Integration of Mindfullness-Based Cognitive Therapy into the Therapeutic Community: Implications for Trauma Treatment Part 1

Introduction nnThe impetus for the groundbreaking implementation of Mindfulness-Based Cognitive Therapy into the Therapeutic Community 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 treatment of post-traumatic stress disorder (PTSD) (Follette, et al., 2006). Amity Foundation’s Circle Tree Ranch provides a peaceful sanctuary that facilitates personal growth and transformation. It is in a setting such as this, drawing on the beautiful and inspirational surroundings, that individuals can face the reality of their life experiences with hope rather than despair. 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 MBCT allows for flexible treatment goals with dually diagnosed individuals and is adaptable to varying lengths of stay in treatment. nnAs 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 communities1. The introduction of strategies which allow individuals to be more fully present during the TC process has vast implications as we are confronted with the challenge of shorter periods of enrollment. 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. The “portability” of these practices provides individuals with skills that may be used long after their enrollment in the TC. nnBackground nnMindfulness-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. nnIn the field of substance abuse treatment, many studies demonstrate the efficacy of cognitive-behavioral therapy (CBT) for a variety of addictive disorders across diverse populations (McCrady, 2001). In recent years, neurobiological findings support the hypothesis that meditation 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 treatment of trauma and addiction in residential TC settings. We believe that Mindfulness-based meditation practices have great potential for personal growth and healing from trauma, substance abuse, and co-occurring disorders within the TC setting, and can support the basic TC methodology of “community as method” (DeLeon, 2000). nnMBCT: Implications for Trauma Treatment nnTrauma is often described by psychologists as overwhelming experiences that exceed an organism’s coping abilities (Goldsmith, Barlow, & Freyd, 2004). When people endure chronically traumatic environments, a frequent adaptive response is to block awareness of the trauma to enable survival. During abuse, victims’ experiences, feelings, and memories are consistently ignored or invalidated, which is likely to inhibit emotional awareness. Coping mechanisms, including dissociation, facilitate this lack of awareness, and interfere with the development of normal systems of attention (DePrince, 2001). Therefore, victims of trauma, abuse, and betrayal often have difficulty identifying and describing their emotional experiences (Freyd, DePrince, & Zurbriggen, 2001). Viewing themselves as damaged or unlovable, trauma survivors select events from their environment which reinforce negative core beliefs including self-blame, self-criticism, shame, guilt, hopelessness, and lack of self-efficacy. Mindfulness-based practices have great potential to heal this internal disconnection. An important component of MBCT is the practice of self-compassion, self-acceptance, openness to experience, and increased present moment awareness (Segal, Williams, & Teasdale, 2002). Offering trauma victims choice, control, empathy, and respect contradicts aspects of the traumatic experience facilitating healing, awareness, and empowerment. nnSeldom do individuals seek help due to the trauma itself, rather it is the distress from its effects, including addiction, depression, anxiety, and other co-occurring disorders that lead people to treatment. Often chemical dependency and other addictive or self-destructive behaviors are related to overwhelming experiences of exposure to abusive power, physical and sexual abuse, disabling losses and disrupted attachment, usually beginning in childhood. Repression, disassociation, or denial of trauma makes subsequent perpetration more likely and may contribute to the perpetuation of violence in our society (Miller, 1983). Some therapists explicitly challenge therapeutic techniques aimed at surfacing and exploring past trauma, proposing this practice may be “re-traumatizing”. However, a growing body of research links the denial of past trauma and abuse with the intergenerational transmission of trauma, violence, and an increased risk of abusive parenting (Milburn & Conrad, 1996; Miller, 1983). Failing to consider all relevant aspects of psychological experience constitutes a disservice to individuals, families, and society. nnWithin the Therapeutic Community we have found the most effective way to heal the dissociation, numbing, and avoidance so prevalent among victims of trauma and betrayal is to experience in community that which was broken. The strong emphasis on “community as method” within the TC encourages acceptance and belonging in order to break the cycle of isolation and exclusion that is common among those dealing with trauma issues. The creation of a safe environment for the exploration of experiences and the development of trusting relationships provides a powerful antidote for those suffering the consequences of betrayal and trauma. Mindfulness practices effectively help create the sanctuary necessary to begin the healing process. nnIn contrast to many schools of psychotherapy, but 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. Mindfulness 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 is this observation-based, self-exploratory journey that offers a means to examine the totality of one's being; physical, emotional, intellectual, and spiritual. MBCT courses teach mindfulness through objective, detached self-observation without reaction. The goal is not to change the content of thoughts, as in traditional cognitive therapy, but to develop a nonjudgmental attitude to thoughts, feelings, and sensations as they occur (Teasdale, Segal, & Williams, 1995). 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). For individuals seeking physical, emotional, and spiritual healing from trauma the practice of mindfulness meditation facilitates the ability to dwell within and resolve internal conflicts. Through the process of turning toward and moving into pure awareness in the midst of pain trauma survivors shift their relationship to the painful experience, providing freedom in both attitude and actions in a given situation.