Mindfulness-Oriented Recovery Enhancement

1. Introduction

Version followed: the current 8-session MORE for chronic pain and opioid use, as structured in Garland's 2024 Guilford treatment manual (session titles from the published table of contents) and in the session content tables of two MORE trial protocols (NCT03894501; NCT04491968). The original 10-session version for alcohol and other drug problems (Garland 2013, NASW Press) is noted where it differs. The 2024 manual's session text and handouts are not drawn on, so step-level detail comes from Garland's own slides, website and protocols; anything beyond that is tagged [synthesis] or [uncertain].

Mindfulness-Oriented Recovery Enhancement (MORE) is a manualised group (or individual) treatment developed by Eric Garland (social work; now University of Utah C-MIIND). It combines mindfulness training, "third-wave" CBT and positive psychology for addiction, chronic pain, opioid misuse and stress [source: C-MIIND overview; Garland site, components].

Theory of change: addiction and chronic pain are seen as a downward spiral. Attention gets captured by drug cues, stress and pain, negative appraisals feed distress, and natural pleasures lose their pull ("hedonic dysregulation"), so the drug becomes the main source of reward and relief. MORE works on three linked processes. Mindfulness builds metacognitive control, so the client notices automatic fixation and turns from emotional to sensory processing. Reappraisal then changes the meaning of stressors. Savoring restores sensitivity to natural rewards, which supplies motivation to keep changing. Garland's summary: mindfulness disengages unhelpful habits, reappraisal builds new beliefs and actions, and savoring sustains change through reward [source: Garland site, components; Garland 2024 TOC, ch. 2 "The Downward Spiral from Chronic Pain to Addiction"; Garland et al. 2014 Front Psychiatry].

2. Framework

Formats [source: Garland site, 8-session structure; NCT03894501; NCT04491968; Garland PCSS slides]

• Group: 8 weekly sessions of 2 hours. Trials used closed groups of about 4–9 members, in clinic or by video or phone.
• Individual: 8 weekly 1-hour sessions.
• Original version: 10 weekly 2-hour groups for alcohol and other drug problems.
• Garland describes MORE as deliverable as a reimbursable group medical visit by physicians, NPs, PAs, social workers or psychologists. Brief single MORE techniques (about 15 minutes) have been used in hospital and surgical settings.
• Home practice: 15 minutes a day of mindfulness, reappraisal or savoring practice. Trials monitored it with daily prompts.

Standard session template (every session) [source: NCT03894501; NCT04491968; Garland site, 8-session structure]

1. Opening formal meditation (mindful breathing or body scan).
2. Debrief of that practice, with the therapist reinforcing and troubleshooting. The manual's named method is "PURER" processing; see 4.1.
3. Debrief of the week's home practice of mindfulness, reappraisal and savoring.
4. New psychoeducation on the session theme.
5. An experiential exercise.
6. Homework assignment.
7. Closing brief mindful breathing.

Time allocation per segment is not specified in the sources [uncertain].

8-session sequence. Titles are from the 2024 manual. Content is from the protocol tables and Garland's slides.

The manual also contains a supplemental session on self-transcendence in recovery (chapter 7); its content is not drawn on [uncertain]. Session 7 content above combines the protocol table (thought suppression, acceptance) with the manual title (interdependence, meaning) [source: Garland 2024 TOC; NCT03894501; NCT04491968; Garland PCSS slides].

Original 10-session sequence (titles only; content [uncertain]):

1. Mindfulness and the Automatic Habit of Addiction
2. Mindful Reappraisal
3. Shifting the Mind to Refocus on Savoring
4. Seeing through the Nature of Craving
5. Overcoming Craving by Coping with Stress
6. Walking the Middle Way between Attachment and Aversion
7. Mindfulness of the Impermanent Body
8. Defusing Relationship Triggers for Relapse
9. Interdependence and Meaning in Recovery
10. Looking Mindfully toward the Future

[source: Garland site, 10-session structure; C-MIIND overview]

Phases and criteria for moving on. MORE is a fixed, session-ordered curriculum, not a criterion-based stepped model. No published criteria for advancing were found [uncertain]. A practical reading of the arc [synthesis]:

• Foundation (sessions 1–2): attention and meta-awareness skills.
• Positive restructuring (3–4): reappraisal and savoring.
• Applying skills to the high-risk links (5–6): craving, stress and pain.
• Meaning and maintenance (7–8).

