Integration of Mindfulness-Based Cognitive Therapy into the Therapeutic Community: Implications for Treatment of Addiction and Co-occurring Disorders

The impetus for the groundbreaking implementation of Mindfulness-Based Cognitive Therapy (MBCT) into the Therapeutic Community (TC) came from Amity Foundation’s interest in providing innovative therapies which help to unravel the complex knots that addictions and co-occurring disorders create. In this article we describe the theoretical basis of MBCT and outline methods of implementing this approach at Amity’s Circle Tree Ranch Teaching and Therapeutic Community. We recognize the interconnectedness that occurs among untreated trauma, depression, addiction, and relapse, and believe an integrative approach is necessary to meet the needs of dually diagnosed individuals while the basic TC tenant of “Community as Method” remains central to the healing process (DeLeon, 2000).

Mindfulness practices, which are simultaneously very new and very ancient, have shown efficacy in reducing anxiety, depression, and chronic pain (Baer, 2003), and promising outcomes in treatment of post-traumatic stress disorder (PTSD) (Follette, et al., 2006). Amity’s Circle Tree Ranch incorporates a culturally responsive, holistic approach to treatment which facilitates personal growth and transformation. Incorporating Mindfulness-based practices in a setting such as this allows individuals to explore the reality of their experiences, and respond with empathy and compassion rather than judgment and shame.

As practitioners of the Therapeutic Community model, we believe that recovery is a developmental learning process requiring a significant length of time. Decreases in funding for individuals in need of long term residential treatment has resulted in shorter lengths of stay in our communities¹. The introduction of strategies which allow individuals to be more fully present during the TC process has significant implications as we are confronted with the challenge of shorter periods of enrollment. Mindfulness practices effectively engage students by increasing moment-by-moment, non-judgmental awareness, cultivating an open and accepting orientation toward their experiences and the experiences of others, teaching core skills of concentration, acceptance, and the development of an aware mode of being. The “portability” of these practices provides individuals with skills that may be used long after their enrollment in the TC.

Background

Mindfulness-based Stress Reduction (MBSR) was introduced by Jon Kabat-Zinn at Massachusetts General Hospital as an eight session course designed to help people cope with chronic pain and physical illness (Kabat-Zinn et al., 1987). Popular awareness increased with Bill Moyers series Healing and the Mind: Part 3 – Healing from Within (1993). Kabat-Zinn is interviewed in this instructional documentary focusing on the relationship between illness/health and the mind. Later, Kabat-Zinn (1995) generalized the application of MBSR to include anxiety and panic disorders, helping people deal with many detrimental effects of emotional and physical pain. More recently MBSR has been combined with cognitive therapy in a group-based skills training in MBCT for the treatment of chronic relapsing depression (Segal, Williams, & Teasdale, 2002). In both MBSR and MBCT participants develop attentional control and awareness of mental processes through repeatedly practicing mindfulness meditation exercises including body-focused attention, shifting focus between different kinds of mental content (sound, thought, feeling, and emotion), mindful movement, mindful walking, and being mindful during everyday activities.

In the field of substance abuse treatment, many studies demonstrate the efficacy of cognitive-behavioral therapy (CBT) for a variety of addictive disorders across diverse populations (McCrady, 2001). In recent years, neurobiological findings support the hypothesis that meditation may be effective in relapse prevention as it enhances awareness and the cultivation of alternatives to mindless, compulsive, or impulsive behavior (Marlatt, 2002). Relapse prevention education has been used effectively as a treatment for substance dependence, and has recently been integrated with mindfulness-based techniques to develop effective coping strategies in the face of high-risk situations (Witkiewitz et al., 2005).

