Dr.Robert Sapolsky of Stanford University found that “Primates are super smart and organized just enough to devote their free time to being miserable to each other and stressing each other out. . . . For example, having your worst rival taking a nap one hundred yards away gets you agitated.” A professor of biological and neurological sciences, Sapolsky has spent more than three decades studying the physiological effects of stress on health. “If you’re a gazelle, you don’t have a very complex emotional life, despite being a social species,” he says. “But primates are just smart enough that they can think their bodies into working differently. It’s not until you get to primates that you get things that look like depression. . . . If you get chronically, psychosocially stressed, you’re going to compromise your health. So, essentially, we’ve evolved to be smart enough to make ourselves sick.”

How Social Rank and Connectedness Impact Stress

Sapolsky’s team has found that baboons, especially “type A” baboons, often have chronically elevated levels of stress hormones that impact their health negatively. “Their reproductive system doesn’t work as well, their wounds heal more slowly and they have elevated blood pressure. . . . So they’re not in great shape.” Interestingly, both low-ranking and type A baboons are among the most susceptible to stress. But here’s an interesting finding, relationships and social connections can actually counter this stress response. Baboons who need baboons, it turns out, are the luckiest baboons in the world, just like people who need people. Among baboons, social isolation may play an even more important role than social rank as far as stress goes.

“Up until fifteen years ago, the most striking thing we found,” says Sapolsky, “was that, if you’re a baboon, you don’t want to be low-ranking, because your health is going to be lousy. But what has become far clearer, and probably took a decade’s worth of data, is the recognition that protection from stress related disease is most powerfully grounded in social connectedness, and that’s far more important than rank.” That’s why when you’re feeling stressed out, calling a friend, gossiping with a co-worker or going out for a walk or lunch with someone can make you feel so much calmer.

How Human Beings Can Use Imagination to Reduce Stress

Human beings can even take stress reduction to another level, we can do something that animals aren’t equipped to even conceive of. We can think creatively. We can imagine ways of seeing a situation, for example, of reframing and understanding it that can turn what could be a stressor into something that we don’t worry about as much or that we can manage differently. “Letting go and letting God”, “turning it over”, “taking baby steps” and living “a day at a time” are all wonderful ways of reducing psychological and emotional stress and unnecessary worry, the kind that adds nothing to our lives and gets in the way of emotional sobriety. Human beings can, in short, conceive of and create change; we can use our minds to reframe, to see things in a better light. “We are capable of social supports that no other primate can even dream of,” says Sapolsky.

For example, I might say, “This job, where I’m a lowly mailroom clerk, really doesn’t matter. What really matters is that I’m the captain of my softball team or deacon of my church”–that sort of thing. It’s not just somebody sitting here, grooming you with their own hands [as in the primate world]. We can actually feel comfort from the discovery that somebody on the other side of the planet is going through the same experience we are and feel, I’m not alone. We can even take comfort reading about a fictional character, and there’s no primate out there that can feel better in life just by listening to Beethoven. So the range of supports that we’re capable of is extraordinary. We can use our creative imaginations to get all tied up in knots or to do just the opposite, to enjoy and relax into the life we’re living.

Twelve step programs are perhaps one of the most successful networks of social connectedness, isolation reduction and stress management in the world. So many of us who find the rooms come to a sense of deep gratitude for whatever brought us there; program also supplies Good Orderly Direction and gives meaning and purpose to our lives and relationships; if ever there were a network that aids in stress and anxiety reduction, this is it.

I was deeply bothered upon hearing this explanation offered to me by a seemingly intelligent addiction professional. Although I have encountered my fair share of alcoholics/addicts who were not ready to commit to recovery, I felt that we as professionals had to take therapeutic action to help our patients work through this pink cloud and be able to self-evaluate. In recent years, I have come to appreciate the immense clinical value of using Eye Movement Desensitization and Reprocessing (EMDR) to help our addicted patients ready themselves for the level of self-evaluation that is needed for meaningful lifestyle change and recovery. EMDR is currently recognized as an efficacious treatment for Posttraumatic stress disorder by several major clinical bodies, such as the American Psychiatric Association, the American Psychological Association, the Veterans Administration and Department of Defense, and the International Society of Traumatic Stress Studies (American Psychiatric Association, 2004; Chambless, 1998; Department of Defense and Veterans Administration, 2004; Foa, Keane, & Friedman, 2000); moreover, several major clinical bodies around the world have validated the clinical merits of EMDR (Maxfield, 2007).  This article assumes the mainstream validation of EMDR and is not focused on debating the EMDR issue. Rather, the purpose of this article is to present a brief overview of EMDR, survey the applications of EMDR to addiction treatment, and offer challenges for new directions in both research and clinical practice.

