Transcript Using Mindfulness in Substance Abuse Treatment

Mindfulness In Addiction
Treatment
Elizabeth Suti, M.F.T.
Program Manager
UCLA Substance Abuse Service
November 13, 2005
Western Conference on Addictions
[email protected]
• “Alcoholism is the disease
of living elsewhere.”
(William Alexander, 1997)
Mindfulness
• “An intentional focused awareness—a way of
paying attention on purpose in the present
moment, non-judgmentally” (Kabat-Zinn, 2005)
• “Quality of openness, of present-moment
awareness and acceptance…experiencing this
moment as the only one that exists” (Bien,2002)
• Mindfulness meditation involves observation of
constantly changing internal and external stimuli
as they arise (Baer, 2003)
Mindfulness
•
•
•
•
Core teachings of the Buddha were the Four
Nobel Truths:
1. Suffering is inherent in life due to the
impermanence of everything
2. The cause of suffering is clinging/craving of
pleasurable experiences and an aversion to
unpleasant ones
3. It is possible to end suffering through nonclinging and acceptance
4. The means to ending suffering is the “EightFold Path” (moral and ethical teachings)
MINDFULNESS-BASED
INTERVENTIONS
Mindfulness-Based Stress Reduction
Program (MBSR) founded by Jon KabatZinn, Ph.D. for medical illnesses and
psychiatric disorders in 1979
Mindfulness in CBT
• Mindfulness-Based Cognitive Therapy (MBCT)
Teasdale, Segal & Williams,1995). Skills of
attentional control taught in mindfulness
meditation could be used to prevent relapse to
major depressive episodes.
• Acceptance and Commitment Therapy (ACT)
“Clients are taught to recognize an observing
self…thoughts are not facts and I am not my
thoughts” (R. Baer,2003)
• Dialectical Behavioral Therapy (DBT) founded by
Marsha Linehan, Ph.D., for Borderline Personality
Mindfulness in Addiction Treatment
Relapse Prevention for addictive disorders using
mindfulness skills (meditation) for coping with
urges to use (“urge surfing”) Alan Marlatt, Ph.D.
“Addiction is a mindless state characterized by an
inability to accept impermanence. The addict
desires to “fix impermanence” by clinging or
grasping on to the high…” (Alan Marlatt, Ph.D.)
Empirically Based Benefits of
Mindfulness Approaches
• Exposure and desensitization: experiencing
physical pain or emotional distress without
excessive emotional reactivity which tends to
make symptoms worse
• Cognitive Change: non-judgmental observation
can lead to understanding that thoughts,
sensations, and emotions do not necessitate escape
or avoidance behaviors (R. Baer, 2003)
• Self-Management: Improved self-observation may
promote use of a range of coping skills (cues and
urges are noted without giving in to them)
Why Use a Mind-Body
Approach?
• Recovery is best viewed as a holistic
process
• M-B approaches recognize a person’s innate
healing abilities
• Illness provides some people with an
opportunity for personal growth and
transformation (a spiritual process for some)
DEFINITIONS
• Mind-Body Medicine: mind’s capacity to
affect health
• Complementary: used together with
conventional medicine
• Alternative: used in place of conventional
medicine
• Integrative: combines mainstream
medicine with evidence-based CAM
Mind-Body Practices
•
•
•
•
•
•
•
•
Traditional Chinese Medicine (TCM)
Meditation
Yoga
Acupuncture
Tai chi and Qi gong
Biofeedback
Dietary/Herbal supplements
Prayer
Is a Mind-Body Approach
Scientific?
• NIH has a National Center for Complementary
and Alternative Medicine (NCCAM,1998)
• Center for Addiction and Alternative Medicine
Research at the U Michigan part of NCCAM
• Many major Universities have Integrative
Medicine Departments
• Managed Care and Insurance Company are
investigating Mind-Body Approaches
• MBSR Programs (over 200 in US)
Research Activities
• NIDA and NIAAA providing research grants for
developing alternative therapies for addiction tx.