In individual work, it is reasonable to stay on a skill until the client can do a short version unprompted and reports at least one real-life use. In a group, keep to the sequence and cover gaps in the debrief [synthesis].

3. Guiding principles

• Mindfulness is trained as metacognitive control, not relaxation. Coach three moves: notice that attention is fixated, shift from emotional to sensory processing, and return to the breath [source: Garland site, components; C-MIIND overview].
• Deconstruct suffering into sensations. Help clients break pain, craving or distress into parts such as heat, tightness and tingling, observed with less reactivity [source: Garland PCSS slides; Wikipedia].
• Mindfulness first, then reframe. Use a brief breathing practice to step back from the first appraisal before generating a new one [source: Garland site, components; Social Work Today 2015].
• Mindfulness serves positive processes. MORE deliberately cultivates positive emotion, reward and meaning, not just non-reactivity. Every session should leave room for what is going well [source: Garland site, components].
• Restore natural reward. Treat loss of pleasure as a target in its own right. Assign savoring of everyday pleasures, not only coping with negatives [source: Garland site, components; Garland et al. 2014 Front Psychiatry].
• Integration is synergistic. The three components are meant to reinforce each other. Link each new skill back to the earlier ones [source: Garland site, components].
• Acknowledge rather than suppress. Cravings, thoughts and pain are allowed and observed. Suppression is shown to backfire (session 7) [source: NCT04491968; Garland et al. 2014 Front Psychiatry].
• Relate to medication with intention. Any dose is taken mindfully and "with respect". For people on MAT, the frame is gratitude for a life-saving treatment, not shame [source: Garland PCSS slides].
• Daily practice is the dose. Ask for about 15 minutes a day, and review practice at every session [source: NCT03894501; NCT04491968].
• Experience before explanation. Each session runs practice, then debrief, then teaching, then an experiential exercise, so concepts are anchored in what the client just felt [source: Garland site, 8-session structure].
• Process practice in a structured way (PURER). Debrief practice systematically so every experience, including "failed" practice, becomes learning [source: Garland 2024 TOC, ch. 5; expansion of acronym uncertain, see 4.1].
• Aim beyond symptoms to meaning and self-transcendence. The later sessions point recovery toward purpose and connection with something larger than oneself [source: Garland 2024 TOC; Garland site, components].
• Collaborative, non-stigmatising stance toward opioid use and pain. Treat pain as real and treat opioid use as an understandable coping habit, not a moral failing [synthesis, consistent with the downward-spiral model].

4. Intervention inventory

Each intervention below is named in the sources. Where the sources name a technique but do not give its steps, the steps are marked [synthesis], built from the stated purpose and standard mindfulness and CBT practice. All example language is illustrative unless it is quoted and cited. No manual text or handouts are reproduced.

4.1 PURER processing of practice (debrief method)

• Purpose / when: Used after every in-session meditation and when reviewing home practice. It turns each client's experience into learning and links it to daily use. The manual devotes a chapter to it ("Processing Mindfulness in a PURER Way") [source: Garland 2024 TOC]. The protocols describe this segment as debrief with therapist reinforcement and troubleshooting [source: NCT03894501].
• Acronym: The expansion is unconfirmed [uncertain]. Per Garland's presentations it is: Phenomenology (what was experienced), Use (how it can be used in daily life), Reframe (recast difficulties as part of learning), Educate (link to the session's psychoeducation), Reinforce (reinforce effort and insight). Check the manual before training others on it.
• Steps [synthesis built on the uncertain expansion]:
  1. Ask open, concrete questions about what the client noticed: sensations, thoughts, emotions and where attention went.
  2. Ask how the experience could help in a real situation this week, such as pain flares, craving or conflict.
  3. Reframe "I couldn't do it" or "my mind wandered constantly" as the practice itself: each noticing is a repetition.
  4. Tie what was said to the session's teaching point.
  5. Specifically praise effort, honesty and any moment of noticing.
• Example language (illustrative):
  • "What did you notice in your body just now?"
  • "Where could a few breaths like that help you on Tuesday when the pain spikes?"
  • "Every time you caught your mind wandering, that was the muscle getting a rep."
• Watch for: Debriefs that drift into general group talk or advice-giving. Clients who evaluate themselves harshly. Working: clients start describing experience in sensory, specific terms and volunteer real-world uses.

