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Intervention and Evaluation ProjectWolfe/Kaleiwahea/MakekauUniversity of Hawaii at ManoaClient Assessment SummaryThe Engagement and Assessment Paper introduces a client named John Doe, a single, forty-one year old Caucasian male, who was recently released from the Hale Nani Correctional Facility. He served approximately nine months for a probation violation, which stemmed from a positive urine test for heroin and methamphetamine in October 2011. He originally was placed on probation for charges which included possession of drugs and drug paraphernalia, his first offense in March 2010. Mr. Doe was released from prison back to probation on September 10, 2012 and mandated by the court to be assessed for his substance abuse problems and further, to follow any recommended course of care. Mr. Doe was required by the Adult Probation Services to attain a substance abuse assessment and follow any recommended course of treatment. Mr. Doe needs to report to his probation officer, Mr. John Smith who initially called the Hawaiian Treatment Center to schedule an appointment for Mr. Doe. No other sources were involved during the initial screening and assessment process. The Hawaiian Treatment Center provides a highly structured environment that is predicated on personal responsibility, individual dignity, and self-esteem. Clients admitted to the program attend a variety of groups based on comprehensive, individualized assessment of their needs and degrees of impairment. The program philosophy of care is based on a belief that people suffering from substance abuse and co-occurring disorders can achieve and maintain stability, and reach their highest and healthiest potential, through the provision of quality, goal-oriented treatment. The following are the issues of concerns based on the client’s assessment:Polysubstance DependenceLegal IssuesLack of Employment/Financial DifficultiesLack of Support Network/Family SupportThe paper also described the client system in terms of all relevant social group memberships and how these social group memberships may or may not be aligned with other social group memberships of the community, agency, and the social worker. Mr. Doe’s social group memberships include his friends, his family, his girlfriend, and his fellow employees at his new place of work. None of these relationships should be out of alignment with those of the community, the agency, or the relationship with Mr. Doe’s social worker, Mr. John Smith, who is concerned with treating his substance abuse problems with a number of services, such as group therapy, outreach, crisis intervention, social rehabilitation, and coping skills he needs to use on a daily basis. In addition, the social worker may support Mr. Doe in order to ease his transition back into the community by reducing the stress he may be experiencing after his terms of imprisonment. It is possible, especially regarding Mr. Doe’s group of friends that a situation may occur that is out of alignment with his progress.Mr. Doe was given a biopsychosocial assessment by his social worker at the treatment center. The biopsychosocial assessment refers to a series of questions asked at the beginning of treatment of an individual that obtain information about the major physical (bio), psychological, and social issues of the individual. This approach is called holistic because it posits that separate issues are often related. The course of a physical illness could influence social interaction or psychological function, or a social and familial background might have an impact on a biological or psychological problem. By asking a series of questions that may establish the most important elements in each of these spheres, a better treatment plan may be derived. Based on DSM-IV Standards, John was given the following provisional diagnosis:Axis I 304.80 Polysubstance DependenceAxis II V71.09 No Diagnosis on Axis IIAxis III ArthritisAxis IV Incarcerated, Probation, Relapse PreventionAxis V 49Mr. Doe was given the Axis I diagnosis, polysubstance dependence, which refers to a type of substance dependence disorder in which an individual uses at least three different classes of substances indiscriminately and does not have a favorite drug that qualifies for dependence on its own. Axis II was deferred due to no personality disorders and mental health issues. John did state that he occasionally suffers from arthritis, which was given in Axis III for General Medical Conditions. Axis IV, the Psychosocial and Environmental Problems for Mr. Doe included incarceration, legal problems such as probation, and the lack of relapse prevention. The Global Assessment of Functioning in Axis V was rated at 49 for serious symptoms or any serious impairment in social, occupational, or school functioning. From a strengths perspective, Mr. Doe was asked to provide a list of his strengths and weaknesses as part of his initial assessment. Mr. Doe lists them as follows:Strengths:John verbalized, as well as demonstrated, the desire to maintain abstinence from drugs.John has support