• Grants submitted to NIH on mindfulness daily
• Current research studies:
•
•
•
•
•
Immune Function
Chronic Pain
Anxiety and Panic
Prostate Cancer
Chronic fatigue/Fibromyalgia/IBS (10 yr. Study by Cigna)
Leading Integrative Medicine
Programs
• Mind-Body Medical Institute at Harvard
founded by Herbert Benson, MD
• UCLA Collaborative Centers for Integrative
Medicine
• Mindfulness-Based Stress Reduction
(MBSR) Program at the University of
Massachusetts
Mind and Life Institute
• The Dalai Lama and Western Scientists (neuroscientist
Francisco Varela) co-founded the Institute in 1987 for
research collaboration between science and Buddhism for
the purpose of understanding the nature of reality and
investigating the mind http://www.mindandlife.org
• Ongoing research at MIT, and other academic institutions
One study involves brain imaging of Buddhist monks
during meditative states (EEG, MEG, fMRI)
• Public dialogues began in Sept. 2003 at MIT
• This year’s conference, Nov. 8-10, in Washington, D.C.
will be on the Science and Clinical Applications of
Meditation
Mindfulness Based Stress
Reduction Program
• Jon Kabat-Zinn, Ph.D. founded program at Univ
of Mass Med Center in 1979
• Healing power of mindfulness within a medical
context
• “While remaining firmly anchored in the worlds
of science and medicine, integrating mindfulness
into the larger cloth of our society is what is now
required. This is what the world is longing for
This is our crossover.” (Kabat-Zinn,2004)
MBSR Clinical Program
--Over 4,000 physicians have referred patients to the
8 week program
--More than 16,000 patients have completed the
program in past 25 years
--There are currently over 200 MBSR clinics in
academic medical centers, hospitals and free
standing clinics
--Medical problems addressed: cancer, heart disease,
back pain, AIDS, and other chronic illnesses
Mindfulness Meditation Methods
• Body Scan Meditation – slow scan of entire body
(greyhound bus tour)
• Gentle Hatha Yoga – practiced with mindful
awareness of the body
• Sitting Meditation – mindfulness of breath, body,
feelings, thoughts, and emotions
• Walking Meditation
• Home assignments – 45 min. sitting meditation
and 15 minutes of informal practice
Professional Education
• 7-Day intensive residential training program
in MBSR for health care professionals
• Teacher certification program in MBSR for
health care professionals (3 part program)
• Supervision for MBSR instructors
• International Assoc. for MBSR practitioners
• Annual meeting of MBSR practitioners and
researchers
MBSR Outreach
•
•
•
•
Inner City Clinic
Prison Project – Norfolk Prison
Elementary School Education
CEOs, judges, attorneys, priests, health
professionals
• Athletes – George Mumford worked with the
Lakers and the Bulls
• Media: Bill Moyer’s PBS Documentary, Oprah,
Dateline, Newsweek
Current Status of MBSR
• The Center for Mindfulness in Medicine, Health
care and Society (CFM) www.umassmed.edu/cfm
• Located at the University of Massachusetts
Medical School
• Mission is to “integrate mindfulness in lives of
individuals, institutions, and in society through
clinical, research, education, and outreach
initiatives”
• The Stress Reduction Program is the clinical
component of CFM
• Saki Santorelli, Ph.D., is current director.
Benefits of
MindfulnessApproaches
•
•
•
•
•
•
•
Decreases stress
Decreases depression and anxiety
Decreases blood pressure and heart rate
Slows or controls chronic diseases
Increases immune functioning
Increases focus, attention and awareness
10 million American meditate regularly
Defining Stress
• “Non specific response of the organism to
any pressure or demand” (Hans Selye
1950s)
• How you see things and how you handle
them makes the difference in how much
stress you will experience (Kabat-Zinn,
1990)
• If we change the way we see we can change
the way we respond (Kabat-Zinn, 1990)
Stress Response
• “Fight or flight” responses are the physiological
changes we undergo when feeling threatened
• Hyper-arousal occurs when there is an excessive
release of stress hormones and neurotransmitters
• Hyper-arousal can become a way of life; being
stuck in “stress reactivity” (Kabat-Zinn, 1990)
• Internalizing the stress reaction doesn’t bring the
resolution of fighting or fleeing and can lead to
illness
Hypothalamic-Pituitary-Adrenal
(HPA) Axis
• Part of the neuroendochrine system
• Controls stress related hormones
• Responsible for controlling hormones,
nervous system, energy expenditure, and
modulates the immune system
• Physical and mental symptoms associated
with suppression of HPA axis
• Denial and maladaptive coping can develop
Relaxation Response
• Relaxation Response published in 1975 by Herbert
Benson, MD, Founder of Harvard’s Mind/Body
Medical Institute
• Offered a biological explanation for how stress
makes people ill, and how relaxation techniques
decrease stress and help people heal--techniques
used for thousands of years
• Responding vs. reacting to stress (addictive
behavior) through awareness and mindfulness
STRESS AND RELAPSE
• Stress is a major relapse indicator (Gorski,
Marlatt, Koob)
• Person with addictive disorders develops changes
in functioning of the HPA axis (due to substance
use and/or compromised ability to modulate stress
secondary to trauma/abuse)
• Medications being developed to target the HPA
process (Koob presented at 2004 CSAM)
Mindfulness and Addiction
• “Mindfulness in this sense is learning to let
go of the desired outcome, to practice nondoing as an alternative to the addictive fix”
(Marlatt)
• “Where mindfulness is, addiction is not.