4.2 Psychoeducation: the downward spiral; nociception, pain and suffering

• Purpose / when: Session 1 (and recurring). Gives a shared model: nociceptive signals, the experience of pain and the emotional suffering layered on top are distinct. Stress, negative appraisal and loss of natural reward drive escalating opioid or substance use [source: NCT03894501; Garland 2024 TOC, ch. 2; Garland PCSS slides].
• Steps [synthesis]:
  1. Draw the spiral with the client's own examples: pain, then distress or catastrophising, then craving or using, then short relief, then more pain sensitivity and less pleasure from everyday life.
  2. Separate the layers: the raw sensation, how it is interpreted, and the emotional reaction.
  3. Say which MORE skill targets which link (mindfulness for attention and automaticity, reappraisal for appraisal, savoring for reward).
• Example language (illustrative): "There's the signal from your back, and then there's the story and the dread that come with it. We can't always turn the signal off, but we can change how much the rest piles on."
• Watch for: Clients hearing "it's all in your head". Validate that the pain is real. Working: clients can place a recent episode on the spiral.

4.3 Mindful breathing (with the "loop of mindfulness")

• Purpose / when: The core formal practice. It opens and closes every session and is part of daily homework. It builds attentional control and meta-awareness [source: Garland PCSS slides; NCT03894501].
• Steps: Garland teaches a four-step loop [source: Garland PCSS slides]:
  1. Focus on an object such as the breath, the body or sound.
  2. The mind wanders into thought, emotion or sensation.
  3. Notice the wandering, for example distraction or rumination.
  4. Acknowledge and accept what came up, then return to the object.
• Delivery [synthesis]:
  1. Upright, comfortable posture; eyes closed or lowered.
  2. Rest attention on sensations of breathing where they are clearest.
  3. Expect the mind to wander. Each time, note briefly where it went and escort it back without criticism.
  4. Start in-session at about 5–10 minutes and build up. Exact durations were not found [uncertain].
• Example language (illustrative): "When you notice you're thinking about something else, that moment of noticing is the practice. Gently name where you went, 'planning' or 'pain', and come back to the next breath."
• Watch for: Breath focus raising anxiety (offer sounds, hands or feet as the anchor instead). Sleepiness. Using the practice to fight pain. Working: quicker noticing of wandering; clients report catching automatic reactions in daily life.

4.4 Body scan

• Purpose / when: Sessions 1 and 6 and at home. Builds interoceptive awareness and lets clients relate to pain areas with curiosity rather than bracing [source: NCT03894501; NCT04491968; Garland PCSS slides]. Interoceptive awareness is proposed as a route to better emotion regulation (Roberts, Ledermann & Garland 2021, cited on Wikipedia).
• Steps [synthesis]:
  1. Lying down or seated.
  2. Move attention systematically through the body, region by region.
  3. At each region, notice whatever sensations are there, including none, pleasant or unpleasant ones.
  4. At painful areas, approach the edge of the sensation, describe its qualities, breathe with it, and move on.
  5. Close with awareness of the whole body.
• Example language (illustrative): "As you come to the area that hurts, see if you can stay at its edge for a few breaths. What's actually here: warmth, pressure, pulsing? Then let it go and move to the next area."
• Watch for: Pain amplification. Shorten the practice, let the client stay at the edges or skip the region. Trauma-related distress with body focus. Discomfort lying down; allow sitting or adjusting. Working: clients describe sensations in specific terms and report less fear of them.

4.5 Mindfulness of pain ("zooming in" on sensations)

• Purpose / when: Session 1 onward, and in daily pain flares. Changes pain from a monolithic, emotionally loaded, unremitting experience into component sensations observed with less reactivity [source: Garland PCSS slides; Garland site, components; Wikipedia].
• Steps:
  1. Settle with a few mindful breaths.
  2. Bring attention to the area of pain.
  3. "Zoom in": break the experience into its specific sensations, such as tingling, heat, tightness or throbbing, and notice location, size, edges and changes over time [source: Garland PCSS slides].
  4. Notice the thoughts and emotions about the pain as separate events [synthesis].
  5. Zoom back out to the breath or the whole body, or to neutral or pleasant sensations elsewhere [synthesis].
• Example language (illustrative):
  • "Instead of 'my knee is killing me', see what the sensations are, moment by moment. Is it hot, tight, sharp? Does it stay exactly the same, or shift?"
  • "Notice the thought 'this will never end' as a thought, separate from the sensation."
• Watch for: Escalation of distress. Switch the anchor to breath or to a non-painful area. Clients using the practice to make pain disappear. Frame the aim as changing the relationship to pain [synthesis]. Working: pain is described as varying and made of parts, with lower distress and unpleasantness ratings even when intensity is unchanged.

