Hybrid Vigor: Integration of Mindfulness Based Cognitive Therapy (MBCT) into the Therapeutic Community Part 3

Method

Orientation:

One week prior to beginning each course, an overview of the MBCT course is presented during a Community Gathering. This provides an opportunity to explain the practice of mindfulness and to emphasize that participation in the course requires commitment and hard work. Core concepts including concentration, being in the moment, de-centering,acceptance/non-aversion, “being rather than doing”, and Mindfulness of thoughts, emotions/feelings, body sensations are outlined and potential benefits of participation in the course are discussed. Following the completion of our first MBCT course we added to the orientation by asking “graduates” to describe what they learned and share their experiences with the Community.

Selection of MBCT Course Participants:

Upon completion of the orientation, Intent Forms are distributed to all members of the Community. Every student is asked to complete a form, whether they are interested in participation or not. Our goal is to elicit from the students a description of their experience with meditation, their attitude toward meditation, their willingness and commitment to fully participate in the course and how they hope to benefit, or their reasons for not wanting to participate. 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.

Design/Adaptations:

The course theme and curriculum, including exercises and handouts, are based upon the work of Zindel Segal and colleagues’ Mindfulness Based Cognitive Therapy for Depression (2002). The course as outlined is intended for outpatient settings which allow for one session per week for 8 weeks (2 hour sessions each day for a total of 16 contact hours). While maintaining fidelity to the content and core aims of this model, we modified the session schedule to accommodate participants in a residential TC setting. Our rationale included a need to deliver the material over a shorter period of time, allowing participants to complete the course and develop a personal practice while in residence at Circle Tree Ranch. This schedule also provides more students the opportunity to participate in the course during their enrollment with the goal of creating a “culture of mindfulness” within our Community. In a residential setting, longer sessions are possible which create opportunities for additional mindfulness exercises such as eating meals in silence, incorporating mindful movement/yoga each day, and providing additional process time following guided meditations and for daily practice review. It is also possible to provide opportunities for the practice of mindfulness meditation skills in a variety of settings.

Our course design includes delivery of the 8 session content in 5 days (three 6 hour days including lunch, two 3 1/2 hour days for a total of 25 contact hours) spanning a period of 2 ½ weeks. Following the curriculum developed by Segal and colleagues (2002), participants engage in a variety of mindfulness practices including formal periods of guided meditation and informal mindfulness of everyday activities. Participants were provided with handouts at the end of each session for reflection and reinforcement of the core skills presented that day, and homework was assigned for the next session.

Interventions:

During the ten-month period from April 2008 – February 2009, we completed seven MBCT courses at Circle Tree Ranch. There were a total of eighty-six participants in these courses. Eighty-one completed the course, three dropped out, and two left treatment early due to a family emergency. Ages of participants ranged from 19 to 57 with a mean age of 33.5. The ethnic diversity of our Community was reflected among course participants with 60% Caucasian, 31% Native American, and 9% Hispanic. With one course composed entirely of women, there were a larger percentage of female participants (57%) than male participants (43%).

When we began our initial course in April we followed the curriculum content as outlined, with the only adaptation being the schedule modifications as described above. We soon discovered that participants’ different past experiences and personal stories resulted in a variety of responses to class exercises. A rich diversity of cultural practices, a broad spectrum of socioeconomic backgrounds, and a wide variety of belief systems, cultural norms and values are woven into the demographic makeup of Amity’s Circle Tree Ranch Community. Despite these apparent differences, the vast majority of individuals 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. Relapse into chemical dependency and other addictive or self-destructive behaviors are often related to overwhelming experiences of exposure to abusive power, physical and sexual abuse, disabling losses and disrupted attachment, usually beginning in childhood. It became evident very quickly that mindfulness meditation practices provided an effective means to surface and address these issues with an attitude of compassion toward oneself, acceptance, and non-aversion to one’s experiences. This correlates with the goals and objectives of the Extensions Curriculum authored by Naya Arbiter and Fernando Mendez utilized by Amity Foundation which helps individuals to explore all realities, causes, and contributing factors which result in chemical dependency and addiction (http://www.extensionsllc.com). Mindfulness-based meditation practices reinforce the intent of the Extensions Curriculum to help individuals accept and reconcile the reality of their life experiences. Therefore, following our initial course we choose to supplement the MBCT curriculum with additional activities and group experiences available in the Therapeutic Community setting.

Examples of supplementary interventions are as follows:

Course #2:

• Class was composed entirely of women.
• During the Body Scan meditation, body memories related to past traumas were being experienced by several of the participants.
• The women were startled to discover the intensity with which their body had stored these memories.
• We chose to include a “talking circle” to provide the women with a group to articulate their experiences to a greater extent than possible within the confines of the class structure.
• The women discovered they had developed similar coping mechanisms to disengage from trauma.
• We provided a luncheon for the women on the last day of the class to facilitate the development of trusting relationships, and to encourage the integration of their experiences into daily treatment activities in the TC.