Mindfulness-based meditation practices have great potential for personal growth and healing from trauma, substance abuse, and co-occurring disorders within the TC setting, and can support the basic TC methodology of “community as method” (DeLeon, 2000). Often chemical dependency and other addictive or self-destructive behaviors are related to overwhelming experiences of exposure to abusive power, physical and sexual abuse, disabling losses and disrupted attachment, usually beginning in childhood. Seldom do individuals seek help due to the trauma itself, rather it is the distress from its effects, including addiction, depression, anxiety, and other co-occurring disorders that lead people to treatment. The creation of a safe environment for the exploration of experiences and the development of trusting relationships provides a powerful antidote for the isolation and exclusion that is common among those dealing with addiction and co-occurring issues.

In contrast to many schools of psychotherapy, but consistent with our philosophy of whole person recovery, mindfulness meditation does not assume pathology, but instead focuses on becoming aware of one’s inner resources and responses as a means of acceptance and transformation of suffering. Mindfulness is the process of paying attention throughout all phases of life which can bring about profound personal change. Mindfulness meditation is a way of self-transformation through self-observation (Kabat-Zinn, 1990). MBCT courses teach mindfulness through objective, detached self-observation without reaction. The goal is not to change the content of thoughts, but to develop a nonjudgmental acceptance of thoughts, feelings, and sensations as they occur, recognizing these experiences as impermanent events not necessarily requiring direct action (Segal, Williams, & Teasdale, 2002).

MBCT at Amity’s Circle Tree Ranch

A series of rather unexpected and fortuitous events lead to the introduction of Mindfulness-based meditation at Amity’s Circle Tree Ranch in March, 2008. Always interested in current academic literature, Rod Mullen, President and CEO of Amity Foundation, and Mary Stanton, Senior Counselor, were drawn to topics concerning neuroplasticity of the adult brain. In studying the capacity of the brain to develop new neuronal/synaptic interconnections and thereby develop new functions and roles (Begley, 2007), we became intrigued with the prospect of incorporating this revolutionary work in treatment of adult sufferers of addiction and psychological disorders. Our interest did not extend to meditation practices until we were presented with the opportunity to attend an intensive retreat and training in the practice of MBCT. The six-day retreat presented by Zindel Segal Ph.D., Sona Dimidjian, Ph.D., and Steven Hickman, Psy.D. in Joshua Tree, California (February 17 – 22, 2008) was a profound experience for both of us, personally and professionally. From that point our preparation included the disciplined development of a personal practice of mindfulness meditation, studying current literature on a variety of applications of Mindfulness-based meditation practices, and planning the implementation of these practices in our community. We discovered that above all else, it is essential for instructors of MBCT to teach from their experience of a personal meditative practice and to embody the attitudes that they invite participants to practice. Our aim was both to teach the MBCT curriculum and to weave mindfulness practices into all aspects of the TC.

We began with a general orientation of the concepts and practice of Mindfulness-based meditation during a week-long workshop at Amity’s Circle Tree Ranch in March 2008. We began each day with a guided meditation and incorporated periods of silence and “mindful walking”. Following the experience of mindfulness practices the concept was presented in a seminar format, defining mindfulness as a “metacognitive state of awareness that emerges through paying attention, on purpose, in the present moment, and nonjudgmental to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p. 145). This provided a foundation and general understanding when it came time to recruit participants for our first 5-Day MBCT course. Students were invited rather than required to attend the course.

Method

Orientation:

• One week prior to beginning each course, an overview of the MBCT course is presented during a Community Gathering, describing the practice of mindfulness and the requirements of the course.
• Core concepts of Mindfulness practices are outlined and potential benefits of participation in the course are discussed.
• Course “graduates” describe what they learned and share their experiences with the community, particularly other non-participating TC residents.

Selection of MBCT Course Participants:

• Following the orientation community members complete an intent form to elicit a description of experiences with meditation, attitudes toward meditation, willingness and commitment to fully participate in the course, and expected benefits.
• The size of the class is limited to 12 – 14 students to allow all participants to share their experiences within the group.
• The inclusion criterion consists of a review of the intent forms, attention to the length of time enrolled in the community (a minimum of 30 days, with special consideration given to students close to their date of departure), and input from other faculty members, including Amity’s nurse and consulting psychiatrist.
• Selected students are given an invitation which includes a course schedule and a RSVP card.