EMDR was developed by California psychologist Francine Shapiro in 1987 as a result of a serendipitous discovery, and her new method for alleviating disturbing memories and cognitions was first presented in scholarly form in the Journal of Traumatic Stress Studies in 1989. Shapiro has described EMDR as, “A comprehensive method of psychotherapy addressing problems that are based on earlier life experiences” (Lovett, 1999; p.xi), and Alan Moskovitz, M.D., an internationally renowned expert in the treatment of borderline personality disorder has illustrated EMDR as, “An artful blend of several therapeutic techniques, including exposure therapy, cognitive therapy, and even an abbreviated form of the free association of psychoanalytic psychotherapy” (p. 184). EMDR is more than just sitting a client down and asking her to move her eyes back and forth while she thinks about a disturbing memory (which is a misconception about EMDR that many professionals still possess). Rather, EMDR offers clinicians who are trained in the method a comprehensive, eight-phase model that combines just about every school of psychotherapeutic intervention. These eight phases allow a clinician to work with the client’s past disturbances to help them live more adaptively in the present, and set up a template for positive future action.

The eye movements, or other forms of bilateral stimulation such as auditory tones or tactile sensations, serve as the physiological mechanism of action to accelerate the processing of information. Although research on the neurological underpinnings of EMDR is still largely theoretical, what has been researched seems to suggest that the bilateral stimulation in EMDR allows clinicians to access material in the lower regions of the brain that are most affected by traumatic memories. Traditional cognitive therapies are primarily focused on accessing the prefrontal cortex of the brain where reasoning and logic takes place; however, when an individual is disturbed, this logic-based region is likely to shut down as the more primal, lower regions of the brain take over as an inherent mechanism of self protection (Brown, 2003). The bilateral stimulation in EMDR allows access to the entire brain, and the ultimate goal is to move material that is maladaptively ensnared in the lower regions of the brain to more adaptive resolution in the prefrontal cortex.

Anyone who has worked with an alcoholic or addict knows that he or she is likely to shut down when confronted with disturbing stimuli, or when he or she feels threatened in any way. In counseling for addiction and PTSD, we refer to these stimuli as triggers. Too often, counselors try to use cognitive, reason-based interventions at times like these, when neurological theory suggests that, in doing this, we are accessing a part of the brain (the prefrontal cortex) that has essentially shut down because the primal brain has taken over. Many addiction counselors who are aware of this phenomenon have turned to alternative therapies, such as EMDR, to help us access an individual’s entire brain, and in doing so, we are accessing the holistic self: emotions, sensations, cognitions, and any other relevant material that may emerge.

Treatment centers throughout the United States and abroad have witnessed the value of incorporating EMDR as an adjunct to their addiction programs. A short list of well-known treatment centers in the United States that are currently offering EMDR include The Meadows, PineGrove Behavioral Health and Addiction Services, Talbott Recovery Campus, Sierra Tucson, Morningside Recovery, and Santé Center for Healing. Community-based centers such as Community Solutions in Warren, Ohio and Home of New Vision in Ann Arbor, Michigan have taken a proactive role in venturing beyond treatment as usual by incorporating EMDR as a service for their clients. Amethyst, Inc., a gender-specific housing and treatment program in Columbus, Ohio has been using EMDR since the mid-1990s to help their clientele address the traps of traumatic recall that can lead to relapse. Amethyst and other programs mentioned are not using EMDR to replace existing recovery strategies, rather, they are incorporating EMDR to enhance existing recovery strategies, which is how Shapiro herself suggested that EMDR be implemented into the treatment of addictions (Shapiro & Forrest, 1997).