Course #3:

• Class was composed of men and women, the majority were under 30 (average age 26.5).
• In addition to substance use and other co-occurring issues that brought these individuals to Amity’s Circle Tree Ranch, more than half (58%) of these young adults had been diagnosed with attention deficit disorder earlier in their lives.
• Many found the practices of mindful movement and mindful walking to be effective in facilitating the meditative process.
• These participants also responded to the seeing/hearing meditations, finding the focusing of attention in this way helped them connect to their present experience.
• A talking circle was included to address the restlessness and frustration experienced by participants, to articulate their experiences in greater detail, identify similarities, and find support.
• Another effective intervention was taking the class hiking, giving them the opportunity to practice mindful walking, hearing, and seeing in an outdoor setting.

Course #4:

• Class included an even number of seven men and seven women. Of the fourteen participants, six were Native American.
• Several of the participants regularly attend the Sweat Lodge2 provided at Circle Tree Ranch and shared how they incorporated some of the mindfulness meditation techniques during Lodge.
• We provided the opportunity for a special Sweat Lodge for the participants in this class which proved to be a profound experience.
• We concluded with a day in the nearby mountains with two guided meditations and mindful walking.

Course #5:

• Class included eight men and five women (the first course with a majority of men). In addition to substance use, all participants had co-occurring issues including depression, anxiety disorders, and post-traumatic stress disorder. At the time of the course, all participants were taking medications prescribed for these disorders.
• Six of the thirteen participants reported difficulty managing anger. Additionally, there were conflicts between some of the participants when the course began.
• This heterogeneous group included such extremes in personality that we had doubts that the course would be successful.
• To improve attendance and completion of homework, we assigned participants to take responsibility for motivating one another between classes
• Participants used encounter groups outside of the class structure to help resolve conflicts3. Groups were also used to explore in greater detail grief and trauma issues that arose during the class.

Courses #6 & 7:

• The positive impact that MBCT had on the participants in our first five courses informed our decision to fully integrate Mindfulness-Based Practices at Amity’s Circle Tree Ranch.
• With this intent, Classes 6 and 7 were composed entirely of Amity Foundation staff members and apprentices. There were 25 participants: 17 women and 8 men.
• We provided the opportunity for staff members to fully experience each session, initially meeting with some resistance. However, upon completion most found the practice to be personally and professionally beneficial.
• Feedback and discussion sessions provided an opportunity to identify both opportunities and barriers as Mindfulness-Based Practices are incorporated into our community.
• We concluded with a day of reflection, including periods of silence, guided meditations, and mindful walking in a nearby park.

Assessment:

In order to illustrate the initial responses of individuals in Amity’s MBCT course and to provide a qualitative assessment of the relevance and effectiveness of this intervention, three summaries are presented. These summaries provide a snapshot of the broad diversity of our Community as well as highlighting the similarities of individual experiences.

“Sam”. Sam is a 54 year old White Mountain Apache. Four years ago Sam made the decision to die. He states, “I didn’t have the courage to kill myself by other methods, so I decided to drink myself to death”. His alcoholism and depression had driven him to the point of abandoning his wife and three children and returning to the northern Arizona Reservation where he grew up. When sober, Sam felt he was a broken shell of a man and turned his anger on himself. When drunk, Sam became aggressive and violent and was arrested on several occasions for DUI’s, disorderly conduct, and assault. Sam came close to death one night when he was intoxicated and unconscious in a gutter, run over by a truck, and left for dead. Someone passing by discovered Sam in this condition and called for help. With multiple broken bones and head trauma, Sam was in a coma for three weeks and hospitalized for several months going through exhausting and painful rehabilitation. However, this experience was not enough for Sam to change his self-destructive behaviors. Severely depressed and in chronic pain, he continued his pattern of drinking and incarceration. Over the next three years Sam was sent to a variety of outpatient and inpatient treatment programs, but failed to maintain sobriety. Finally, with the guidance of a case worker from his Reservation, Sam acknowledged he needed long term residential treatment and enrolled at Amity’s Circle Tree Ranch.

As a new student, Sam was introduced to Mindfulness-based meditation during a workshop. He expressed his interest in participating in the course was “none”. Over the next two months Sam observed others who were enrolled in MBCT and became curious. He asked to be included stating, “I want to learn as much as I can about Mindfulness meditation and how I can use it for my wellness in sobriety.” His hope was to “gain some peace and serenity”. On the first day of the course Sam described his experience of the Body Scan by focusing on every broken bone in his body, expressing the overwhelming feeling of “brokenness” that he carried into the present moment. On the second day when guided to focus on the breath, Sam described how in that moment he had the profound experience of freedom from pain. Sam diligently practiced outside of class, beautifully describing being so still that he could hear the pods falling from the mesquite trees. He combined prayer with mindful walking early each morning finding relief from emotional and physical pain. Sam also participated in the Sweat Lodge with others in the class practicing “allowing” and “letting be” while releasing self-judgment. He particularly enjoyed meditating during our outing to the mountains, feeling spiritually connected when outdoors. Following the course Sam described himself as “more hopeful” and “better able to accept things as they are”. He continues his formal practice early each morning, and uses the 3-minute breathing space throughout the day.