4.6 Mindfulness of automatic pilot and automatic use

• Purpose / when: Session 2 (in the 10-session version, session 1, on the automatic habit of addiction). Builds awareness of the automatic pain-coping habits and automatic opioid or substance use that run without choice [source: NCT03894501; Garland site, 10-session structure].
• Steps [synthesis; the manual's specific experiential exercise was not found [uncertain]]:
  1. Teach how habits chain cue, then automatic thought or urge, then action, then short-term relief.
  2. With the client, map one recent automatic use or pain behaviour: where they were, what triggered it, and when they first noticed.
  3. Do an everyday activity with full attention, then contrast it with doing it on autopilot.
  4. Assign noticing autopilot moments during the week, especially around medication times.
• Example language (illustrative): "A lot of using happens before we've decided anything. This week, the aim isn't to change it, just to catch the moment autopilot kicks in."
• Watch for: Shame on recognising how automatic use has become. Normalise it as how habits work. Working: clients report noticing earlier in the chain.

4.7 Three-minute breathing space before taking medication or drugs

• Purpose / when: Taught in MORE for chronic pain and opioid use and used daily before any dose. It aims to tell craving apart from a genuine need for pain relief, to prevent unnecessary dosing by offering a non-opioid way to relieve pain, and to increase commitment to MAT [source: Garland PCSS slides].
• Steps (paraphrased) [source: Garland PCSS slides]:
  1. Stop just before taking the medication or drug.
  2. Spend a few minutes in mindful breathing.
  3. Observe thoughts, feelings and body sensations, especially attention pulled toward the sight of the drug, thoughts and feelings about it, and craving. Return to the breath when needed to re-centre.
  4. Then proceed with intention. If taking the dose, take it with awareness and respect for its power. For MAT, reflect on how it protects life.
• Example language:
  • Garland's key line: "You can have an urge, but you don't have to give into it." [source: Garland PCSS slides]
  • Illustrative: "Before the pill, three minutes. Then ask: is this pain that needs treating, or is this craving? Either way, you choose with your eyes open."
• Watch for: Clients reading this as advice to skip prescribed doses. It is not a taper instruction. Medication changes belong to the prescriber, so coordinate with them [synthesis]. Working: clients can say whether a particular urge was pain-driven or craving-driven, and report fewer automatic or extra doses.

4.8 Mindful reappraisal

• Purpose / when: Session 3 (session 2 in the 10-session version), then ongoing. Uses mindfulness to step back from negative appraisals, then reframes the event as benign, a source of growth or a learning opportunity. This reduces negative affect and stress-driven craving [source: Garland site, components; Garland PCSS slides; NCT04491968].
• Steps:
  1. Start with a brief mindful breathing to reach a calmer, decentred state [source: Social Work Today 2015].
  2. Identify the adverse event and the automatic negative appraisal. The process draws on Ellis's ABCDE model: adversity, beliefs, consequences, dispute, new effect [source: Social Work Today 2015].
  3. Observe the thought as a mental event rather than fact [source: Garland site, components; Garland et al. 2014 Front Psychiatry].
  4. Generate alternative meanings with guided questions: silver linings, what one learned, how one grew, other explanations for others' behaviour [source: Social Work Today 2015].
  5. Choose a reappraisal that feels believable, notice its emotional effect, and plan an action consistent with it [synthesis].
• Clinical example from the source: a man drinking to cope with a harsh boss reconsidered the boss's behaviour as a product of workplace pressure rather than a personal attack [source: Social Work Today 2015].
• Example language (illustrative):
  • "Take three breaths and let the first story settle. Now, is there any other way of seeing what happened?"
  • "Is there anything this has taught you, or any strength it has asked of you?"
• Watch for:
  • Reframes that invalidate real harm, such as abuse or injustice. In those cases look for growth or coping meaning, not a "benign" frame [synthesis].
  • Forced positivity the client doesn't believe.
  • Skipping the mindfulness step and jumping into debate.
  • Working: the client generates believable alternatives independently and reports less distress or craving after stressors.

