Hybrid Vigor: Integration of Mindfulness Based Cognitive Therapy (MBCT) into the Therapeutic Community Part 1

Introduction

The impetus for the groundbreaking implementation of Mindfulness-Based Cognitive Therapy (MBCT) into the Therapeutic Community (TC) setting came from Amity Foundation’s interest in providing innovative therapies which help to unravel the complex knots that addictions and co-occurring disorders create. 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 the treatment of individuals who have experienced traumatic events and are exhibiting post-traumatic stress disorder and/or related correlates of past trauma (Follette, et al., 2006). The interconnectedness that occurs among untreated trauma, depression, addiction, and relapse patterns has become increasingly apparent as a growing number of individuals with co-occurring disorders enroll in our communities. An integrative approach is necessary to unravel the complex knots that addictions and trauma create, incorporating new and innovative theories and therapeutic practices such as MBCT into the TC.

The evolutionary process of the TC allows for modifications which are crucial to improving the lives of people within continually changing populations. In order to facilitate an individual’s process of change from addiction and alienation to sobriety and wholeness, Amity incorporates a culturally responsive, holistic approach to rehabilitation. We have found that MBCT allows for flexible treatment goals with dual diagnosed individuals and is adaptable to varying lengths of stay in treatment. The “portability” of these practices provides individuals with skills that may be used long after their enrollment in the TC.

As practitioners of the Therapeutic Community (TC) 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 communities. As we are confronted with the challenge of shorter periods of enrollment, the introduction of strategies that allow individuals to be more fully present during the TC process has vast implications. Training in mindfulness helps individuals develop the skill to “turn toward” rather than “turn away from” emotional or physical pain, trauma, or other areas of difficulty (Kabat-Zinn, 1990). 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.

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). 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. An important component is the practice of self-compassion, self-acceptance, openness to experience, and increased present moment awareness. Several aspects of cognitive therapy are integrated into mindfulness practices to target automatic, depression-linked thought patterns that lead to rumination and may trigger relapse. Examples include the identification of individual “relapse signatures” and encouraging the development of self-care strategies for use when relapse threatens (Segal et al., 2002).

In the field of substance abuse treatment, many studies demonstrate the effectiveness of cognitive-behavioral therapy (CBT) for a variety of addictive disorders across diverse populations (McCrady, 2001). Additionally, there has been a resurgence of interest in incorporating meditation practices in the treatment of addictions. However, this is not a new concept. Practitioners of transcendental meditation (TM) techniques began to study meditation as an intervention for substance abuse in the early 1970’s (Marcus, 1974). Marlatt and colleagues (1984) studied the effectiveness of relaxation techniques (TM, deep muscle relaxation, and daily quiet recreation reading), among high-risk drinkers. In recent years, neurobiological findings support the hypothesis that mindful awareness 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). An extensive literature review conducted by the authors revealed a vast array of applications of mindfulness-based meditation practices. However, we found no reference to the use of MBCT as an intervention for whole person recovery in long term residential Therapeutic Community settings. In addition to its effectiveness in relapse prevention, we propose that Mindfulness-based meditation practices have great potential for personal growth and healing in substance abuse treatment and treatment for persons with co-occurring disorders within the TC setting.

Mindfulness is simple to understand, but challenging to practice. It 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). It focuses on the deep interconnection between mind and body, which can be experienced through disciplined attention to the physical sensations that form the life of the body. It is this observation-based, self-exploratory journey that offers a means to examine the totality of one's being; physical, emotional, intellectual, and spiritual. The goal is not to change the content of thoughts, as in traditional cognitive therapy, but to develop a different, nonjudgmental attitude to thoughts, feelings, and sensations as they occur (Teasdale, Segal, & Williams, 1995). MBCT courses teach mindfulness through objective, detached self-observation without reaction. This absence of reaction allows acceptance of thoughts, feelings, and sensations as independent, impermanent events and not necessarily requiring direct action (Segal, Williams, & Teasdale, 2002).

In contrast to many schools of psychotherapy, and 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. This perspective relates to the concept of “rehabilitation” which is generally thought to mean a process of learning to do again what we were able to do in the past. However, when we examine the word rehabilitation, the root words “habilitate” and “habitat” and the French word “habiter” which means “to inhabit” or “to dwell inside” are revealed (Meili & Kabat-Zinn, 2004). From this perspective, the concept of rehabilitation is expanded to include the ability to live inside once again. For individuals seeking physical, emotional, and spiritual healing in a residential TC setting, the practice of mindfulness meditation facilitates their ability to dwell within and resolve internal conflicts. It is through the process of being fully present that we discover healing.