Mindfulness and Problem Gambling Treatment

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1 Mindfulness and Problem Gambling Treatment Loreen Rugle, Ph.D., ICGC-II, BACC Program Director, Maryland Center of Excellence on Problem Gambling 1 Beginner s Mind In the beginner's mind there are many possibilities. In the expert's mind there are few. Shunryu Suzuki 2 1

2 Going in Circles Thich Nhat Hanh O you who are going in circles, please stop, What are you doing it for? I cannot be without going, Because I don t know where to go. That s why I go in circles O you who are going in circles, please stop But if I stop going, I will stop being. 3 Going in Circles Thich Nhat Hanh O my friend who is going in circles, You are not one with This crazy business of going in circles. You may enjoy going, But not going in circles Where can I go? Go where you can find your beloved, Where you can find yourself. 4 2

3 Mindfulness A consciousness discipline The intentional cultivation of non-judgmental moment-tomoment awareness. Jon Kabat-Zinn (1990) 5 Mindfulness Freshness Beginner s Mind Understanding Non-striving Non-attachment Responding not Reacting Gentleness and Compassion 6 3

4 Where to Intervene in Addiction Cycle? Judson Brewer Positive Cue (paycheck) Neutral Cue (driving car) Negative Cue (argument) Positive Affect happy/content Craving Negative Affect Frustration Gamble Increased Importance Maintain or increase positive affect/decrease negative affect Increased Importance Positive Reinforcement Reinforcement of Associative Memory/Habit Gambling makes me feel better Negative Reinforcement Where to Intervene in Addiction Cycle? Judson Brewer Positive Cue (paycheck) Positive Affect happy/content Neutral Cue (driving car) Craving Cue Avoidance Negative Cue (argument) Negative Affect Frustration Gamble Substitute Behaviors Increased Importance Maintain or increase positive affect/decrease negative affect Increased Importance Positive Reinforcement Reinforcement of Associative Memory/Habit Gambling makes me feel better Negative Reinforcement 4

5 Top Down or Bottom Up Top Down Modulation (Prefrontal Cortex, Orbitofrontal Cortex) MBRP improves higher order executive control of typically automatic reactions to discomfort Bottom Up (Insula, amygdala) Decreased reactivity to craving related stimuli or decreased reactivity to stressors Where and How to Intervene Mindfulness Observe thought without attachment or judgment Sit with bare feelings acceptance Develop compassion 10 5

6 Mindfulness and Cognitive Therapy Cognitive Therapy Goal: Change Thoughts Identify thoughts that trigger gambling Identify irrational thoughts Change triggering and irrational thoughts Change thoughts in order to ameliorate distressing feelings Mindfulness Goal: Change Relationship to Thoughts and Feelings Observation of thoughts and feelings Disidentification Acceptance of thoughts and feelings as transitory Hold distressing feelings with compassion 11 Mindfulness Based Relapse Prevention Change relationship to gambling thoughts Coping with cravings Self-awareness Affect tolerance Decrease impulsivity (Bowen, Chawla & Marlatt, 2010;Toneatto et al., 2007) 6

7 Mindfulness Based Recovery Promotion Attitude toward internal and external triggers Curiosity Investigation and exploration Deep understanding Acceptance Tolerance Nonjudgmentalness Non-identification Mindfulness Listen to your life. See it for the fathomless mystery that it is. In the boredom and the pain of it no less than in the excitement and gladness Frederick Buechner (1983) 14 7

8 Mindfulness Experience thoughts as thoughts I am not my thoughts My thoughts are not Truth or Reality Experience emotions as emotions I am not my emotions They are not Truth or Reality 15 Crises and Relapse Prevention Mindful awareness of cues/triggers Awareness of small thoughts, feelings Keep focus on original cue/trigger in sequence Mindfulness of irrational responses Use of emotion with rational thinking to make mindful decisions and choices. 16 8

9 Mindfulness Addresses Impulsivity Cravings Staying in Today Self-awareness Affect Tolerance Self-forgiveness and self-acceptance 17 Mindfulness Based Recovery Promotion I. Automatic Pilot and Relapse II. Awareness of Triggers III. Mindfulness in Daily Life IV. Mindfulness in High Risk Situations V. Acceptance and Skillful Action VI. Seeing Thoughts as Thoughts VII. Self-Care and Lifestyle Balance VIII.Social Support and Continuing Practice 9

10 Mindfulness Based Recovery Promotion R.A.I.N R Recognize A Accept/Allow I Investigate N - Non- Identification S.O.B.E.R S Stop O Observe B Breath E Expand R - Respond Being Happy with Crappy: Making Friends with Feelings The Guest House -- Rumi This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, Some momentary awareness comes As an unexpected visitor. Welcome and entertain them all! Even if they re a crowd of sorrows, Who violently sweep your house Empty of its furniture, Still, treat each guest honorably. It may be clearing you out For some new delight. The dark thought, the shame, the malice. Meet them at the door laughing. And invite them in. Be grateful for whoever, comes, Because each has been sent As a guide from beyond

