Integration of Mindfullness-Based Cognitive Therapy into the Therapeutic Community: Implications for Trauma Treatment Part 2

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 Teaching and Therapeutic Community in March, 2008. Rod Mullen, President and CEO of Amity Foundation, and Mary Stanton, Senior Counselor and Trainer with Amity Foundation, are the presenters and authors of this work. Always interested in current academic literature, we were drawn to topics concerning neuroplasticity of the adult brain, and the capacity of the brain to develop new neuronal/synaptic interconnections and thereby develop new functions and roles (Begley, 2007). We were intrigued by newly discovered principles which are at the heart of some revolutionary work in the therapy of adult sufferers of a variety of physical and psychological disorders. However, this 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 first introduced the concepts and practice of Mindfulness-based meditation to the entire community during a week-long workshop in March 2008. This general orientation included a description of 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). Each day of the workshop began with a guided meditation. Periods of silence and “mindful walking” were also included. Throughout the workshop, participants first experienced mindfulness practices, and then the concept was presented in a seminar format. 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. 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, particularly other non-participating TC residents.

Selection of MBCT Course Participants:

Upon completion of the orientation, intent forms are distributed to all members of the TC. 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 eight month period from April - November, 2008, we completed five MBCT courses at Amity’s Circle Tree Ranch. There were a total of sixty participants in these courses. Fifty-six completed the course, three dropped out, and one 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 62% Caucasian, 30% Native American, and 8% Hispanic. With one course composed entirely of women, there were a larger percentage of female participants (58%) than male participants (42%).

When we began our initial course in April we followed the curriculum content as outlined, with the only modification 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. 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, and an attitude of “turning toward” rather than “turning away from” emotionally charged memories. This correlates with the goals and objectives of the Extensions Curriculum authored by Naya Arbiter and Fernando Mendez. This curriculum, utilized by Amity Foundation, 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 to us in the TC 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.

Assessment:

When we initiated this project we hypothesized that integrating Mindfulness-based practices in the Therapeutic Community setting would facilitate physical, emotional, and spiritual healing as individuals develop the ability to dwell within and resolve internal conflicts. 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 describing their experiences and reactions to the Mindfulness-based practices presented. We chose to assess participants subjective experience immediately following the course to increase the reliability of responses. Participants were asked to rate how relevant the course was to their personal process of recovery within the TC. The mean rating (max=10) was 8.26. This high degree of relevance was also reflected in the low dropout rate (4 out of 60).

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.