Cultivation of one leaves lees room for the
other” (Bien, 2002)
• “Calm awareness is an antidote for an
addicted state of mind” (Bien, 2002)
Mindfulness and Addiction
• Marlatt’s Relapse Prevention Model: clients are taught to
recognize triggers and cravings (desire) and the urge
(intention)
• Mindfulness is characterized by a freedom from rigid
attitudes, cognitions and behaviors
• Practice “non-doing” as an alternative to the “next fix”
• Addiction is a means of trying to control the nature of
reality by maintaining the highs and avoiding the lows.
• Nature of present experience is one of constant change or
flux. Thoughts come and go, physical sensations rise and
fall like the breathe. Everything is impermanent.
Mindfulness and Addiction
• Addiction is a means of trying to control the
nature of reality by maintaining the highs and
avoiding the lows.
• Nature of present experience is one of constant
change or flux. Thoughts come and go, physical
sensations rise and fall like the breath.
• No need to “fix” what happens next. Addicts are
devoted to the next fix because of the great
difficulty in accepting the present moment.
(Marlatt)
Mindfulness and Relapse
Prevention
• Chemicals are used to change our mindbody state when we don’t like how we’re
feeling
• Addictive behaviors are maladaptive
attempts at suppressing symptoms of
disregulation--physical and mental (KabatZinn, 1990)
Relapse Prevention
• Intervening in addictive, classically
conditioned responses
• Recognizing triggers, cravings, and the urge
(intent) to use (Matrix Institute, Marlatt)
• Identify above and teach clients they can
accept cravings and urges without
automatically engaging in the addictive
behavior
Relapse Prevention – Cont.
• Urge Surfing—mindfully riding the urge. “The
urge is portrayed as an ocean wave. Like a wave,
an urge begins slowly and gradually, grows in size
until it crests, and then gently subsides.” (Marlatt)
• Compatible with “thought Stopping” techniques
for interrupting the craving process (Matrix
Model)
• Rather than giving in, letting go
The Therapeutic Relationship
• “The therapist is the most powerful tool for
change” (Marlatt)
• Person-Centered (Rogerian approach)
• Qualities of authenticity, unconditional
acceptance, empathy humor, present moment
experience, teacher and student both experiencing
the process, and each being changed as a result of
it (Santorelli)
• Clinician must practice mindfulness if she/he is
teaching it to clients
Clinical Applications
• It’s not just a set of techniques—it’s about paying
attention, moment by moment
• One day at a time: in the present we have choices,
including sobriety
• Honoring one’s experience, just as it is, even when
there’s guilt and shame present
• Bringing compassionate awareness to whatever is
going on (cravings, regrets, etc.)
• Awareness helps diminish self destructive
impulses first arise, before the behavior begins
Clinical Applications
• Balance is the antidote to craving. In the absence
of balance, we take away one thing, only to
replace it with another--cross-addiction (Griffin,
2004)
• Stress is decreased, change is a process and
happens more effectively when the mind is calm
• Increased self awareness and self efficacy
• Compatibility with 12-Steps (Kevin Griffin, 2004)
• Acceptance of relapses vs. abstinence violation
effect
Treatment and Research
• Marlatt conducted studies on Meditation and
Alcohol Use and Recidivism (Univ. of Wash)
• M. Marcus study using MBSR in therapeutic
community
• MBSR currently being used with clients at
Summit Centers, Malibu
• Center for Studies of Addiction at U Penn Medical
School has used MBSR in addicted adults
• Center for Motivation and Change Treatment
Program in New York has started using MBSR
•
MINDFULNESS AT UCLA
• UCLA PHP program has began a mindfulness
stress management group this fall
• UCLA Dept. of Psychology conducting a study on
Mindfulness meditation with patients with HIV
• UCLA-NPI has a Mindful Awareness Research
Center under direction of Susan Smalley, Ph.D.
(ADHD)
• UCLA Integrative Medicine and UCLA Pediatric
Pain Program started MBSR program with Trudy
Goodman, M.F.T.
UCLA Partial Hospitalization Program
Mindfulness Stress Management Group
• Definition of stress and stress inventory
• Mindfulness approaches as tools for reducing
stress
• Mindful eating
• Sensory awareness
• Vipassana sitting meditation
• Walking meditation
• Writing and poetry
“Live Your Life as if
it Really Mattered”
(J. Kabat-Zinn, 2005)