Integrating Mindfulness Based Therapy to Traditional Addiction Treatment Interventions to Address Co-occurring Addiction and Trauma
Working with substance use disorder populations is my primary area of focus in my career as a social worker. An abundance of evidence has pointed to the connection between addiction and traumatic stress (citation SAMHSA, NIDA,NIH). In order to most effectively treat co-occurring conditons we need to develop interventions designed to address both conditions simultaneously. Traditional evidenced based addiction treatment interventions, although effective at times, were not specifically designed to address the symptoms of trauma or stressor related disorders.
For purposes of clarification I will operationalize trauma related and substance use disorders. In this paper the terms “substance use disorder” and “addiction” may be used interchangeably. Trauma related disorders are disorders, “in which exposure to a traumatic or stressful event is a specific criterion; the symptomology of these disorders can present as anxiety or fear based symptoms, anhedonic or dysphoric symptoms, externalizing or aggressive symptoms, or dissociative symptoms (American Psychiatric Association, 2013)”. Included in this category are “reactive attachment disorder, disinhibited social engagement disorder, post-traumatic stress disorder, acute stress disorder, and adjustment disorders (American Psychiatric Association, 2013)”. “Substance use disorders are defined as a cluster of cognitive, behavioral, and physiological symptoms where the individual continues to use substances despite significant functional impairments related to their use (American Psychiatric Association, 2013)”. “It is important to note that a characteristic of substance use disorders is a change in brain circuits that may persist beyond initial detoxification from the substance, exhibited in repeated relapses and intense cravings for the drug (American Psychiatric Association, 2013)”. I feel it is important to recognize substance use disorder patients as suffering from the disease of addiction, as defined American Society of Addiction Medicine (2011). Because of this purpose I will refer to this population as patients, as they are suffering from a medical illness, and not clients. This distinction is made to in order to prevent the outdated morality based perspective associated with substance use disorders.
To understand mindfulness, it is helpful if we operationalize its meaning. Mindfulness is a way of paying attention that originated in Eastern meditation practices, which can be described as bringing attention purposefully, to the present moment, and nonjudgmentally (Baer, 2009). Practice of this way of being has been demonstrated to effective as a treatment intervention in female population but has had limited research committed to working with male populations (Witkiewitz, Marlat, Walker, 2005; Lee, Zaharlick Akers, 2009). In this paper I will offer a look at using mindfulness as a clinical intervention with this population in personal practice.
In my practice I have been comprehensively trained in 12 step and CBT strategies as primary interventions with this population. More recently I have been immersed and trained in mindfulness practice, specifically Mindfulness Based Cognitive Therapy. Over the past few years I have been incorporating mindfulness approaches into my practice, in addition to traditional interventions. I will discuss how I have combined these interventions into a more comprehensive approach to working with this population. In the following I will discuss a practice situation with a particular patient in which I utilized mindfulness practice interventions.
A 20 year old patient of mine had been an active IV heroin user for several years with a significant trauma history. At 7 years old he witnessed the aftermath of his father’s suicide. Following that his mother remarried an active alcoholic and lived with chronic fear of chaos and violence in the home. This patient had had several attempts at treatment prior and had multiple relapses that appeared to be impulsive in nature. During our initial sessions the patient identified “overwhelming sense of anxiety” as the primary trigger to his previous relapses. In our session we explored the anxiety he described prior to relapse to examine the situations in order to develop strategies to cope with these feelings. I would typically ask the patient to begin by remembering a time when he felt this anxiety. I would then ask him to describe and physical feelings he had in the moment while recalling this event. I would also ask him to identify and describe his emotions and thoughts at the moment, in as much detail as he could, while recalling this event. By conducting this exploration, while remaining focused on the present moment experiences, helped the patient to feel comfortable exposing himself to these feelings, reducing their impact on his mental state. To the patient’s frustration he was often unable to identify a common pattern for his “overwhelming anxiety” and would describe these feelings as “coming out of nowhere” as if there “were just days when it was outside of my ability to understand why I was anxious”. This inability to rationalize or understand these processes is consistent with van der Kolk’s (1994) description of the complex processes of trauma as being almost immune to cognitive processing interventions. By using a self-compassionate and present moment focused approach, I encouraged the client, as far as he was comfortable, to continue to explore past relapses and draw attention to somatic feelings he experienced in session to bring him more in tune with his physical reactions to stress. I also encouraged a non-judgmental approach to the patient’s way of thinking about himself. Often the patient would refer to himself negatively (loser, fuck-up, junkie, etc…), as the patient would describe himself in this manner I would gently ask him how he felt about referring to himself in that manner in the current moment. To the client’s surprise he realized that these negative self-descriptions increased his feelings of negativity and anxiety. It was as if he had no awareness of how his thoughts and words led to continued negative thoughts and feelings. I would then encourage this patient to describe himself from a sense of self-compassion. I would ask him to refer to himself in positive terms (honest, caring, loving, compassionate, etc…) and ask him to be compassionate with himself for his suffering.