Programs have proceeded to use EMDR with alcoholics and addicts since EMDR’s inception because the correlation between addiction and PTSD has been long established (Kessler, Sonnega, Bromet, et al., 1995; Ouimette & Newman, 2002). Although limited, research does exist on the specific use of EMDR with addiction, and the last five years has witnessed a particular flourishing of interest in this field. Some of the most recent publications include Marich’s (in press) case study of a cross-addicted female’s treatment and early recovery experience, which includes a phenomenological follow-up interview six months after the termination of EMDR treatment, and a randomized controlled study by Hase, Schallmayer, & Sack (2008) which demonstrated that a group receiving treatment as usual along withEMDR showed a significant reduction in addiction craving 1 month post-treatment and at 6 month follow-up compared to the group receiving only treatment as usual. Brown and Gilman’s (2007) pilot study in a county Drug Court program in the Pacific Northwest showed that 83% of those completing EMDR along with Seeking Safety (Najavits, 2001) protocols graduated from the Drug Court program, compared to 33% graduation rate for those declining EMDR as part of their treatment. Cox and Howard (2007) drew attention to EMDR in their case study article that demonstrated EMDR’s role in successfully treating a male sex addict. They called for further research not just in using EMDR as a treatment for PTSD in addicts, but also in using EMDR as a way to enhance the addict’s overall recovery experience.

Indeed, more research is needed in documenting the efficacy of EMDR as an adjunct to the addiction recovery experience. For clinicians already using EMDR with recovering addicts, consider documenting your cases or beginning the early stages of research in your usual care setting; there are many individuals in the EMDR community (see www.emdria.org, or contact this author) who would be willing to help you with research projects. From the standpoint of clinical practice, there are also individuals in the EMDR community who would be willing to work with you on finding EMDR-trained clinicians in your area, or guiding you to obtain training for yourself or others in your treatment programs. If you are an addiction professional who is interested in learning all that you can about innovative ways to help your clients work through the challenges of early recovery, consider educating yourself even more about EMDR. The following websites provide excellent orientations to the principles of EMDR, and keep you updated on the latest research and developments:

• EMDR International Association: www.emdria.org
• EMDR Institute: www.emdr.com
• LifeForce Trauma Solutions: www.lifeforceservices.com
• Chrysalis Mental Health & Wellness: www.rtpgh.com

Stay tuned for further articles on how to assess if a recovering addict is appropriate for EMDR, and for research updates on the use of EMDR with recovering addicts.

References
Alcoholics Anonymous World Services. (2001). Alcoholics anonymous (4th ed.). New York: Author.

American Psychiatric Association. (2004). Practice Guidelines for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines.

Brown, S. (2003). The missing piece: The case for EMDR-based treatment for posttraumatic stress disorder and co-occurring substance abuse disorder. LifeForce Trauma Solutions. Retrieved June 4, 2008, from http://www.lifeforceservices.com/ article_detail.php?recordid=5

Brown, S., & Gilman, S. (2007). Utilizing an integrated trauma treatment program (ITTP) in the Thurston County Drug Court program: Enhancing outcomes by integrating an evidence-based, phase trauma treatment program for posttraumatic stress disorder, trauma, and substance abuse. La Mesa, CA: Lifeforce Trauma Solutions.

Chambless, D. L. et al. (1998). Update of empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.

Cox, R.P., & Howard, M.D. (2007). Utilization of EMDR in the treatment of sexual addiction: A case study. Sexual Addiction & Compulsivity, 14, 1-20.

Department of Veteran Affairs & Department of Defense (2004). VA/DoD Clinical Practice Guidelines for the Management of Post-Traumatic Stress. Washington, D.C.

Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies. New York: Guilford Press.

Hase, M., Schallmayer, S., & Sack, M. (2008). EMDR reprocessing of the addiction memory: Pretreatment, posttreatment, and 1-month follow-up. Journal of EMDR Practice and Research, 2 (3), 170–179.

Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060.

Lovett, J. (1999). Small wonders: Healing childhood trauma with EMDR. New York: Free Press.