“Greg”. A bright, goal oriented man in his early 30’s, Greg came from a privileged background. Greg is Caucasian, the son of parents who are both successful professionals. Throughout his life he had all of his physical and material needs met. However, Greg’s emotional needs were neglected, and he experienced verbal abuse which deeply wounded him and created a very negative self-concept. Describing himself as “long on ideas but short on follow through”, Greg saw himself as a “quitter” and believed he would never measure up to his parent’s expectations. Beginning in high school, Greg began to “party”, abusing alcohol and experiencing blackouts at a very early age. He stated that he has always had an anger problem, and the combination of alcohol and anger resulted in multiple arrests during his twenties. Following a recent arrest for an aggravated DUI, Greg enrolled at Amity’s Circle Tree Ranch. Since then he has struggled with impatience and frustration, and has great difficulty connecting thoughts with feelings when responding to curriculum tasks in group settings.

As a member of the Community, Greg heard other men in his dorm discussing the MBCT course. His intent in participating was to “learn to relax when I feel overwhelmed with negative thoughts” and to “manage my anger”. Initially Greg struggled with the formal meditation practices stating, “My mind constantly wanders and I can’t stop my thoughts”. It took time and practice for Greg to realize that Mindfulness-based practices are not about “stopping” or “changing” anything. Mindfulness is simply allowing experiences to be as they are in the moment. He described experiencing a profound shift when he was able to internalize the concept that “thoughts are not facts” and allowed himself to be open and aware without judgment or self-criticism. For Greg, the most significant aspects of the course were “learning to step back, breathe, and practice allowing/letting be”. He also stated, “I became aware of how materialistic I am, and how seldom I’m fully in the present. I’m becoming more grateful, and find I’m less angry”. Although he recognizes these benefits, Greg sees “disciplining myself to do it” to be the biggest obstacle to continuing daily practice following the course. He feels the Guided Practice during Mid-day Community Gatherings will help to reinforce what he has learned before he transitions back to the larger community.

‘Ana’. Ana, age 24, grew up in a small town in southern Arizona. In describing her family, Ana speaks of generations of alcohol and drug abuse. She experienced neglect and abuse growing up in a chaotic household with two alcoholic parents. When she was 6 years old Ana began playing basketball with her cousins, and recalls spending hours each day at the community center practicing and participating in tournaments. Although basketball provided an outlet for Ana, by the age of 12 (7th grade) she was diagnosed as suffering from depression, was prescribed antidepressant medication, and began using marijuana and alcohol. Ana states that the only time she felt relief from depression and did not abuse substances was when she played basketball. As a senior in high school she was offered a full athletic scholarship. It was a devastating blow when Ana suffered two serious knee injuries later that school year and the university withdrew the scholarship offer. The injury that ended her basketball career occurred when she was intoxicated resulting in intense feelings of self-loathing, shame, and regret. Her depression and substance use escalated and she became heavily addicted to cocaine and prescription pills.

Ana’s first exposure to meditation was our introduction to Mindfulness practices during a community workshop at Amity’s Circle Tree Ranch. Although curious, she struggled with being still and focusing attention on her body. Prior to the course Ana stated, “I want to learn how to stop. I am always on the run, or moving around. When I stop, I feel anxious and depressed. I sometimes think of using. I want to learn to stop and be okay with myself.” She struggled the first two sessions, and expressed feeling “frustrated, agitated, and angry” with the process of “non-doing”. The Body Scan meditation was emotionally painful, but provided her with an opportunity to become aware and to articulate many difficult memories, thoughts, and feelings. Ana found the mindful walking the most helpful strategy for being fully in the present. During the fourth day of the course Ana described how present-moment living has helped to reduce her feelings of anger and increase acceptance and gratitude. Ana’s eyes filled with tears as she described the experience of extending compassion, kindness, and gentleness toward herself and her experiences. In her informal practice, Ana spoke of picking up a basketball and taking a few shots, something she had previously resisted, and allowing herself to be present with the full range of emotions associated with this activity. Following the course Ana expressed how she used the 3-minute breathing space several times each day as a way of centering herself when things were overwhelming. Being conscious of her present experience has helped Ana to identify and challenge negative self talk. The concept “thoughts are not facts” has helped her to shift her perspective when difficult thoughts and feelings are present. She stated, “I find I am more patient when I focus on the moment instead of future worries or past regrets”. As an apprentice at Amity’s Circle Tree Ranch, Ana’s intent is to maintain both formal and informal practices, and to support other students in the community as they participate in the MBCT course and learn these techniques.

Follow-up:

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. Additionally we have designed one-day “Mindfulness Reunions” which provide rich feedback regarding changes in mindfulness, degree of rumination, changes in ability to respond to stressful situations. Reunion days are 8 hours in length (8am – 4pm), and include practice and review of the core features of MBCT. During the day we move from indoor to outdoor settings, guiding participants through Body Scan and Sitting Meditations, Mindful Movement and Mindful Walking practices, and providing a Mindful Eating experience during lunch. Periods of interchange and review follow each practice throughout the day. This process reinforces learning and provides valuable qualitative data regarding the benefits of this course.