4.9 Mindful savoring (in-session practice)

• Purpose / when: Session 4 (session 3 in the 10-session version), then daily. Strengthens responsiveness to natural rewards, boosts positive emotion and counters the hedonic dysregulation that makes the drug the dominant reward [source: Garland site, components; Garland PCSS slides; NCT04491968].
• Steps:
  1. Place a pleasant object in front of the group. Garland's example is a bouquet of flowers [source: Social Work Today 2015].
  2. Brief mindful breathing to settle [synthesis].
  3. Attend fully to the object's pleasant sensory features: colour, texture, scent [source: Garland site, components].
  4. Notice the pleasant body sensations and positive emotions that arise, and let attention rest on them so they are appreciated and amplified [source: Garland site, components; Wikipedia].
  5. Optionally reflect on the deeper meaning the experience evokes, such as gratitude, beauty or connection [source: Garland site, components; Garland PCSS slides].
  6. Debrief with PURER (4.1).
• Example language (illustrative): "Take in the colours, really look. Now notice what happens in your body as you take it in. Is there any warmth, softening, a small lift? Stay with that for a few breaths and let it grow if it wants to."
• Watch for:
  • Anhedonia ("I feel nothing"). Reframe this as expected early on, and treat any small shift as success [synthesis].
  • Grief or longing triggered by pleasure.
  • Choosing objects tied to drug use.
  • Working: clients report more noticeable pleasure from ordinary events. In trials this was tracked as greater reward responsiveness [source: Wikipedia, citing Garland et al. 2019 Science Advances].

4.10 Daily savoring homework

• Purpose / when: From session 4. Clients identify and draw reward from everyday experiences between sessions [source: Social Work Today 2015; Garland site, components].
• Steps [synthesis on the specifics]:
  1. Each day, choose one naturally rewarding experience, such as nature, a meal, music or time with a loved one.
  2. Slow down and savor it as in 4.9, including sensations, emotions and meaning.
  3. Note briefly what was savored and what was felt.
  4. Review it in the next session.
• Example language (illustrative): "Look for one small good thing each day: the first sip of coffee, the sun on your face. Give it 30 seconds of full attention and let it land."
• Watch for: Choosing only big events. Coach towards small, frequent ones. Working: clients spontaneously report savoring moments.

4.11 Mindfulness of craving

• Purpose / when: Session 5 (session 4 in the 10-session version, "Seeing through the Nature of Craving"), and whenever craving arises. Deconstructs craving into sensations, thoughts and impulses observed without acting [source: NCT03894501; Garland site, components; Social Work Today 2015].
• Steps:
  1. Notice that attention has been captured by craving.
  2. Shift from the emotional pull to the sensory components: where it is felt in the body and what its qualities are [source: Garland site, components].
  3. Watch it rise and fall while returning to the breath as an anchor [synthesis; consistent with 4.7].
  4. Recognise the urge as a passing event that need not be obeyed. Garland: clients can experience themselves as "much bigger than any one thought or craving" [source: Social Work Today 2015].
• Example language (illustrative): "Where in your body is the craving right now? What's it like: tight, buzzing, hollow? Watch it the way you'd watch a wave. You don't have to do anything with it."
• Watch for: Intensifying craving with no decline. Combine with consequence contemplation (4.12) and coping plans, and check safety [synthesis]. Working: clients report urges peaking and passing without use, and lower craving.

4.12 Contemplating negative consequences of use

• Purpose / when: Session 5. Weakens the pull of craving by bringing the realistic downstream costs of use into awareness [source: NCT03894501; NCT04491968].
• Steps [synthesis; the manual's procedure is not drawn on]:
  1. While mindful of a craving, real or imagined, extend the scene forward in time.
  2. Picture the hours and days after use: physical effects, emotions, relationships, pain, safety.
  3. Notice the felt response in the body.
  4. Contrast this with the values-consistent alternative.
• Example language (illustrative): "Stay with the urge, and now let the film run on. What happens an hour later? The next morning? What do you see on your family's faces?"
• Watch for: Shame spirals. Keep the focus on consequences, not self-condemnation. Working: craving loses some of its attraction during the exercise.