from his son, girlfriend, and a close friend.Stable living condition.Legal pressures exist which served as increased motivation for help.John demonstrated above average intelligence.Weaknesses:No past attempts to stay abstinent from drugs.Poor impulse controlJohn stated that he did not feel the need to attend “Twelve-Step” meetings.As a result of this diagnosis, Mr. Doe was referred to the Intensive Outpatient Program (IOP) of the Hawaiian Treatment Center to address his chemical dependence issues. IOP will give Mr. Doe a structured environment which will allow him to maintain a regular commitment to family, work, and educational responsibilities. In this case, Mr. Doe must voluntarily abstain from drug or alcohol use, which requires a greater amount of diligence. Client is not experiencing any withdrawal symptoms at this time. Due to his sexual behaviors while under the influence of drugs, he was counseled and given information about HIV and AIDS, and did voluntarily submit for laboratory testing; results came back negative. At the time that treatment began, his probation officer stated that if he were to get in trouble again due to his substance abuse, he would probably be sent to prison. This type of pressure was instrumental in formulating the following treatment plan for Mr. Doe:TREATMENT PLANProblems:Polysubstance DependenceLegal DifficultiesPoor Relationships with Immediate Family MembersLack of Employment / Financial DifficultiesPossible Sexually Transmitted DiseasesShort-Term Goals:Initiate abstinence.Gain insight to the concept of substance abuse and dependenceIncrease level of responsibility.Introduce to the Twelve Steps and initiate regular attendance at NA/AA meetings.To advise John to obtain a temporary sponsor in AA.To instruct John to take the responsibility to include and meet the needs of his probation officer during his treatment.To instruct John coping skills and relapse prevention skills.To counsel John regarding HIV and AIDS, as well as other sexually transmitted diseases, and provide testing.Long-Term Goals:To have an understanding of the concept of substance abuse and dependence.To obtain a permanent sponsor.To continue to work the “Twelve Steps” with his sponsor.To attend NA/AA meetings 2-3 times a week.To establish coping skills and relapse prevention skills appropriate for the individual’s needs.To establish employment preparation skills to gain new employment.To attend college to further his education; this will help him gain better employment.Socialize with individuals that share an interest in long-term recovery.To continue follow-up with the Probation Department.Intervention and Measurement PlanTargetOne goal to guide the building of an intervention for John is to initiate abstinence, and one subsequent objective to focus on is to do so through the use of cognitive behavioral skills development prior to his taking part in a 12-step program. The specific cognitive behavioral skill that will be developed in this intervention will be mindfulness.DefinitionsThe conceptual definition of the intervention, namely cognitive behavioral therapy, is a generalized approach to psychological care using both methodologies from both cognitive therapy and behavioral therapy, both of which have been created in alignment with operant conditioning techniques (Beck, 2005). In particular, the form of intervention used will be mindfulness meditation, which is similar to the traditional behavioral technique of self-monitoring or, in this case, thought monitoring (Witkiewitz, Marlatt, & Walker, 2005). The operational definition of the intervention is that by being introduced to cognitive behavioral skills recognition, John can learn how to avoid negative consequences through practicing social habits that address his underlying issues. By isolating his thoughts from harmful practices or actions, John can monitor their feelings, independent of taking action on those feelings in both the short and the long term.The target of the intervention is to help John build his coping skills and relapse prevention skills through the application of specific cognitive behavioral skills, in particular that of mindfulness. By becoming aware and understanding how and why he makes life choices, and how he can shift those choices, his recovery process may be supported. InterventionThe theoretical background of the cognitive behavioral therapy is as follows. The fundamental theory at the heart of behaviorism is that choosing conditioning will allow individuals to repeat new actions which will, in effect, train their brains to respond differently to stimuli. This draws on the idea that the synaptic connections in our brains need to be reinforced through certain actions, which can, over time, change the way that we think about ourselves. This is significantly different from pure cognitive theory, which is centered on the visual and auditory connections in our brains’ neurological functions and how these can be reprogrammed through cognitive development. Cognitive behavioral theory draws together both of these approaches to understanding the development