Combining mindfulness and traditional 12 step approaches I would encourage this patient to utilize prayer or metta bhavana as a brief self-help intervention. The patient was encouraged to ask for acceptance of himself in times of distress, as he is, and provide himself with feelings of compassion. He would use this intervention as an act of self-compassion that could provide him with the ability to increase his self-acceptance and allowing him to be exposed to pain and suffering without being personally activated, disarmed or distracted (Briere, 2012). The patient struggled at times to be self-compassionate as he tended to “moralize” his addiction and also was accustomed to self-defeating talk. To address this, when he would be harsh towards himself I would ask him if he would feel comfortable reframing his words into a sense of self-compassion. For example if he said, “I was such an idiot for doing that”, I would ask him if he felt comfortable in referring to himself from a compassionate viewpoint and he would often reply “I was really sick with my disease at that time and made some bad choices.”
This patient also experienced a lot of resentment towards perpetrators of his trauma as a result of the traumatic experience he was victim to in his life. These resentments often precipitated or increased his anxiety, increasing the possibility of relapse. Twelve Step literature (Alcoholics Anonymous) is further in congruence with mindfulness (metta practice), suggests the following:
“’If you have a resentment you want to be free of, if you will pray for the person or the thing that you resent, you will be free. If you will ask in prayer for everything you want for yourself to be given to them you will be free. Ask for their health, their prosperity, their happiness, and you will be free. Even when you don’t really want it for them, and your prayers are only words and you don’t mean it, go ahead and do it anyway. Do it for two weeks and you will find you have come to mean it and to want it for them, and you will realize that where you used to feel bitterness and resentment and hatred, you now feel compassionate understanding and love (Alcoholics Anonymous, 2001, p 552).”
This intervention is consistent with mindfulness metta practice which encourages persons to ask for compassion for those who they are in conflict with in order to develop a sense of compassion towards them (Germer & Siegel, 2012). By practicing Metta in session and encouraging this practice at home by the patient, he has been able to address the feelings of resentment that may resulted in future relapse and provided him with an healthy and empowering way to address his feelings should they arise. At times the patient struggled to be compassionate towards the perpetrators of his violence, but we discussed that to be able to receive the forgiveness he sought from others it may be beneficial to give the same to those who harmed him.
Another major mindfulness intervention that I have combined with traditional 12 step facilitation and CBT is the practice of meditation. In session I have introduced the client to various mindfulness meditation practices, such as the focused breathing, body scan, loving kindness, and cultivating compassion. These mediation practices are consistent with the 11th step of the 12 step facilitation which states “Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only knowledge of His will for us and the power to carry that out (Alcoholics Anonymous, 2001, p. 59).” These meditation practices in theory should improve CBT interventions as well, as they have shown to improve emotional regulation through improving neural regions of the dorsal prefrontal cortex, which are the regions of the brain involved with cognitive processing utilized in CBT (Hozel, et al., 011). In addition, areas involved in subcortical traumatic response that may not be immediately cognitively processed, like those described earlier by van der Kolk (1994), are also shown to be improved through mindfulness mediation practice (Hozel et al., 2011). By leading this patient through guided mediations in session and encouraging it as homework between sessions the patient has shown marked improvement in emotional regulation. The patient has described himself in session as, “No longer controlled by everything little feeling…” but able to “let the feelings wash over me” without reacting. This is consistent with Hozel et al.’s (2011) report findings of increased non-reactivity to inner experiences.
Integration of mindfulness with traditional treatment approaches can be a great support to current existing evidenced based models for addressing trauma and addiction. Implementing appropriate interventions that allow patients to be comfortable in expressing and experiencing the full range of emotions associated with trauma will create a social norm where patients learn to cope without the use of drugs, alcohol, or violence. By incorporating mindfulness interventions into their therapeutic milieu with traditional interventions practitioners can offer patients a more holistic and effective treatment approach.