTSD/SUD samples (Bowen, De Boer, & Bergman, 2017).

Time-Line Follow-Back (TLFB; Robinson, Sobell, Sobell, & Leo, 2014; Sobell & Sobell, 1992).

Self-report of substance use was collected using the TLFB assessment method, administered in interview format throughout the study by trained research assistants, to gather information about the timing, number of episodes, and amount of substances used during the study. Using a calendar format, each participant was asked, by a trained research assistant at each study session, to retrospectively estimate the frequency and quantity of each substance used (e.g., alcohol, cocaine) since the last study session. The TLFB method has demonstrated strong psychometric properties (e.g., Rueger, Trela, Palmeri, & King, 2012).

Addiction Severity Index-Lite (ASI-Lite; Cacciola, Alterman, McLellan, Lin, & Lynch, 2007; McLellan et al., 1992).

The ASI-Lite is a well-established, multi-dimensional, interview-based measure for SUD that assesses the respondent’s lifetime and past-month status across seven domains (e.g., alcohol and drug use, employment/self-support). In the present study, the ASI-Lite was administered at baseline to obtain descriptive data regarding substance use history and sociodemographic information.

Procedure

This investigation represents a secondary analysis of data from the parent study, a randomized clinical trial of a novel CBT for PTSD/SUD (ClinicalTrials.gov Identifier: ). The trial consisted of two baseline appointments (described below) and twelve 60-minute CBT sessions, delivered twice weekly for six weeks. The trial compared standard CBT for SUD (e.g., relapse prevention) with a novel integrated CBT for PTSD/SUD (i.e., Treatment of Integrated Posttraumatic Stress and Substance Use [TIPSS]), comprised of cognitive processing therapy for PTSD and CBT for SUD (Vujanovic, Smith, Green, Lane, & Schmitz, 2018). Details regarding the treatment conditions are summarized elsewhere (see Vujanovic et al., 2018; Vujanovic, Smith, Tipton, & Schmitz, 2019). Notably, the TIPSS condition included one brief mindfulness-related exercise (‘Surfing the Urge’) during the fourth session as part of a coping skills review session (Bowen, Chawla, & Marlatt, 2010). Adults interested in treatment of SUD and trauma-related symptoms were recruited via community-based recruitment strategies (e.g., newspaper ads). Interested individuals called the treatment research clinic and were screened for general eligibility (e.g., age, substance use, English proficiency) via telephone; potentially eligible individuals were scheduled for an appointment.

The two initial baseline appointments consisted of the administration of the SCID-I, CAPS-5, ASI-Lite, and self-report questionnaires. The first baseline session included the SCID-I and ASI-Lite; the second baseline session included administration of the CAPS-5 and self-report measures. The second baseline appointment was scheduled within 10 days of the first (M = 3.56, SD = 1.20). At both baseline appointments and each of the twelve treatment sessions, the TLFB was administered. The CAPS-5 was re-administered at end of treatment (Session 12). Of the 53 participants enrolled, 41 were randomized to treatment condition (CBT for SUD: n = 22; TIPSS; n = 19) and 12 were non-randomized (CBT for SUD; n = 10; TIPSS: n = 2). Data for non-randomized participants were collected during an extended pilot phase at the beginning of the study, and these participants were assigned to treatment condition based upon availability of trained therapists rather than randomization.

Data Analytic Plan

First, descriptive statistics and bivariate correlations among all study variables were examined. Pre-treatment differences on sociodemographic, diagnostic, trauma-related, and substance-related variables were evaluated between treatment completers and non-completers. Treatment completers were defined as those who completed all 12 sessions of either treatment condition, as consistent with past work (e.g., Back et al., 2019; Flanagan et al., 2017; Persson et al., 2017). Any missing TLFB data was imputed as positive use days (e.g., Maisto et al., 2008; Persson et al., 2017; Pettinati et al., 2008). Second, a series of hierarchical regression analyses was conducted. Treatment condition, baseline PTSD symptom severity (CAPS-5: total score), and baseline substance use (SCID-I: number of SUD diagnoses) were covariates (step one); baseline FFMQ total score (mindfulness) was the predictor (step two). Outcome variables included: (1) PTSD symptom severity (CAPS-5: total score) at end-of-treatment (Session 12); and (2) longest sustained abstinence (TLFB; number of days) from primary substance of choice during the study.

Third, post hoc exploratory analyses were conducted to examine the impact of baseline mindfulness on CAPS-5 PTSD symptom cluster severity scores at end-of-treatment (Session 12). A series of four hierarchical regression analyses was conducted for: (1) intrusion symptom severity; (2) avoidance symptom severity; (3) negative alterations in cognitions and mood symptom severity; and (4) arousal and reactivity symptom severity.