of the human mind. The focus of this theory is that by changing behaviors, cognitive schema can change more easily as well. As noted by Kirsch, Lynn, Vigorito, and Miller (2004), instrumental learning situations produce expectancies that particular behaviors will produce particular outcomes. In this case, a dialectical behavioral therapy (DBT) strategy that is a derivative of CBT will be used.The evidence supporting the use of this intervention for substance abuse challenges is significant. Kiluk, Nich, Babuscio, and Carroll (2010) note that cognitive behavioral therapy has been used successfully in the treatment of substance abuse. This approach works in this patient context because of the fact that it allows patients to shift both their thinking and their physical use of drugs at the same time. As Walters (2002) notes, one of the key issues within traditional addictions treatment and management is that the responsibility is placed on the individual rather than the social context in which the individual operates. Cognitive behavioral therapy allows the individual to examine how he or she reacts to challenges in his or her environment, instead of taking on the entire responsibility for change. Marlatt (2002) agrees with this assessment, and discusses results of research into cognitive behavioral therapy with a focus on mindfulness skills development. He notes in particular that for substance-abuse clients who use 12-step programs, cognitive-behavioral mindfulness skill development is appealing. Witkiewitz, Marlatt, and Walker (2005) write that mindfulness meditation is similar to the traditional behavioral technique of self-monitoring or, in this case, thought monitoring. The difference between traditional cognitive-behavioral therapy and a focus on mindfulness skill development, however, is that instead of changing the content of one’s thoughts, the latter approach builds a detached awareness of the thoughts themselves. By isolating the thoughts from harmful practices or actions, individuals can monitor their feelings or, in the case of an addict, cravings, independent of taking action on those feelings in both the short and the long term.The intervention reflects evidence-based or evidence-informed practice because, asMcGovern, Fox, Xie., and Drake (2004) note, there is substantial evidence in the literature and in research that a more eclectic approach to substance abuse therapy is warranted than models espoused in the past. This means that the common, traditional 12-step model worksbut it is most successful when combined with other interventions. This means that substance abuse clients often focused on repeating behavior which illustrate that their lives have no meaning. Cognitive behavioral therapy allows the individual to better determine which behaviors will allow him or to meet his or her personal goals. There is, as Kelly (2008) notes, objective medical support for mindfulness practice in particular. In a number of neurological studies, Kelly (2008) notes that brain electrical activity before and after 8-week mindfulness meditation program caused both brain function and immune levels in the body to change. This has been proven to help those clients trying to understand the relationship between their thoughts and their actions due to stress.The client and I selected the intervention as described because it provides the means to refocus John’s need for control and acceptance in his life and bring mindfulness to his life choices. Due to his assessment, it is evident that John is unlikely to have an addictive personality disorder per se, such as a proneness to physical addiction, but rather a more complex combination of personal issues linked to stress levels that led him to addiction. He recognizes the fact that the first thing that needs to be addressed within a therapeutic context is his own motivations to change, and he wants to work on this opportunity before he immerses himself in the 12-step program. Once these motivations have been examined, the client and I will work together to create goals for new target behaviors. John has chosen to incorporate principles of relaxation training into his skills building exercises, which he can practice daily. We began with the relaxation techniques in week 1 through 2, and added meditation in week 3 of the intervention. We began mindfulness in week 6, after John had had the opportunity to immerse himself in the skills practices. I monitored the target and the intervention through discussion with John, and a measurement of his blood pressure both before and after the intervention. I also asked him to keep a journal of his activities and his feelings before and after taking part in each practice. Issues of diversity have had an impact on this analysis and recommendations for this case. Walters (2002) writes that there is a common misconception that substance abuse is linked to denial and weak motivations for change, when it is more important to deal with the fact that individuals affected by substance abuse are often utilizing the only means they have at their disposal to cope with very