Marich, J. (in press). EMDR in the addiction continuing care process: Case study of a cross-addicted female’s treatment and recovery. Journal of EMDR Practice and Research, 3(2).

Maxfield, L. (2007). Current status and future directions for EMDR research. Journal of EMDR Practice and Research,1(1), 6-14.

Moskovitz, A. (2001). Lost in the mirror: An inside look at borderline personality disorder. (2nd ed.) Latham, MD: Taylor Trade Publishing.

Ouimette, P., & Brown, P.J. (2002). Trauma and substance abuse: Causes, consequences, and treatment of comorbid disorders. Washington, D.C.: American Psychological Association Press.

Shapiro, F. & Forrest, M. (1997). EMDR: The breakthrough “eye movement” therapy for overcoming stress, anxiety, and trauma. New York: Basic Books.

The treatment field is now confronted with an equally daunting challenge: a skyrocketing degree of acuity and complexity seen in outpatient and inpatient settings alike. Individuals presenting for care with a simple history of alcohol dependence and depression are a rare find in our day.  More typically, patient’s difficulties include a mood as well as an addictive disorder, an eating disturbance of some kind, a history of childhood abuse of some type, along with overwhelming psychosocial disturbances. Where the criteria for full-blown PTSD may not be met, many symptoms of that diagnosis are often present as well. And don’t neglect to look at the patient’s presentation of chronic pain either!

The purpose of this article is to propose an integrated model of treatment to address highly acute and diagnostically complex patients. To accomplish this, I will describe the recent experiences of administrators in a well-heeled psychiatric setting with multiple treatment options within the larger facility. I was one of those administrators and will speak from that experience

Recently, as an administrator in a large psychiatric hospital with multiple program offerings, it became almost impossible to determine which program track would be most efficacious for many newly admitted patients. Given the contents of a pre-admission assessment, conversation among the administrative –clinical team often went as follows: “Should she enter the Mood Program? Well, she is also an alcoholic so she should probably attend the Dual Diagnosis Program. Yeah, but look at her trauma history, shouldn’t she go straight into the Trauma Program and then we can send her to lots of AA meetings and relapse prevention groups at night? You know, maybe we should look at the Eating Disorder Program instead, her eating disorder pre-dated her chemical dependency and perhaps her depression as well. Her depression isn’t going to lift if she continues to be malnourished and significantly underweight…” This may sound like a parody of an admissions team trying to make this critically important decision, but I submit that these discourses are happening everyday, in treatment centers and master treatment planning meetings everywhere. The central question remains: What issues to address first without neglecting or deferring equally important clinical needs?

The answer is that as treatment providers we cannot prioritize in a linear manner – we must find ways in which to integrate modalities that will address the underlying drivers of addictions (both substance and process), behaviors related to said addictions, as well as alleviate the debilitating symptomotology of mood, eating and trauma related disorders.

The TouchStone Model strives to accomplish these tasks with an integration of four specific approaches to care: The modalities include: Dialectical Behavioral Therapy Skills Training as the core foundation , Experiential and Psychodynamic therapies for trauma resolution and processing of family of origin issues, Psycho-Education for denial management and relapse prevention and Life Coaching for mapping a satisfying and rewarding future in health. When these four approaches are integrated and delivered within the context of a structured, motivational and nurturing milieu, the most highly complex and acute patients have an opportunity to experience deep and lasting gains. This model does not preclude adjunct therapies as well: EMDR and Somatic Experiencing provide opportunities for patients to deepen and transform in ways in which they may have previously felt “stuck” despite their greatest efforts and sincere attempts to make therapeutic gains.

This preliminary discussion of the TouchStone Model requires far more elaboration than the scope of this article allows. Clearly, more data will be required to empirically validate the premise that this degree of intensive, integrated work can be tolerated by individuals with acute and complex conditions. However, the initial anecdotal experience of the pilot program of the TouchStone Model at the previously mentioned psychiatric facility suggests that the experiential, psycho-educational and dialectical approaches combined will be an answer to the daunting psychiatric challenges that our patients present.

An operational definition of shame

According to Merriam-Webster, shame is “a  painful emotion caused by consciousness of guilt, shortcoming, or impropriety; a condition of humiliating disgrace or disrepute.”
This definition mirrors the vast research on the topic, viewing shame as either an emotion, a state of mind, or both.

