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Overcoming Barriers in Teaching Contemplative Practices to Highly Marginalized African-American and Latina Women with Histories of Addiction and Trauma
After decades of practicing meditation and seeking to deepen my meditation skills, a journey that took me to Japan, Burma, India, and living three years in Nepal, in 1998 I traveled to the Omega Institute in Rhinebeck, NY, for a seven day intensive program in Mindfulness-Based Stress Reduction (MBSR), taught annually by Jon Kabat-Zinn and Saki Santorelli. Two years later I began an MBSR Teacher's Training program at the Center for Mindfulness in Medicine, Health Care, and Society (CFM), University of Massachusetts Medical School in Worcester. I never imagined that during the eight weeks required to complete the course, my life would turn around completely, giving rise to a most amazing journey, filled with inspiration, purpose, and the passion to help lessen my own and the suffering of others. One part of that journey is described below.
After completing other teacher trainings I was invited to teach at the CFM. While teaching at the CFM I was requested to teach MBSR in a community based addiction treatment setting in Boston. I taught two classes per week- one in English and one in Spanish during a period of 4 years. The population consisted of highly marginalized and poor African-American and Latina women with low literacy levels in very early recovery from drug and alcohol addiction. Most of the women had been previously incarcerated, many had been homeless, and the great majority had a history of trauma and mental illness.
A major concern of teaching contemplative skills to these women was the possibility of retraumatizing them by asking them to sustain attention on previously abused parts of the body while scanning the body sequentially part by part while lying down, and also creating the possibility of disturbing flashbacks and flooding of body memories. We were also quite concerned about the potential to exacerbate the cravings and urges present immediately after detoxification treatment. In addition, it was appraised that meditation might amplify the mental “noise” and agitation rather than bring serenity. Other concerns were that some of the practices could induce sleep due to medication prescribed to treat addiction along with the very busy schedule that is an inherent part of residential addiction treatment. Moreover, a sense of failure could arise at the inability to keep the body still in a period where the mind and the body tend to be hypervigilant and hyperactive, often with uncontrolled tremors and movement.
We had hoped that participants would derive some satisfaction as the course progressed, but often found the opposite. Many women expressed that they just hated coming to class. Anxiety and agitation often increased as the class progressed. Some women would take a mat and follow the instructions while lying on the floor, saying they had back pains, etc. But they often just fell asleep! They had a strong negative association with practice between classes, and literally no one did it. The 45 minute practice tapes were too long and even when the tapes and CD's were reduced to 15 minutes and subsequently to 5-7 minute tracks, often they would pretend to be listening to the meditation practice while in fact they had erased the meditation and recorded over their favorite music.
In the beginning of every class, the women almost universally strongly resisted the meditations focused on awareness of breath, stating that it increased their anxiety and it created 'crawling up the wall” feelings. Most were unable to see the relevance of the body scan, sitting and walking meditations (three of the four 'formal' practices) to their recovery program. Mindful yoga, the fourth 'formal' practice was the only meditation that almost everyone participated in and enjoyed. Comments like “what does paying attention to the breath have to do with my recovery?”, “these exercises are making me want to use again”, and “I don't see any connection in this sitting still to reduce my stress level when it actually increases my anxiety and makes me feel more stressed” were often heard. These statements were wonderful opportunities to investigate assumptions, feelings, and judgments. However the women's willingness to explore them tended not to be present. Some participants equated mindfulness with sleepiness, other participants were clearly upset to be in the classroom, and yet, some participants reported positive experiences, primarily in the area of physical symptom reduction. There were also logistical difficulties in introducing a new intervention to the treatment setting. For example, attendance was poor, partly because the staff did not initially value the MBSR program and they would make appointments with doctors and courts when participants were supposed to attend class.
A clear sense began to emerge that the intervention as presented was not really working. We were realizing that substantial changes related to the content and approach of the standard MBSR format were required, but were unsure about the depth and nature of the changes. There was also a distinct and clearly stated feeling from the participants that because I was not in recovery I could not possibly understand their situation and teach anything of value to them. This changed when instead of ignoring these comments, I explored them at the beginning of every new group expressing the commonality of suffering in all of us, and how we were all part of the 'community of the suffering'. I shared some of my personal experiences in how having a “formal” and daily mindfulness practice had been vitally helpful to me in learning to relate differently to my own physical and emotional pain.
It was evident after a few cycles of teaching the program that participants needed more structure than we were providing. They needed to see important concepts and information presented in a written form, in addition to listening to it. The importance of recording as much as possible on a flipchart before class, using charts, diagrams, simple stories, and role plays, became clear. Changes in voice tone and body gestures were also essential to keep the participants engaged and awake. Since the attention span was relatively short, the activities and meditations needed to be shorter and more varied. Moreover, considering the 'fogginess' that is part of the withdrawal process, and the low literacy level, the concepts and exercises needed to be presented in a language that was direct and comprehensible. Alcoholic Anonymous (AA) served as good model for this, and I began to attend AA meetings and to familiarize myself with its literature.