4.13 Imaginal opioid cue exposure

• Purpose / when: Session 5. Practise mindfulness of craving and the breathing space while craving is evoked by imagining drug cues, under the therapist's guidance [source: NCT03894501; NCT04491968].
• Steps [synthesis on the specifics]:
  1. Obtain consent and explain the purpose, and agree a stop signal.
  2. Guide a short imagined scene of a typical use situation (place, time, cues such as the pill bottle).
  3. When craving arises, cue the client to zoom in on its sensations, breathe with it and observe thoughts.
  4. Optionally add consequence contemplation (4.12).
  5. End with mindful breathing and grounding.
  6. Debrief and check craving before the client leaves.
• Safety and contraindications [synthesis]:
  • Use imagery only, never real drugs or paraphernalia.
  • Assess current use and risk before the session. Be cautious with clients in acute withdrawal, early abstinence with high relapse risk, active suicidality, or trauma linked to use scenes.
  • Leave time to settle craving before leaving, and review the client's coping plan and naloxone access.
• Example language (illustrative): "In a moment I'll describe a scene. If it gets too strong, raise your hand and we'll come back to the breath. You're in charge of how far we go."
• Watch for: Overwhelm or dissociation, which means stop and ground. Lingering craving after the session. Working: craving is noticed and tolerated in the scene, and peak craving falls over repetitions.

4.14 Stress–pain–craving chain and imaginal stress exposure

• Purpose / when: Session 6 ("Breaking the Chain between Emotional Pain and Craving"; session 5 in the 10-session version, "Overcoming Craving by Coping with Stress"). Teaches how the stress response amplifies pain and triggers craving, then rehearses interrupting the chain with mindfulness and reappraisal under imagined stress [source: NCT03894501; NCT04491968; Garland 2024 TOC].
• Steps [synthesis on the specifics]:
  1. Map the client's chain, for example: conflict, then tension, then a pain flare, then craving.
  2. Briefly explain the stress response.
  3. Guide imagery of a moderate recent stressor.
  4. At peak arousal, cue the breathing space, zooming in on body sensations, and then reappraisal.
  5. Close with a body scan or breathing.
• Example language (illustrative): "Notice where the stress lands in your body. Now take a breathing space. What's another way to read what just happened?"
• Watch for: Choose moderate stressors, not traumatic ones. Use the same safety steps as 4.13. Working: clients can identify the link in the chain where they intervened.

4.15 Futility-of-thought-suppression exercise

• Purpose / when: Session 7. Shows experientially that trying to push thoughts or cravings away makes them come back, which motivates acceptance [source: NCT03894501; NCT04491968].
• Steps [synthesis; the manual's specific exercise is not drawn on [uncertain]]:
  1. Ask clients to try hard not to think about a neutral target for a minute and to count intrusions.
  2. Debrief what happened.
  3. Link this to trying to suppress cravings or pain thoughts.
• Example language (illustrative): "How did it go, not thinking about it? What does that tell us about trying to force a craving out of your head?"
• Watch for: Clients concluding they are hopeless. Point to the alternative: allowing and observing. Working: clients see the paradox and shift toward acceptance.

4.16 Acceptance practice: the middle way between attachment and aversion

• Purpose / when: Session 7 (in the 10-session version, session 6). Builds the ability to let experiences come and go without clinging to pleasant ones or fighting unpleasant ones [source: NCT03894501; Garland site, 10-session structure].
• Steps [synthesis]:
  1. Mindful breathing.
  2. Open awareness to whatever arises.
  3. Notice any pull toward or away from each experience, labelling it "wanting" or "pushing away".
  4. Soften around it and return to the breath.
• Example language (illustrative): "See if you can notice the pull, 'I want more of this' or 'make this stop', and let the sensation be just as it is for this breath."
• Watch for: Acceptance being heard as resignation, or as giving up on pain relief. Working: clients report less struggle with symptoms.

4.17 Mindfulness to meaning: interdependence and self-transcendence

• Purpose / when: Session 7, and the manual's supplemental self-transcendence session (10-session version: "Interdependence and Meaning in Recovery"). Helps clients find meaning, purpose and a sense of connection to something larger than oneself, which MORE treats as a protective outcome of practice [source: Garland 2024 TOC; Garland site, components; Garland PCSS slides].
• Steps [synthesis; the specific practices are not drawn on [uncertain]]:
  1. Guided reflection on how one's life depends on and affects others, nature and community.
  2. Identify sources of meaning and purpose.
  3. Link these to recovery motivation.
• Example language (illustrative): "Think of everything and everyone that made this morning possible for you. What does your recovery make possible for others?"
• Watch for: Spiritual framing that alienates some clients. Keep it secular-compatible. Working: clients articulate reasons for recovery beyond symptom relief.

