Marianne T. Marcus, EdD, RN, FAAN Deidra D.

Carroll, BS

 Define Discus

mindfulness

utility of mindfulness for substance use disorder treatment the congruence between mindfulnessbased stress reduction and therapeutic community philosophy methods for integrating mindfulness in therapeutic community treatment

Identify

Describe

TCs are highly structured behavior modification environments TCs play an important role in substance abuse treatment but dropout rate is high, particularly in the first 3 months Successful outcomes for TCs are associated with time in treatment Stress may mediate progress and retention in TC treatment

 Mechanism

underlying association not fully

understood
Stress

is associated with initiation of substance

use
Stress

linked to increased drug-taking and relapse

Individuals

in recovery can benefit from acquisition of stress management skills

 No

empirical data on stress and coping with TC treatment with the exception of our work of similar restrictive environments, jails, prisons, and military training identify stress and associated stimuli

Studies

Stimuli

novelty, predictability, controllability, anticipation of negative consequences and egoinvolvement.

 An

approach to life based on Zen traditions

particular way of paying attention to the present moment non-judging awareness

Moment-to-moment, Wakefulness

 Waking

up to living the process of thinking

Befriending Knowing Knowing

a thought as a thought

an emotion as an emotion

 We

have a tendency to operate on automatic pilot, not just a Buddhist observation Duffy lived a short distance from his body. - James Joyces Dubliners of mans difficulties are caused by his inability to sit quietly in a room by himself. Pascal

Mr.

All

A Theory A shift in perspective..

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

(Shapiro, Carlson, Astin, Freedman)

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

 Sitting Body

Scan

Walking Hatha Yoga Mindful

Movement

 At

the heart of cultivating mindfulness in daily living intentional cultivation of presentmoment, non-judgmental awareness

Systematic,

Not

a relaxation technique but a way of being present, insightful, discerning

 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 without judgment, then gently escort the mind back to the breath

Guided Practice

 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)

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)

Substance use a false refuge (Marlatt, 2002) Experiential avoidance unwillingness 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 and experiences

 Two

issues of Substance Abuse dedicated to MBSR review

Zgierska

 Operationally

define and standardize principles and techniques of MBSR test and refine MBSR in TC treatment

Pilot
Test

hypotheses of mediators and mechanisms of change using historical control methodology

Defining the population

Identifying indicators of behavioral change Standardizing the intervention Aligning the intervention with the substance abuse treatment methodology Creating the manual Training the therapists/teachers Developing a treatment integrity/fidelity plan

Cenikor

Foundation Houston, Tx TC method

Standard

Usual

course of recovery is 18 months

Baseline

1 Mos

3 Mos

6 Mos

9 Mos

Salivary Cortisol SOSI Symptoms of Stress Inventory Focus groups (on completion)

Cortisol

Cortisol Cortisol Cortisol Cortisol

SOSI

SOSI

SOSI

SOSI

SOSI

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 schedule 6 longer sessions
Shorter meditations eyes open Mindful movement in every session

MINDFULNESS THEME Reducing the tendency to operate on automatic pilot, becoming awake

THERAPEUTIC COMMUNITY

CONCEPT
Right living is being in the personal present, the here and now To be awake is to be alive

The universality of the wandering

Keep it simple or focusing on one

mind, how thoughts influence

experience, sense of community Bringing awareness to the sense of wonder developed through being present to our experience

thing at a time. Letting go

Community as method You get back what you put in or focusing on participating fully in the therapeutic community

MINDFULNESS THEME

THERAPEUTIC COMMUNITY CONCEPT Remember who you are or remembering

Noticing how the body responds to stress, how

thoughts affect stress reactions and behaviors,

and how to handle stress

the basic goodness and potential of ones

inner self in coping with stresses

Befriending ones emotions and handling them in Its better to understand than to be a different way, acceptance understood or learning by listening and accepting others

Emphasizing the importance of

taking responsibility for ones own mindfulness practice

No gain without pain or anything worth

having is worth working for

DeLeon, 2000

Mindfulness-Based Stress Reduction in Therapeutic Community Treatment

The aim of the study was to determine the effect of a Mindfulness-Based Stress Reduction (MBSR) intervention on the psychological and physiological stress responses of individuals in an 18 month TC.

 Self-report

demographic form Symptoms of Stress Inventory (SOSI) 94-item self-report instrument, alpha = .98 10 subscales, alpha = .77-.92 Measures physical, psychological, and behavioral responses to stress Awakening Salivary Cortisol Samples taken at 0, 15, 30, and 45 minutes

HC n = 164 76.2 Male 23.8 Female 57.3

MBSR n = 295 85.8 14.2 53.6 29.8 16.6 34.3

White
29.9 Black 12.2 Hispanic and other 36.2

Age in years*

* Age in years reported as mean

HC n= 164 Education: HS or more Criminal justice referral Cocaine* Marijuana* Alcohol* Prior drug treatment 74.6 27.5 33.3 21.0 21.0 71.7

MBSR n = 295 75.3 28.0 33.7 25.8 17.2 69.3

* Primary drug of abuse

 Total

SOSI scores decreased significantly over time for both groups, p=.01 Lower scores in MBSR group at 3 months tension and emotional irritability subscales showed greater improvement over time for the MBSR group with greater differences at 3 months

Muscle

High SOSI total mean and muscle tension subscale at baseline were associated with increased likelihood of drop out (p<.03, <.02 respectively)

 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 intervention subjects (p=<.01).

 Participation

level was based on calculation of product of number of class hours (0-17) multiplied by level engagement. (Range 1 to 85) in participation level was associated with decrease in likelihood of dropout (hazard ratio = .975, p < .01).

Increase

Focus Group Evaluation of Mindfulness-Based Stress Reduction

The purpose of this qualitative analysis of focus group discussion was to determine how TC residents describe MBSRs contribution to the recovery experience using previously analyzed stories of stress to formulate discussion group questions.

 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?

Focus groups
study by two researchers (P. L., B. L) who had no previous contact with participants

Conducted about 1 year after closing admission to

23

Participants

Completed intervention Different phases of the program Approaching graduation 1 yr into the treatment program Re-admits to treatment program

Changing Attitudes and Perceptions

Heightening Sense of Awareness

Increasing Emotional Control

Recognizing Breath as an Ally

Outcomes
Increased Physical Relaxation Renewed Energy Inner Peace

Stress class helps you focus on you, and whats going on with you, and your body. It gave me different ways of looking at different situations, 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.

I find myself, like when someone creates some feelings in me like a verbal 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.

I use the breathingit all plays a part in bringing you back to the moment and you focus on whats going on.trying to get myself together, in a nutshell, going over not getting excited and breathing. a lot of times after taking the class, Id think about the breathing like whenever I just got irritated or something, Id just focus on my breathing and it would kinda relax me and put me out of that state of mind. I dont really picture the stop, take a breath, observe, and proceed. I justits just kinda in me now from taking the class.

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.

 According

to TC residents, MBSR facilitates selfchange in the areas of emotional control, sense of awareness, and breath as an ally

This

self-change leads to increased relaxation, renewed energy, and inner peace

residents attribute self-change to an internalization of MBSR concepts and techniques

TC

Final Conclusions

 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.
is possible the MBSR attenuates physiological stress reactivity but this demands further investigation

It

SOSI was the most sensitive self-report measure for capturing change in stress related to an MBSR intervention SOSI was strongly correlated with salivary cortisol (p<.01) Salivary cortisol was time intensive and incurred subject burden Participant voice provides a unique perspective that must be considered to fully understand the impact of the intervention Further research which fully integrates MBSR into TC environment is warranted

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 been possible.