Mindfulnesmindfulnesss in Tc Treatment Presentation

8/12/2019 Mindfulnesmindfulnesss in Tc Treatment Presentation

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Marianne T. Marcus, EdD, RN, FAAN

Deidra D. Carroll, BS


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Define mindfulness

Discus utility of mindfulness for substance use

disorder treatment

Identify the congruence between mindfulness-

based stress reduction and therapeutic

community philosophy

Describe methods for integrating mindfulness in

therapeutic community treatment


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TCs are highly structured behavior modification

environments

TCs play an important role in substance abusetreatment but dropout rate is high, particularly in the

first 3 months

Successful outcomes for TCs are associated with timein treatment

Stress may mediate progress and retention in TC

treatment


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No empirical data on stress and coping with TC

treatment with the exception of our work

Studies of similar restrictive environments, jails,

prisons, and military training identify stress and

associated stimuli

Stimulinovelty, predictability, controllability,

anticipation of negative consequences and ego-

involvement.


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An approach to life based on Zen traditions

A particular way of paying attention to the presentmoment

Moment-to-moment, non-judging awareness

Wakefulness


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Waking up to living

Befriending the process of thinking

Knowing a thought as a thought

Knowing an emotion as an emotion


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A TheoryA shift in perspective..

Re-perceiving Self regulation Values clarification Cognitive, emotional, behavioral flexibility

Exposure

(Shapiro, Carlson, Astin, Freedman)


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Developed by Jon Kabat-Zinn

Eight-week program, 2 1/2 hours a week

Includes eating meditation, the body scan, awareness of

breathing, mindful Hatha yoga and walking meditation

Daily meditation practice, workbook

Used as adjunct to treatment in a wide range of chronic

illnesses


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At the heart of cultivating mindfulness in daily

living

Systematic, intentional cultivation of present-

moment, non-judgmental awareness

Not a relaxation technique but a way of beingpresent, insightful, discerning


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Follow the breath, feel it in the nostrils, the

belly

Experience the silence underneath the rhythmic

movements of the breath

If something comes up, notice it withoutjudgment, then gently escort the mind back to

the breath


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Guided Practice


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Chronic pain (Kabat-Zinn) Depression (Segal) Fibromyaligia (Kaplan) Anxiety (Kabat-Zinn) Binge eating (Kristeller) Substance use disorders (Marcus)Non-clinical populations (Astin, Shapiro) Change in Brain & Immune Function (Davidson)


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Mindfulness-Based Cognitive Therapy: for depression (Segal,

Williams, Teasdale, 2002)

Dialectical Behavior Therapy: emphasizes balance integration, or

synthesis of opposing ideas (Linehan, 1993)

Acceptance and Commitment Therapy: experiential avoidance is

central theme (Hayes et al, 1999)

Mindfulness-Based Relapse Prevention: urge surfing (Marlatt)

Mindfulness-Based Therapeutic Community (Marcus, 2009)


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Substance use a false refuge (Marlatt, 2002)

Experiential avoidanceunwillingness to remain in

contact with ones experience (Hayes et al, 1999)

Mindfulness opposes escape and experiential avoidance

(Simpson et al, 2007).

Mindfulness involves accepting thoughts andexperiences


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Two issues of Substance Abuse dedicated to

MBSR

Zgierska review


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Operationally define and standardize principles

and techniques of MBSR

Pilot test and refine MBSR in TC treatment

Test hypotheses of mediators and mechanisms

of change using historical control methodology


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Defining the population

Identifying indicators of behavioral change

Standardizing the intervention

Aligning the intervention with the substance abusetreatment methodology

Creating the manual Training the therapists/teachers

Developing a treatment integrity/fidelity plan


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Cenikor FoundationHouston, Tx

Standard TC method

Usual course of recovery is 18 months


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Baseline 1 Mos 3 Mos 6 Mos 9 Mos

Cortisol Cortisol Cortisol Cortisol Cortisol

SOSI SOSI SOSI SOSI SOSI

Salivary Cortisol

SOSISymptoms ofStress Inventory

Focus groups (on

completion)


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Adapted MBSR 8-Week Program

Added exercises from MBCT

Thoughts and Feelings Exercise Adapted Moods and Thoughts/Alternative Viewpoints Exercise