Pattison (2000) emphasizes the cognitive aspects of shame, in the following description:

A distinctive set of features that helps to distinguish shame from other experiences revolves around the perception of the self as being judged to be inferior, defective, incompetent, undesirable, or unlovable . . . Shame experience is often described as inducing a sense of inferiority, valuelessness, or personal diminishment through failing to meet one’s own adopted standards and ideals (p. 76).

Bradshaw (1988) describes shame as “an excruciatingly internal experience of unexpected exposure.”  This definition helps us distinguish shame from embarrassment. While the latter has everything to do with exposure (being seen by others in a negative light), and is generally accompanied by blushing, aversion of the eyes, and other physiological reactions, the former is an inner state of being, a series of self-judgments, negative self-talk, linked to a core belief (schema) of worthlessness, and concomitant maladaptive assumptions and automatic thoughts.

From a clinical perspective, this schema of shame is the source of numerous negative patterns of thought, emotion, and behavior, including poor self-esteem, self-sabotage, and over-apologizing.  Shame is a state of mind that may not be easily identified by the client, but will manifest in behavioral or physical form.  The client only knows, “I’m no good,” “I’ve always been bad,” “I’m not worth saving,” “I can’t be helped.”  Such statements are sure-fire indications of a state of shame.

By way of example, my client, Ronnie, a businesswoman in her mid-40s with a history of sexual trauma and poor interpersonal boundaries, stated upset at friends who had overstayed their welcome in her home.

“I was very angry at them.”
“Did you tell them to go?”
“Not really.”
“Eventually they left.”
“They did, and I was angry at them and…” (a pause)
“Yourself?”
(a nod)  “Myself, too.”

Exploring her thoughts and behaviors, I arrived at the conclusion that this negative pattern of caretaking rested on a foundation of worthlessness.  Ronnie felt that she had no rights and/or that her rights were secondary to the desires of others.  She was able to recognize her rage, but lacked awareness of the shame underlying and fueling the anger.
Ronnie, like many clients, was able to connect with a readily accessible emotion (anger), but unable to see its connection to shame.

How can shame be diminished?

Shame can be lessened through revelation.  The shame-based client hides.  He fears exposure.  His negative patterns of thought, emotion and behavior are designed to disguise his deep feelings of shame, which must be brought into the light.

Shame can also be lessened through alteration, which connotes a shift in self-perception.  To build a client’s self-esteem, the clinician must help alter the client’s negative self-image.  This can be done by addressing specific patterns of behavior – manifestations of the deep, core shame – or by tackling the shame directly.

Attacking shame-related patterns:  an oblique approach

Using an oblique approach, the clinician would first note the negative patterns of thought, emotion and behavior through individual counseling and/or observation of the client in a group or milieu setting.  Patterns are revealed through speech, mannerism, and inter- personal interaction, as well as writings, drawings, dreams, and other expressions of the self.

Let’s look at Scott, a middle-aged client with an easygoing manner, who demonstrates people-pleasing behavior in a dual diagnosis treatment center setting.  He is always the first to group, has words of encouragement for his peers, and confesses that while he thinks highly of others, he does not think so well of himself.  When questioned further, Scott gives a nervous smile, and tentatively states, “I never feel like I mean very much, you know?”

Rather than dealing with the shame directly, the clinician can address the people-pleasing behavior and its unstated message:  “I will be pleasant and prizing to you so that you won’t attack me, revealing my hidden, horrible self to the world.”

This can be done using any number of modalities, e.g., brief psychodynamic, objection relations, cognitive-behavioral, etc.  One could, for instance, utilize REBT techniques to look at the behaviors and consequences around a specific shameful incident, and dispute the client’s irrational thoughts surrounding that incident.  A brief psychodynamic psychotherapy approach in a 30-90 day, residential treatment center setting could also be fruitful.

In a similar vein, the Pointing Out Patterns® approach (Kadish, 2008) would help the client to recognize his people-pleasing thoughts and behaviors, and diminish these by having him refrain from “cheerleading” while simultaneously being more truthful with others.  Treatment center staff would, in turn, increase positive behaviors through verbal reinforcement, e.g., “Good job, Scott.”

