Mindfulness-Oriented Recovery Enhancement As a Transdiagnostic Treatment for Co-Occurring Substance Dependence, Traumatic Stress, and Psychiatric Disorders Among Formerly Homeless Persons: Proximal Outcomes from a Cluster Randomized Trial

Background and Purpose: In social work treatment settings for among homeless individuals, there is a high comorbidity between substance dependence, psychiatric disorders, and traumatic stress. As such, transdiagnostic therapies are needed to address these co-occurring issues efficiently. One such novel therapy, Mindfulness-Oriented Recovery Enhancement (MORE), was designed to target transdiagnostic mechanisms linking stress-related conditions and addiction. MORE is a 10 session group therapy intervention that unites complementary aspects of mindfulness training, third-wave cognitive behavioral therapy, and principles from positive psychology into an integrative treatment approach. The primary aim of the present study was to compare MORE to a gold-standard cognitive-behavioral treatment for substance dependent individuals with trauma histories (i.e., Seeking Safety), as well as treatment-as-usual (TAU) in a modified therapeutic community environment. We hypothesized that MORE would produce significantly greater therapeutic change in craving, post-traumatic stress symptoms, and psychological distress, dispositional mindfulness, and positive and negative affect than Seeking Safety and TAU.

Methods: Men with co-occurring substance use and psychiatric disorders, as well as histories of extensive trauma and homelessness, were recruited for this study from a modified therapeutic community in an urban area in the Southeastern United States. Participants were randomly assigned to 10 weeks of group treatment with MORE (n=64), Seeking Safety (n=64), or TAU (n=52). Pre- and post-treatment, participants completed validated questionnaires to assess proximal outcomes. Repeated-measures mixed models were computed to test our hypotheses that MORE would outperform Seeking Safety and TAU. These mixed models accounted for the variability associated with the nesting of multiple observations (i.e., pre- and post-intervention assessments; Level 1) within participants (Level 2) within group cohorts (Level 3). Two simple path analyses were conducted with a dummy coded treatment variable (MORE vs. other treatments) as the independent variable, changes in craving and PTSD as dependent variables, and changes in dispositional mindfulness as a mediator.

Results: Intention-to-treat (ITT) analyses were conducted on the entire randomized sample (N=180). Study findings indicated that from pre- to post-treatment MORE led to significantly greater improvements in substance craving (p=.014), post-traumatic stress (p=.036), and negative affect (p=.043) than Seeking Safety, and significantly greater improvements in post-traumatic stress (p=.056) and positive affect than TAU (p=.042). MORE also led to significantly greater increases in mindfulness than Seeking Safety (p=.001) and TAU (p=.004). A significant indirect effect of MORE on decreasing craving and post-traumatic stress by increasing dispositional mindfulness was observed (craving Sobel p=.01; post-traumatic stress Sobel p=.02), suggesting that MORE may target this comorbidity via enhancing mindful awareness in everyday life.

Discussion: This RCT represents the first head-to-head comparison of MORE against an empirically-supported treatment for co-occurring disorders. Results from this trial indicate that MORE outperformed Seeking Safety across a number of domains, including significantly greater reductions in craving, post-traumatic stress, and negative affect from pre- to post-treatment. These positive outcomes are notable, in that study participants suffered from multiple, chronic, severe vulnerabilities, including psychiatric disturbance, trauma, addiction, and homelessness. MORE, as an integrative therapy designed to bolster self-regulatory capacity, may serve as a transdiagnostic treatment for intersecting clinical conditions.