Seeing/Hearing Meditations

Modified MBSR to adapt to population and environment

Modified to adapt to TC schedule6 longer sessions

Shorter meditationseyes open

Mindful movement in every session


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MINDFULNESS THEME THERAPEUTIC COMMUNITY

CONCEPT

Reducing the tendency to operate

on automatic pilot, becoming awake

Right living is being in the personal

present,the here and now To be

awake is to be alive

The universality of the wandering

mind, how thoughts influence

experience, sense of community

Keep it simple or focusing on one

thing at a time. Letting go

Community as method

Bringing awareness to the sense

of wonder developed through being

present to our experience

You get back what you put in or

focusingon participating fully in the

therapeutic community


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MINDFULNESS THEME THERAPEUTIC COMMUNITY

CONCEPT

Noticing how the body respondsto stress, how

thoughts affectstress reactions and behaviors,

and how to handle stress

Remember who you are or remembering

the basic goodness and potential ofones

inner self in coping with stresses

Befriending ones emotions andhandling them in

a differentway, acceptance

Its better to understand than to be

understood or learning by listening and

accepting others

Emphasizing the importance of

taking responsibility for onesown mindfulness

practice

No gain without pain or anything worth

having is worth working for

DeLeon, 2000


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Mindfulness-Based Stress

Reduction in Therapeutic CommunityTreatment


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The aim of the study was to determine the

effect of a Mindfulness-Based StressReduction (MBSR) intervention on the

psychological and physiological stress

responses of individuals in an 18 month TC.


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HC MBSR

n = 164 n = 295

Male

76.2 85.8

Female

23.8 14.2

White

57.3 53.6

Black

29.9 29.8

Hispanic and other

12.2 16.6

Age in years*

36.2 34.3

* Age in years reported as mean


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HC MBSR

n= 164 n = 295

Education: HS or more 74.6 75.3

Criminal justice referral 27.5 28.0Cocaine* 33.3 33.7

Marijuana* 21.0 25.8

Alcohol* 21.0 17.2

Prior drug treatment 71.7 69.3

* Primary drug of abuse


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Total SOSI scores decreased significantly over

time for both groups, p=.01

Lower scores in MBSR group at 3 months

Muscle tension and emotional irritability subscales

showed greater improvement over time for the

MBSR group with greater differences at 3 months


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High SOSI total mean and muscle tension

subscale at baseline were associated withincreased likelihood of drop out (p


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Two groups had different trends over time (p = .03)

Historical controls showed an irregular pattern of

change MBSR group exhibited a steady decline

Overall the historical control subjects tended to

have higher cortisol values than the interventionsubjects (p=


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Participation level was based on calculation

of product of number of class hours (0-17)

multiplied by level engagement. (Range 1 to

85)

Increase in participation level was

associated with decrease in likelihood ofdropout (hazard ratio = .975, p < .01).


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Focus Group Evaluation of

Mindfulness-Based Stress Reduction


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Utility

How do the stress class tools affect your thoughts,

feelings, and bodily sensations?

Portability

What lessons from the stress class do you use to deal

with difficult situations?

Sustainability How will you use the stress class techniques to achieve

your goals once you leave the TC?


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2 Focus groupsConducted about 1 year after closing admission to

study by two researchers (P. L., B. L) who had no

previous contact with participants

23 ParticipantsCompleted intervention

Different phases of the program Approaching graduation

1 yr into the treatment program

Re-admits to treatment program


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Stress class helps you focus on you, and whats

going on with you, and your body.

It gave me different ways of looking at differentsituations, how to stop and take some time to think

about it, and process it, and then move forward with

it.

I begin to reintegrate with society, start making better

decisions, start sharing better, start participating better

and that out there is where its gonna happennot in

here.


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I find myself, like when someone creates some feelings in me like averbal confrontation or something, because you know Im emotional

and I wanna react to them, I find myself way more than I did before I

came to this program and I practice these techniquestaking that deep

breath

It has helped me out a lot because I dont get to where I use to. I dont

take myself over that level, when I feel the anger surfacing, when I feel

the frustration surfacing, the stress and stuff. I dont go where I went

before.

Especially with the addictions that we have where we had to have

two or three different types of treatmentsto find something that

clicking for youactually changingsomething thats mindful,

something that making me more aware of whats going on around me

and in my body and making me think before I act and speak.


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Increased physical relaxation:

I just felt relaxed [at the end of class], just peace of

mind instead of walking around tense and tight.

Renewed energy: It seemed like you were calm and relaxed during the

class, but then when you leave the class, your energy is

up.

Inner peace:

It was another avenue versus the one I was doing

before I came in here [using drugs], to find quietness or

an inner peace.


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Final Conclusions


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MBSR intervention appears to facilitate

improvement of stress responses as long as TC

residents are participating in intervention.

Gradual decrease in MBSR psychological effects

after intervention ends, which suggests a need for

continuing intervention throughout treatment.

It is possible the MBSR attenuates physiological

stress reactivity but this demands further

investigation


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This study was supported by National Institute on Drug

Abuse grant DA RO1 DA017719 to Dr. Marianne T

Marcus. The authors are grateful to the administration,

staff, and clients of the Houston facility of Cenikor

Foundation for their participation. They also thank the

dedicated MBSR instructors, Michele Fine, Linda Safranak,

Susan Wolfe, and Patricia Palmer, without whose

commitment and assistance the study would not have beenpossible.


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Mindfulnesmindfulnesss in Tc Treatment Presentation