Informed Consent:

• The MBCT course goals and objectives, schedule, and expectations are clearly outlined for potential participants. The requirement to practice for 45 minutes each day outside of class sessions is emphasized.
• Signing and returning the RSVP card confirms their understanding of course expectations and their intent and commitment to fully participate.

Demographics:

• The ethnic diversity of our community² was reflected among course participants with 63% Caucasian, 31% Native American, and 7% Hispanic. With one course composed entirely of women, there were a significantly larger percentage of female participants (58%) than male participants (42%).

Course Design/Adaptations

During the eight month period from April – November, 2008, we completed five MBCT courses at Amity’s Circle Tree Ranch. The vast majority of individuals enrolled in our Community are suffering from the dual effects of chemical dependency and trauma, abuse, violence, post-traumatic stress disorder (PTSD), compulsive behaviors, and psychological disturbances. It became evident during our first course that mindfulness meditation practices provided an effective means to surface and address these issues. To facilitate this process we choose to supplement the MBCT curriculum with additional activities and group experiences during subsequent courses.

Supplementary Interventions to MBCT for the TC:

Adopting an attitude of compassion toward oneself, acceptance and non-aversion to one’s experiences, and a practice of “turning toward” rather than “turning away from” emotionally charged memories correlates with the goals and objectives of the Extensions Curriculum authored by Naya Arbiter and Fernando Mendez (http://www.extensionsllc.com). This curriculum, utilized by Amity Foundation, helps individuals to explore all realities, causes, and contributing factors which result in chemical dependency and addiction. Mindfulness-based meditation practices reinforce the intent of the Extensions Curriculum to help individuals accept and reconcile the reality of their life experiences.

Assessment:

Our early assessment of the effectiveness of incorporating Mindfulness-based practices in the Therapeutic Community is based on the self-reporting of individual participants during the MBCT course and our observations and interactions with participants in the community setting following the course. Based on qualitative data collected, initial findings demonstrate significant personal growth and healing among participants. All participants completed a questionnaire on the final day of each course which included:

• Describing their experiences and reactions to the Mindfulness-based practices presented.
• Rating the relevance of the course to their personal process of recovery. The mean rating (max=10) was 8.26.

Relevance to Process of Recovery RatingScale: 1 = not relevant; 10 = highly relevant

Follow-up:

Follow-up interviews with participants and “Mindfulness Reunions” have allowed us to determine the degree to which participants maintain formal and informal mindfulness practices. One-day “Mindfulness Reunions” reinforce learning and provide valuable qualitative data regarding the benefits of this course. Reunion days are 8 hours in length, and include practice and review of the core features of MBCT. During the day we move from indoor to outdoor settings, and provide participants with periods of reflection and discussion following each activity. Initial results confirmed that most participants are continuing to integrate skills learned in the MBCT course in their daily lives.

What We Have Learned: Mindfulness Meditation and the TC Perspective

The Mindfulness Meditation program as it is designed and implemented at Amity’s Circle Tree Ranch provides a number of benefits and enrichment to the TC model. Mindfulness meditation practices help facilitate self discovery and increase awareness in the participants. Historically, the social organization of the TC is designed to address the whole person through surfacing and raising awareness of negative behaviors (Arbiter & Mullen, 2002). Remarkable changes in lifestyle are possible when individuals live and work in community where every element has an educational and therapeutic impact on their process (DeLeon, 2000). As students of mindfulness meditation courses develop an increased ability to “dwell within”, they become more conscious of internal and external triggers to negative behaviors. This ability to live more fully in the present moment allows every element of the therapeutic community process to have an increased potential for influencing positive change.

