Mindfulness In Addiction Treatment

1. Mindfulness In Addiction Treatment Elizabeth Suti, M.F.T. Program Manager UCLA Substance Abuse Service November 13, 2005 Western Conference on Addictions esuti@mednet.ucla.edu

2. “Alcoholism is the disease of living elsewhere.” (William Alexander, 1997)

3. 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)

5. 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 non-clinging and acceptance • 4. The means to ending suffering is the “Eight-Fold Path” (moral and ethical teachings)

6. MINDFULNESS-BASEDINTERVENTIONS Mindfulness-Based Stress Reduction Program (MBSR) founded by Jon Kabat-Zinn, Ph.D. for medical illnesses and psychiatric disorders in 1979

7. 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

8. 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.)

9. 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)

10. 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)

11. 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

12. Mind-Body Practices • Traditional Chinese Medicine (TCM) • Meditation • Yoga • Acupuncture • Tai chi and Qi gong • Biofeedback • Dietary/Herbal supplements • Prayer

14. 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)

15. 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)

16. 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

18. 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

20. 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)

21. 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

22. 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

23. 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

24. 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

25. 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.

27. 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

28. 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)

29. 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

30. 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

31. 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

32. 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)

33. Mindfulness and Addiction • “Mindfulness in this sense is learning to let go of the desired outcome, to practice non-doing 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)

34. 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.

35. 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)

36. Mindfulness and Relapse Prevention • Chemicals are used to change our mind-body state when we don’t like how we’re feeling • Addictive behaviors are maladaptive attempts at suppressing symptoms of disregulation--physical and mental (Kabat-Zinn, 1990)

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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.

44. UCLA Partial Hospitalization ProgramMindfulness Stress Management Group • Definition of stress and stress inventory • Mindfulness approaches as tools for reducingstress • Mindful eating • Sensory awareness • Vipassana sitting meditation • Walking meditation • Writing and poetry

45. “Live Your Life as if it Really Mattered” (J. Kabat-Zinn, 2005)