Results

Descriptive Statistics

Overall, 77.4% (n = 41) of participants completed all 12 treatment sessions. Bivariate correlations and descriptive data are presented in Table 2. Mindfulness demonstrated significant negative associations with baseline and end-of-treatment PTSD symptom severity (r’s = −.48 to −.61; p’s < .01). Mindfulness was not significantly related to any substance use variables.

Table 2.

Descriptive Statistics and Bivariate Correlations between Study Variables (N=53).

Mean SD Range 1 2 3 4 5 6
1. Treatment Condition1 -- -- CBT for SUD or TIPSS -
2. PTSD Symptom Severity (Baseline)2 36.74 12.16 9–61 .18 -
3. Number of SUD Diagnoses3 1.72 0.89 1–5 .04 −.01 -
4. Mindfulness Total (Baseline)4 117.45 17.33 77–154 .03 −.48** −.08 -
5. PTSD Symptom Severity (Final)5 26.15 15.61 0–56 .03 .73** .05 −.61** -
6. LSA Primary Substance6 16.02 18.49 0–84 days −.12 −.04 .11 −.01 −.09 -
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**

p < .01;

Note.

1

Treatment condition = CBT for SUD (Cognitive Behavioral Therapy for Substance Use Disorders) or TIPSS (Treatment of Integrated Posttraumatic Stress and Substance Use);

2

Score based on Clinician Administered PTSD Scale for DSM-5 at treatment baseline;

3

SUD= substance use disorder diagnoses; variable based on Structured Clinical Interview for DSM-IV Axis I Disorders at treatment baseline;

4

Score based on Five Facet Mindfulness Questionnaire total score at baseline;

5

Score based on Clinician Administered PTSD Scale for DSM-5 at end of treatment (session 12; entire sample);

6

Longest sustained abstinence from primary substance of choice (entire sample).

Among treatment completers, 5 participants (4 in CBT group and 1 in TIPSS group) were missing TLFB data between sessions 11–12 (Mdays = 2.4; SD = 3.13; Range = 1–8 days) and 2 participants (1 in CBT group and 1 in TIPPS group) were missing TLFB data at prior points in treatment (Mdays = 13.5; SD = 12.02; Range = 5–22 days). Among treatment non-completers, 2 participants (1 in CBT group and 1 in TIPPS group) were missing TLFB data (Mdays = 4; SD = 4.24; Range = 1–7 days). All missing data were imputed as positive use days.

Hierarchical Regression Analyses

Table 3 provides the details of the hierarchical regression analyses. Higher levels of baseline mindfulness predicted lower end-of-treatment PTSD total symptom severity, after controlling for treatment condition, baseline PTSD symptom severity, and baseline number of SUD diagnoses. At step two, mindfulness contributed 11% of unique variance to the model, above and beyond covariates (p = .002). However, mindfulness was not related to longest sustained abstinence (self-report; number of days) from the primary substance. Notably, the pattern of results remained consistent when the percentage of substance use days (primary substance) during treatment was evaluated as an alternate outcome. While these results included both randomized and non-randomized individuals, the pattern of results remained the same when analyzing the randomized participants only (n = 41).

Table 3.

Hierarchical Regression Results: Main Outcomes

Session 12 PTSD Symptom Severity
ΔR2 β SE sr2 p
Level 1 .55 < .001
Treatment Condition1 −.13 3.66 .03 .26
PTSD Symptom Severity (Baseline)2 .76 .14 .55 < .001
Number of SUD Diagnoses (Baseline)3 .04 2.27 .00 .75
Level 2 .11 .002
Mindfulness Total (Baseline)4 −.37 .12 .24 .002
Longest Sustained Abstinence from Primary Substance
ΔR2 β SE sr2 p
Level 1 .03 .72
Treatment Condition1 −.13 5.70 .02 .40
PTSD Symptom Severity (Baseline)2 −.02 0.22 .00 .90
Number of SUD Diagnoses (Baseline)3 .12 3.07 .01 .43
Level 2 .00 .95
Mindfulness Total (Baseline)4 .01 .19 .00 .95
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Note.

1

Treatment condition = CBT for SUD (Cognitive Behavioral Therapy for Substance Use Disorders) or TIPSS (Treatment of Integrated Posttraumatic Stress and Substance Use);

2

Score based on Clinician Administered PTSD Scale for DSM-5 at treatment baseline;

3

Score based on Structured Clinical Interview for DSM-IV Axis I Disorders at treatment baseline;

4

Score based on Five Facet Mindfulness Questionnaire total score at baseline.

Post Hoc Exploratory Analyses

Post-hoc exploratory analyses examined the predictive validity of baseline mindfulness on Session 12 PTSD symptom cluster severity (DSM-5; intrusion, avoidance, negative alterations in mood, arousal), after considering covariates. Please see Table 4. Specifically, higher baseline mindfulness was significantly predictive of lower end-of-treatment PTSD intrusion symptoms, PTSD negative cognitions/mood symptoms, and PTSD arousal/reactivity symptoms. However, mindfulness was not related to PTSD avoidance symptoms. While these results included both randomized and non-randomized individuals, the pattern of results remained the same when analyzing the randomized participants only (n = 41).