11 Acceptance, Humility, Loving Kindness and Self-Forgiveness Compassion for myself Step 4: Searching Inventory Step 5: Share my wrongs Steps 6 & 7: Remove shortcomings Step 10: Continuing personal inventory Compassion for others Step 8 and 9: making amends Steps 11 & 12: Transformation, Forgiveness and Connection 21 Self-Compassion and Loving Kindness SELF-COMPASSION BREAK This exercise evokes the 3 components of self-compassion: mindfulness, common humanity, and self-kindness. When you notice that you re under stress, see if you can find the stress in your body. Where do you feel it the most? Make gentle contact with the stress as it arises in your body. Then say to yourself: This is a moment of suffering That s mindfulness. Find language that speaks authentically to you, such as: This is stress. This hurts. Ouch! 11

12 Self-Compassion Break Suffering in a part of life - Everybody Hurts That s common humanity. Other options include: Other people feel this way. I m not alone. We all struggle in our lives. Now, put your hands over your heart, feel the warmth of your hands and the gentle touch of your hands on your chest. Ask yourself, What do I need to hear right now? The question and the answer are an expression of self-kindness. Say to yourself: May I be kind to myself Or. May I give myself the compassion that I need May I accept myself as I am May I learn to accept myself as I am May I forgive myself. May I be strong. May I be safe May I be peaceful May we live in peace Loving-Kindness and Self-Compassion Meditation Sit in a comfortable position, reasonably upright and relaxed. Fully or partially close your eyes. Take a few deep breaths to settle into your body and into the present moment. Put your hand on your heart for a moment as a reminder to be kind to yourself. Form an image of yourself sitting down. Note your posture on the chair as if you were seeing yourself from the outside. Now bring your attention inside your body and feel the pulsation and vibration of your body. Locate your breathing where you can feel it most easily. Feel how your breath moves in your body, and when your attention wanders, gently feel the movement of your breath once again. After a few minutes, start to notice physical sensations of stress that you re holding in your body, perhaps in your neck, jaw, belly, or forehead. Also notice if you re holding some difficult emotions, such as worry about the future or uneasiness about the past. Understand that every human body bears stress and worry throughout the day. 12

13 Now offer yourself goodwill because of what you re holding in your body right now. Say the following phrases to yourself, softly and gently: May I be safe. May I be peaceful. May I be kind to myself. May I accept myself as I am. When you notice that your mind has wandered, return to the words or the experience of discomfort in your body or mind. Go slow. If you are ever overwhelmed with emotion, you can always return to your breathing. You can also name the emotion, or find it in the physical body and soften that area. Then, when you re comfortable, return to the phrases. Finally, take a few breaths and just rest sit quietly in your own body. Know that you can return to the phrases anytime you wish. Gently open your eyes. Therapist Mindfulness Skills Acceptance Nonjudgmental Attentive being present Observant (self and others) Reflective Listening Awareness (self and others) Relaxed alertness Understanding Compassionate communication 26 13

14 Therapist Mindfulness Skills Persistence Patience Belief in efficacy of therapy Mindful risk taking The gift of presence 27 Therapist Mindfulness Skills Acceptance Nonjudgmental Observant (self and others) Reflective Listening Awareness (self and others) Relaxed alertness Understanding Compassionate communication 28 14

15 Therapist Mindfulness Skills Persistence Patience Belief in efficacy of therapy Mindful risk taking 29 Please Call Me by My True Names Thich Nhat Hahn Do not say that I ll depart tomorrow Because even today I still arrive. Look deeply; I arrive in every second To be a bud on a spring branch, To be a tiny bird, with wings till fragile learning to sing in my new nest, To be a caterpillar in the heart of a flower, To be a jewel hiding itself in a stone

16 Please Call Me by My True Names Thich Nhat Hahn I still arrive, in order to laugh and to cry, In order to fear and to hope, The rhythm of my heart is the birth and death Of all that are alive. I am the mayfly metamorphosing on the surface of the river, And I am the bird which, when spring comes, arrives in time to eat the mayfly 31 Please Call Me by My True Names Thich Nhat Hahn I am a frog swimming happily in the clear water of a pond, And I am the grass-snake, who, approaching in silence, feeds itself on the frog. I am the child in Uganda, all skin and bones, My legs as thin as bamboo sticks, And I am the arms merchant, selling deadly weapons to Uganda 32 16

17 Please Call Me by My True Names Thich Nhat Hahn I am the twelve-year-old girl, refugee on a small boat, Who throws herself into the ocean after being raped by a sea pirate, And I am the pirate, my heart not yet capable of seeing and loving. I am a member of the Politburo with plenty of power in my hands, And I am the man who has to pay his debt of blood to my people dying slowly in a forced labor camp. 33 Please Call Me by My True Names Thich Nhat Hahn My joy is like spring, so warm it makes flowers bloom in all walks of life. My pain is like a river of tears, so full it fills all four oceans. Please call me by my true names, So I can hear all my cries and laughs at once, So I can see that my joy and pain are one. Please call me by my true names So I can wake up and so the door of my heart can be left open, The door of compassion

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