4.18 Mindful recovery plan and imaginal rehearsal

• Purpose / when: Session 8 (10-session version: "Looking Mindfully toward the Future"). Consolidates continuing practice and plans for high-risk situations, then rehearses skills in imagery [source: NCT03894501; NCT04491968].
• Steps [synthesis on the specifics]:
  1. The client writes their own plan covering:
     • a daily practice commitment;
     • personal triggers in pain, stress, cues and relationships;
     • which MORE skill to use for each;
     • savoring sources;
     • supports and professional contacts.
  2. Imaginally rehearse one or two future high-risk scenes using the skills.
  3. Close with mindful breathing.
• Example language (illustrative): "Picture next month: a bad pain day, an argument. Walk us through what you'll do, step by step."
• Watch for: Vague plans. Push for specific times and situations. Working: the client can describe concrete skill use for each trigger.

4.19 Daily home practice (structure)

• Purpose / when: Every week. Practice amount is treated as a driver of outcome [source: NCT03894501; NCT04491968].
• Steps:
  1. Assign about 15 minutes a day of formal mindfulness (breathing or body scan), reappraisal or savoring [source: NCT03894501; NCT04491968].
  2. Add the breathing space before every dose [source: Garland PCSS slides].
  3. Provide audio-guided practices. Guided practices are noted in the manual's description; the format is not confirmed [uncertain].
  4. Track practice and review it at every session [synthesis].
• Example language (illustrative): "Fifteen minutes a day: the same time, the same place. If you only get five, five counts."
• Watch for: See non-adherence in section 5.

4.20 Versions and components not drawn on

• 10-session sessions "Mindfulness of the Impermanent Body" and "Defusing Relationship Triggers for Relapse": titles only; procedures not found [uncertain]. Do not improvise them as "MORE" content.
• Brief MORE (about 15-minute single technique) for acute or hospital pain: described only in outline [source: Garland PCSS slides].

5. Handling problems

The sources say little about handling difficulties. The trial protocols give only safety procedures. Most guidance below is therefore [synthesis], marked individually.

Safety baseline from the protocols [source: NCT03894501; NCT04491968]:

• Members may decline to discuss any topic.
• Clinicians record adverse events seen in group.
• Statements of suicidal intent or risk to others trigger a written protocol: assessment with clinic staff, with confidentiality broken if needed.
• Referrals for counselling or psychiatric evaluation are made as needed.
• Trials excluded people with acute suicidal risk, psychosis, cognitive impairment or inability to attend groups.
• Overdose-specific procedures were not described [uncertain]. Add your own (below).

Stuck client: "I feel nothing" / no benefit from practice [synthesis]

• Normalise: dulled pleasure and noisy minds are expected effects of the downward spiral, not personal failure. Use PURER reframing (4.1).
• Shorten and diversify anchors (sound, hands, feet). Do brief practices several times a day rather than one long one.
• For savoring, scale down to tiny, sensory-rich moments and ask about any change at all, however small.
• Review the spiral map and pick one link to focus on for two weeks.

Resistance or scepticism ("meditation is not for me", "my pain is real") [synthesis]

• Validate pain as physical. Present MORE as attention and brain training for living with pain and cravings, not a claim that pain is imaginary.
• Invite a behavioural experiment: rate distress before and after a 3-minute practice.
• Keep spiritual language optional. Interdependence and meaning can be framed secularly.

Overwhelm during body-focused or exposure exercises [synthesis]

• Agree stop signals in advance.
• Move attention to a neutral or pleasant anchor, or open the eyes and ground through the senses.
• Shorten the exercise. Approach pain areas at their edges only.
• For trauma survivors, offer choice of posture and eyes-open practice, and skip the body region or image if needed.
• Do not end a session with a client in high craving or distress. Settle, check in and review the coping plan.

Non-adherence to daily practice [synthesis]

• Problem-solve concretely: time, place, cue (for example, linking practice to medication times through the breathing space), and audio guidance.
• Lower the bar ("five minutes counts") and reinforce any practice reported.
• Explore what got in the way with curiosity rather than judgment.
• In groups, invite members to share strategies that worked.