Table 4.

Hierarchical Regression Results: Post-hoc Analyses

Session 12 PTSD Symptom Severity: Intrusion
ΔR2 β SE sr2 p
Level 1 .36 .001
Treatment Condition1 .02 1.22 .00 .91
PTSD Symptom Severity (Baseline)2 .60 .05 .34 < .001
Number of SUD Diagnoses (Baseline)3 −.05 .76 −.00 .72
Level 2 .08 .029
Mindfulness Total (Baseline)4 −.32 .04 .13 .029
Session 12 PTSD Symptom Severity: Avoidance
ΔR2 β SE sr2 p
Level 1 .21 .03
Treatment Condition1 −.20 .78 .05 .19
PTSD Symptom Severity (Baseline)2 .44 .03 .19 .01
Number of SUD Diagnoses (Baseline)3 −.10 .48 .01 .49
Level 2 .01 .45
Mindfulness Total (Baseline)4 −.13 .03 .02 .45
Session 12 PTSD Symptom Severity: Negative Alterations in Cognitions and Mood
ΔR2 β SE sr2 p
Level 1 .54 < .001
Treatment Condition1 −.23 1.67 .10 .05
PTSD Symptom Severity (Baseline)2 .75 .06 .54 < .001
Number of SUD Diagnoses (Baseline)3 .04 1.03 .00 .71
Level 2 .08 .01
Mindfulness Total (Baseline)4 −.31 .05 .16 .01
Session 12 PTSD Symptom Severity: Arousal and Reactivity
ΔR2 β SE sr2 p
Level 1 .43 < .001
Treatment Condition1 .01 1.24 .00 .95
PTSD Symptom Severity (Baseline)2 .63 .05 .40 < .001
Number of SUD Diagnoses (Baseline)3 .16 .77 .04 .22
Level 2 .13 <.01
Mindfulness Total (Baseline)4 −.40 .04 .22 <.01
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Note.

1

Treatment condition = CBT for SUD (Cognitive Behavioral Therapy for Substance Use Disorders) or TIPSS (Treatment of Integrated Posttraumatic Stress and Substance Use);

2

Score based on Clinician Administered PTSD Scale for DSM-5 at treatment baseline;

3

Score based on Structured Clinical Interview for DSM-IV Axis I Disorders at treatment baseline;

4

Score based on Five Facet Mindfulness Questionnaire total score at baseline.

Discussion

Higher baseline levels of mindfulness were significantly predictive of lower end-of-treatment PTSD symptom severity, above and beyond covariates, contributing 11% of unique variance to end-of-treatment PTSD severity. Individuals with higher levels of mindfulness at the outset of treatment may have been more aware of internal emotional and physiological states associated with PTSD symptomatology and thus better able to non-judgmentally engage with these states in a therapeutic context. These individuals may have exhibited a greater ability to accept negative emotionality and focus on cognitive and emotional trauma processing. Indeed, post-hoc exploration of end-of-treatment PTSD symptom clusters revealed that baseline mindfulness predicted PTSD intrusion, negative cognitions/mood, and arousal and reactivity symptoms, contributing between 8–13% of unique variance. Results are reflective of the extant literature demonstrating negative (i.e., inverse) associations between mindfulness and PTSD symptomatology (e.g., Call, Pitcock, & Pyne, 2015; Meyer et al., 2019; Smith et al., 2011; Thompson & Waltz, 2010; Wahbeh et al., 2011).

Interestingly, mindfulness was not related to PTSD avoidance symptoms. This is inconsistent with some past work (e.g., Kearney et al., 2012; Thompson & Waltz, 2010) but consistent with other literature that has not documented direct associations between mindfulness and PTSD avoidance symptoms (e.g., Martin et al., 2018; Reffy, Pinciotti, Darnell, & Orcutt, 2019). It may be that mindfulness is indirectly associated with PTSD-related avoidance through other mechanisms, such as increased ability to tolerate distress or greater emotion regulation abilities (e.g., Chambers, Gullone, & Allen, 2009; Teper, Segal, & Inzlicht, 2013). For example, greater mindfulness may impact an individual’s ability to tolerate and/or regulate negative emotion more adaptively over time by virtue of his/her ability to be aware and accepting of emotional experiences, which might ultimately translate into lower levels of avoidance. Future work should further investigate the association between mindfulness and PTSD symptom clusters to examine mechanisms which may account for, or interact with, associations between mindfulness and PTSD symptoms.