Addressing Barriers
The most fundamental change was the reorientation of MBSR into a program whose central focus was the role of stress in relapse. This was accomplished in part by teaching the participants to become aware of the cravings and urges, observing them with a certain spaciousness and affectionate curiosity. A drawing of a triangle with thoughts, feelings/emotions, and body sensations represented in a corresponding apex was presented in every class and created a visual tool that the women remembered easily. By separating the emotions, bodily sensations, and thoughts, and paying attention to each one individually in a systematic, moment-to-moment awareness, with the intention to hold judgments lightly, participants gradually began to feel freedom in choosing their responses instead of continuing with their habitual automatic ways of reacting. Most participants found this visual exercise and the freedom experienced very helpful.
Structure was created in class by having the group formulate ground rules that seemed fair to everyone. The ground rules were posted in every class and any deviation was named and corrected immediately. Each class was divided into delineated segments with the objectives of the class clearly stated and written on a flipchart. Class usually started with a few moments of silence, a brief one word check-in, presentation of the theme and objectives for the class, some stretching and/or one of the four 'formal' practices used in MBSR (body scan, sitting and walking meditations, and yoga), a psychoeducational portion related to the theme that was being covered in that particular class, readings of recovery literature and poems by the participants, revision of daily practice for the following week (which was generally ignored), a few breaths in silence and thanking of participants for attending the class. Each class had a theme related to areas that were meaningful to the participants. Some of the class themes included learning to prevent relapse through mindfulness, responding creatively and developing positive coping mechanisms during recovery, and understanding how perceptions could compromise treatment and lead to relapse. Other themes were associated with learning how to use mindfulness skills to relate differently to difficult feelings such as anxiety, panic attacks, fear, guilt, and shame; to improve communication with oneself and others; and to manage anger, self-violence, and violence to others.
The four practices employed in the traditional MBSR classes were used but the length, sequence, and ways of presenting them varied substantially. The body scan was shortened to reduce potential interference from trauma experience. It was performed in a sitting or standing position, non-sequentially, and interspersed with yoga movements. The eyes were open to promote a sense of safety. The scan began with with the feet and legs, followed by yoga for the feet and legs. This process was repeated for all the different parts of the body. Instead of a detailed scan of the pelvic area and breasts, the revised body scan focused on the abdominal area and front of the chest. At times, movement took place first followed by the scanning in order to enhance connectivity with the body. Though the participants did not do a lengthy body scan they would usually practice daily a two or three minute scanning of the body.
Sometimes the body scan was preceded by very fast walking meditation, running, or jumping in place, decreasing the movement gradually and ending in the mountain pose. After that they could do walking meditation at a slow pace. The goal was to meet the participants where they were, matching the movement to the agitation and pent-up energy they would exhibit and progressively slow down.
Sounds were an easier gateway to awareness than the breath. Sitting meditation started with sounds, progressed to body sensations, and then the breath. Participants initially experienced the breath as boring and abstract. At times, it also triggered flashbacks for some of the women with trauma histories that included choking or a hand being held over their mouths. Interestingly, even though the breath was very difficult to connect with at the beginning, when asked in six and twelve month follow-up interviews, the women often reported that awareness of breath was the 'tool' that they practiced on a regular basis and the most helpful to ride cravings, urges, and impulses.
Hatha yoga, called mindful stretching exercises to avoid connotation of a religious nature that exists in some Spanish speaking regions, was the basic staple, and it was performed in any of the segments if the mood of the participants was too lethargic or to distracted. Participants enjoyed both the floor and standing yoga and often mentioned how helpful it was for lower back pain, shoulder and neck pain, and to release tension.
Participants expressed at the end of the program, over and over, how beneficial was to discover the breath as an ever-present internal resource, always available to help them reconnect to the present moment, and to respond instead of reacting to external and internal stressors. Participants mentioned benefits in self-regulation: decrease in physical symptoms such as less severe and less frequent migraines, decreased back pain, less gastro-intestinal problems, reduction in sleep disorders, decreases in panic attacks and frequency of depressions. They also mentioned that they felt more connected and compassionate towards their bodies, their families, and others in the program. They said that they were more understanding of the family and cultural conditioning, and more patient with their children.
The experience of teaching the class was for me extremely challenging and at the same time one of the greatest gifts ever received. I felt privileged to be in the presence of bright, creative, vivacious individuals whose lives had been severely damaged due to trauma, mental illness, and substance abuse. In most cases they had lost the support of their families and had lost custody of their children. The fact that they had entered treatment was a huge accomplishment. Most participants found the mindfulness practice healing, informative and useful in their recovery process and to have been a small part of that process is a huge blessing.