Mindfulness meditation practice not only involves being fully present within yourself, but includes being fully present with others as well. From the perspective of drug abuse as a disorder of the whole person involving cognitive, behavioral, emotional, social, and spiritual functioning, it is necessary to live with others in a social setting where all of who they are can be displayed, seen, and changed (DeLeon, 2000). Feedback from students in our Community who have not participated in the MBCT course showed that roommates or members of their circle who participated in the course are “calmer”, “easier to talk to” or “seem to really listen” as they practice being more mindful in daily activities. This illustrates the positive effect mindfulness-based practices have on building authentic relationships along with stimulating greater interest and incentive for other students to enroll in future MBCT courses.

Another benefit of the MBCT course is in the way participants are more successful in recognizing, communicating, and identifying the feelings they experience. Persons living in a TC have many shared characteristics including some or all of the following: poor tolerance for frustration, a desire for instant gratification, low self esteem, difficulty with authority, problems with responsibility, poor impulse control, unrealistic or distorted perception of self, and difficulty coping with feelings (DeLeon, 2000). One of the many examples from the MBCT course is of a young woman who shared her experience of being held hostage and brutally raped before coming to Circle Tree Ranch. Suffering still from paralyzing fear, panic attacks, and sleep disturbance as well as feelings of self-condemnation for “putting myself in that situation”, closing her eyes in a room full of people, and lying in a prone position was initially impossible for her. She came to accept the core concept that “whatever emerges is already there”, and began to experience self-compassion, gentleness, and allowing rather than resisting her experiences.

Participants in MBCT courses develop an attitude of non-judgmental acceptance towards whatever is experienced in the present moment. Within the TC, recovery is seen as a developmental learning process where the individual is the main contributor to their own change (DeLeon, 2000). Peer support and feedback within the community allows individuals to see more clearly when negative responses are being triggered, and to help themselves through helping others.

Finally, the practice of mindfulness as a way of being fully present facilitates increased personal and social responsibility, and the development of a compassionate, non-judgmental attitude toward self and others. The Therapeutic Community is influenced by values. This fundamental view of right living includes a belief in certain values that are essential to personal growth, health, and well being. Included in these basic precepts is a focus on the here and now, truth and honesty, personal responsibility for one’s destiny, social responsibility, and moral development (DeLeon, 2000). Many of the participants reported that MBCT positively altered their behavior within the TC, and helped to shift their perspective and attitude, raising consciousness and facilitating moral development.

Mindfulness-based meditation requires practice and continued learning in order to develop and reinforce skills. We found that maintaining an environment within our Community which reinforces the use of new skills helps students to generalize their learning and enhances all aspects of the TC experience. Our findings indicate that the synthesis of Therapeutic Community traditions and Mindfulness-Based practices has important implications for healing from trauma, substance abuse, and co-occurring disorders within our communities.

¹ In the 1980’s the average length of stay at Amity’s Circle Tree Ranch was 18 months. Currently, individuals enrolled in our community stay an average of 90 to 210 days.
² From April through November 2008 the ethnic distribution at Circle Tree Ranch was: Caucasian – 49.4%; Native American – 34.2%; Hispanic – 13.9%; Other – 2.5%.
³ In Native American culture, the sacred Sweat Lodge Purification Ceremony is a traditional way of cleansing body, mind, and spirit, allowing a balanced relationship with the self, the earth, and all relations.

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For the purpose of the online CE Course, the article objectives are:

• To develop an understanding of the background and the methodology of Mindfulness-based meditation practices including MBCT and MBSR.
• To demonstrate the effectiveness of quieting the mind in order to identify patters of thoughts, feelings, and emotions in the treatment of addiction and co-occurring disorders.
• To outline a variety of practices and approaches to mindfulness-based meditation, including mindful movement, and mindfulness in outdoor settings.
• To illustrate how mindfulness practices may be adapted as an intervention in either residential or outpatient treatment settings.
• To gain understanding of the Therapeutic Community perspective and how mindfulness meditative practices are a promising intervention for treatment of addiction, depression, or co-occurring disorders within the Therapeutic Community.

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