Attacking shame-related patterns:  a direct approach

To redeem oneself – to once again deem ourselves important and worthwhile – is a liberating experience.  We were not born “less than,” but instead developed a negative self-image in response to particular life events, coupled with the influential words and actions of authority figures.  It is the clinician’s task in working with the shame-based client to help him reclaim his birthright of wholeness and completeness.

To cite a popular example, in the movie, “Rocky,” the title character redeems himself by going all the way in the title fight.  Rocky’s battle with Apollo Creed is a powerful personal metaphor for fighting back in life.  He does not have to win to feel worthwhile, but must fight with all his strength and heart, proving to himself that he is a man of substance and character, and not a loser.  The shame-based client can redeem himself, too, with the assistance of the clinician, who takes a direct and straightforward approach to the client’s shame.

Having the client stand in front of a group of peers and share an intimate thought or feeling, or even stand quietly and merely allow others to look at him, is a simple and powerful technique to break shame.  The client will want to defend against feelings of exposure and vulnerability.  Standing and holding will surface these feelings, and allow a working-through.  (Note that this should only be done with the client’s cooperation, otherwise the client may feel shamed into doing it.  This would be contradictory to the purpose of the exercise.)

The clinician, working with the client’s resistance, may also pull the client into a spontaneous public performance, e.g., singing, dancing, clowning that will further diminish feelings of shame and anxiety at being looked at and judged.  The client might be encouraged to diminish shame by acting silly in a public setting, sharing from the heart at a 12 step meeting, or telling a close friend or family member his true thoughts and feelings.

Assisting the client in developing a list of strengths and weaknesses is another direct method of attacking shame and increasing self-esteem.  If the client cannot do this, ask for a list of his likes and dislikes.  A client may be unable or unwilling to describe himself, but can usually express mild opinions:  “I like mustard, I like football, I like summer.  I do not like ketchup, hockey, and winter.”  A list of simple likes and dislikes is often an entryway into a list of strengths and weaknesses.

Ideally, the clinician will provide a direct and honest appraisal of the client.  In addition, the client can ask peers or family members for an assessment of strengths and weaknesses (assuming the clinician believes the client has the ego strength and insight to tolerate the results of this inquiry).

The shame-based client may insist that others tell him only his weaknesses which will, of course, perpetuate the negative self-image.  Conversely, only praise for the shame-based client may inflate the ego, exacerbating narcissism and entitlement.  A balanced view of the self must be given.  Shame is best combated through honest appraisal, and not self-reproach or grandiosity.

The client next acknowledges these strengths.  If he cannot tolerate hearing positive feedback, the focus must shift to helping the client accept such compassionate and truthful feedback from others.  It is imperative that this feedback be sincere; insincere compliments will only erode the client’s faith in the other person’s truthfulness and credibility, and quickly damage the relationship.

The shame-based client will often ignore or minimize the positive words.  The clinician might counteract such avoidance with a bit of humorous coaching to the client:  “There is only one right response to a compliment – thank you!”

Through revelation and alteration, the client begins to see himself in a different light and is able to accept positive aspects of his personality.  He gains a sense of hope and possibility.  The shame-based client has been mired in lifelong negativity.  He may now be able to say, “I’m no good sometimes,” or “I’m OK, but some parts of me need work” rather than “I am no good at all.”

Bibliography

Cognitive Therapy: 100 Key Points. Neenan & Dryden.  Brunner-Routledge (2004).

Healing the Shame That Binds You. Bradshaw.  HCI (1988).

Shame and the Adolescent. Ten Eyck.  Corrections Today, Vol. 65, July 2003.

Shame on You: An Analysis of Modern Shame Punishment as an Alternative to Incarceration. Book.  William and Mary Law Review, Vol. 40, 1999

Shame: Theory, Therapy, Theology. Pattison.  Cambridge University Press (2000).

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

• To understand the nature and effects of shame on the dual diagnosis client.
• To recognize the depth and impact of shame on the dual diagnosis client.
• To learn ways to diminish shame, e.g. through revelation and alteration.

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.