Furthermore, higher baseline levels of mindfulness were not significantly predictive of longest sustained abstinence from the substance of choice. Thus, pre-treatment mindfulness may not directly predict substance use treatment outcomes in the context of CBT. This may appear to run against the literature documenting the therapeutic benefits of mindfulness in preventing relapse among populations with SUD (e.g., Bowen et al., 2005; Bowen et al., 2014). However, there may be a difference between achieving initial abstinence and preventing relapse once abstinence has been achieved (e.g., Kalivas & O’Brien, 2008). There is evidence that different patterns of neuroplasticity (i.e., new learning) take place in these two phases of recovery. These phases may be biologically unique (Kalivas & O’Brien, 2008; Seo & Sinha, 2015) and thus differentially affected by state or trait mindfulness. This may represent a meaningful facet for future studies to explore. It is noteworthy that substance use outcomes following mindfulness-based relapse prevention are at least partially mediated by reductions in stress (Davis et al., 2018), which might suggest that substance use outcomes predicted by mindfulness levels may be indirect and apparent only following reductions in PTSD.

In addition, individuals with SUD may require more intensive mindfulness skills interventions before or during treatment in order to increase willingness to experience distressing thoughts, feelings, or substance cravings. Indeed, baseline mindfulness was not predictive of PTSD avoidance symptoms, further bolstering this hypothesis. Integrating mindfulness-based interventions to empirically supported cognitive-behavioral interventions for SUD or PTSD/SUD may increase emotional awareness and approach-oriented coping, enhance ability to be in the present moment, and bolster ability to engage in treatment and to weather cravings or withdrawal symptoms (e.g., Bowen et al., 2014). Finally, the substance-related outcomes measured in this study were based upon retrospective self-report of use of the substance of choice, possibly an artifact of recall or social desirability bias. Given the diversity of substances used by the present sample, biochemical verification measures available (i.e., urine drug screening) were not equally sensitive across substance classes given the relatively short duration of the study. It will be important for extensions of this work to focus on specific substance classes and to integrate sensitive biochemical verification of substance use for more accurate outcome measurement. Furthermore, this study did not include a re-assessment of substance dependence symptoms or a substance use severity measure at the beginning and at the end of treatment, which might have provided a diagnostic severity indicator comparable to the PTSD symptom severity outcome. Given these methodological limitations, definitive conclusions regarding the associations between pre-treatment mindfulness and substance use-related treatment outcomes cannot be drawn.

Several additional study limitations are worthy of note. First, the sample size was relatively small (N = 53), thus limiting statistical power to identify small effects, and future research should replicate and extend this work with larger samples. Second, the sample was comprised of predominantly African-American, low-income, inner-city adults seeking treatment for SUD and trauma symptoms. In addition, the majority of participants (67.9%) met criteria for cocaine dependence. The underrepresented, clinically severe nature of the sample is certainly a strength of this study, but it also limits generalizability to less severe substance-using populations or those of greater socioeconomic advantage. Replication and extension are necessary. Third, the CAPS-5 was administered only at baseline and the final treatment session (session 12), compromising our ability to examine the effects of pre-treatment mindfulness on CAPS-5 PTSD symptoms over time during treatment. Fourth, no follow-up assessments were conducted after the conclusion of treatment. Future research may incorporate follow-up procedures in order to better understand the stability of treatment effects over time, as well as the potential moderating and/or mediating effects of resilience factors, such as mindfulness, on PTSD/SUD treatment outcomes over time. Finally, mindfulness was measured via self-report and only at pre-treatment baseline. Future work might examine mindfulness over time during PTSD/SUD treatment and include experimental indices of mindfulness (e.g., Murphy & MacKillop, 2014) in addition to self-report measures.

Overall, the current study was a novel examination of associations of pre-treatment levels of mindfulness and CBT outcomes among low-income inner-city adults with SUD and PTSD symptomatology. The clinical sample was comprised of a socioeconomically disadvantaged population with SUD and elevated PTSD symptomatology. Results indicate that higher levels of pre-treatment mindfulness were associated with lower end-of-treatment PTSD symptom severity but not longest sustained abstinence from substance use. This preliminary work, pending replication and extension, suggests that pre-treatment adjunctive mindfulness skills interventions may be useful in improving PTSD symptom severity in individuals with PTSD/SUD, thus potentially improving treatment outcomes.

Highlights.

  • Mindfulness predicts PTSD outcomes in treatment-seeking adults with PTSD/SUD.

  • Higher baseline mindfulness predicted end-of-treatment PTSD symptoms.

  • Mindfulness did not predict substance use treatment outcomes.

Acknowledgements

This study was funded by the National Institutes of Health KL2 Career Development Award (KL2TR000370-07: PI: Vujanovic). The work was also supported by the National Institute on Drug Abuse (P50 DA009262; PIs: Schmitz, Lane, Green).

Footnotes

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The authors have no conflicts of interest to disclose.

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