Ruptures (client feels blamed, dismissed or lectured) [synthesis]

• Name it, take responsibility for your part, and ask what would help.
• Common triggers in MORE are:
  • reappraisal that sounds like minimising real hardship; reframe toward growth or coping meaning instead;
  • craving or opioid talk that feels moralising; return to the habit model and a stigma-free stance.
• In group, address it briefly in session and offer an individual follow-up.

Modality-specific difficulties

• Breathing space read as "stop your medication" [synthesis]: Clarify that the aim is intentional, aware use. Dose decisions belong to the prescriber, and you should coordinate with them. Garland frames MAT positively [source: Garland PCSS slides].
• Lapse or relapse during treatment [synthesis]:
  • Treat it as information. Map the chain and find the earliest point a skill could have been used.
  • Revise the recovery plan.
  • Review overdose risk after any period of reduced tolerance, naloxone access, and not using alone.
  • Liaise with the prescriber or MAT programme.
• Escalating pain or opioid misuse, or withdrawal symptoms [synthesis]: Refer for medical review promptly. MORE does not replace medical management.
• Suicidal ideation [synthesis, standard practice]:
  • Ask directly and assess with your service's structured approach.
  • Make a collaborative safety plan.
  • Use lethal-means counselling, including safe storage or removal of stockpiled opioids and medications.
  • Follow your service's escalation and confidentiality procedures, as in the trial protocols.
• Hedonic flatness persisting despite practice [synthesis]: Screen for depression and consider adjunctive treatment.
• Craving rising during cue exposure and not subsiding [synthesis]: End the imagery, run a full breathing space, use consequence contemplation and coping-plan review. Arrange contact before the next session if risk is high.
• Group dynamics [synthesis]:
  • One member dominating debriefs: structure the PURER rounds.
  • War stories about use: redirect to present-moment experience of the urge.
  • Mixed levels of use or recovery: set norms for non-graphic talk about use.
• Telehealth groups [source: NCT04491968; details synthesis]: Have a phone back-up and know each member's location and emergency contact. Ask members to practise in a private space.
• Fidelity drift [source: C-MIIND overview]: A MORE Fidelity Measure (MORE-FM; Hanley & Garland, 2021) exists to rate adherence and competence. Its items are not drawn on [uncertain]. Self-review recordings against the session template [synthesis].
• Training: Formal training is offered through Garland's MORE training channel (referenced as moretherapy.com/training on his site). The page is not drawn on, so requirements are [uncertain].

Sources

Sources:

• 8 session treatment structure – Eric Garland
• MORE session structure (original 10-session) – Eric Garland
• The components of MORE – Eric Garland
• Overview of MORE – C-MIIND, University of Utah
• Mindfulness-Oriented Recovery Enhancement: contents – Guilford Press
• Mindfulness-Oriented Recovery Enhancement: product page – Guilford Press
• Healing the Opioid Crisis with Mindfulness Oriented Recovery Enhancement (Garland, PCSS slides)
• Pilot of MORE in Methadone Treatment – protocol, NCT03894501
• MORE for Chronic Pain and Opioid Relapse – protocol, NCT04491968
• Social Work Today (2015) article on MORE
• Mindfulness training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface – Frontiers in Psychiatry
• Mindfulness-Oriented Recovery Enhancement – Wikipedia

Further reading (not drawn on): the Guilford chapter 1 excerpt PDF, the Guilford reproducible-forms page, and PMC3532846.

Books and papers cited:

• Garland, E. L. (2024). Mindfulness-Oriented Recovery Enhancement: An Evidence-Based Treatment for Chronic Pain and Opioid Use. Guilford Press. Table of contents and description only.
• Garland, E. L. (2013). Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain. NASW Press. Not drawn on.
• Garland, E. L., Froeliger, B., & Howard, M. O. (2014). Mindfulness training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Frontiers in Psychiatry.
• Hanley, A. W., & Garland, E. L. (2021). MORE Fidelity Measure (MORE-FM). Cited via the C-MIIND overview; not drawn on.
• Roberts, R. L., Ledermann, K., & Garland, E. L. (2021). Journal of Psychosomatic Research. Cited via Wikipedia; not drawn on.
• Garland, E. L., et al. (2019). Science Advances. Cited via Wikipedia; not drawn on.