difficult psychosocial issues. In John’s case, these may be linked to the challenges that he himself has experienced associated with his incarceration, legal problems, lack of relapse prevention, and social challenges related to his lack of employment. There are strengths in this design from a social justice perspective due to the fact that it allows John a great deal of control over the process of addressing his addiction, which is meaningful to the client. He has felt out of control for a long period of time, and therefore he feels that there is value in working on his challenges in this way. MethodologyThe ABA design of the intervention is as follows. Based on the cognitive behavioral skills development orientation, the A baseline condition is that John’s psychopathology is linked to substance use and dependence developed over an extended period of time, as he practiced stress-avoidance behaviors that reinforced this dependence. By establishing the baseline, the counselor is able to observe how the participant performs with no treatment. John’s baseline is that he continues to be affected by substance abuse which has led to legal problems and social challenges related to his lack of employment. This means that his baseline can be measured by a diary of his daily activity and daily feelings for one week prior to the intervention. As Weiten (2004) notes, behavioral modification programs grounded in mindfulness techniques work best when they are flexible and can be adjusted to meet realistic goals. These programs can be adapted so that, over time, there may be a way for individuals to change the way that they operate and learn a different way of doing things to make themselves more successful. The B experimental condition or treatment is as follows. This framework of cognitive behavioral skills development, specifically the use of mindfulness, was selected to begin to unwrap some of the challenging elements within John’s psychological history and rewrite the patterns with which he addresses his issues in life. The focus of this intervention is to devise other means than substance use to refocus John’s approach to stress if and when stress occurs. The first skill that will be addressed is that of relaxation, which John will need to practice daily. This is recommended as the first step in mindfulness skills practice. John has chosen to address this practice through the use of a graduated approach to relaxation, first with the aid of externalities such as hot baths and quiet reading, and later through the use of relaxed stretching such as yoga for a minimum of 20 minutes per day. The second skill that will be addressed is that of guided meditation, which is central to stress reduction in cognitive behavioral skills development. This will begin with five minutes of meditation per day, under instruction. The third skill that will be addressed by John is that of mindfulness itself, such as experiential exercises, where he practices becoming aware of the process of stress on his body and choices. The measurement of the new A baseline condition will be as follows. A diary of his daily activity and daily feelings will be collected for one week after the intervention is finished, and combined with an interview with John, a second baseline will be established. Cognitive behavioral theory posits that cognitive and performance-based interventions produce changes in feeling, thinking, and behavior. It is assumed that full abstinence will not necessarily be achieved during this intervention, although that will be ideal, so instead changes in John’s feeling, thinking, and behavior that may predict abstinence such as the use of mindfulness techniques outside of the therapy sessions over the long term will instead be the focus of this measurement. Thus this approach is concerned with both the external environment of the individual, and his or her internal processing of the world, and therefore a qualitative analysis of the changes in his life will need to take place. Qualitative interview data which will be collected will contain John’s experiences, opinions, feelings, and personal information.Given the research methodology, only verbalized cues or comments will be included as raw data in the recording and transcription, although field notes will be taken at the time of the interviews in order to ensure that all non-verbalized information is also captured. Having each interview transcribed verbatim and keeping detailed notes will help to establish descriptive validity for this study (Giorgi, 2002). The following ethical standards will be followed. Before starting, the confidentiality and anonymity processes of the interview will be explained to John, questions about the nature of participation and the interview will be answered, and consent forms will be explained as well. A letter that includes a guarantee of confidentiality and additional information will accompany this process. John will be reminded that participation is voluntary and anonymous, and the decision to withdraw from the intervention has no penalty.ResultsInitial treatment sessions with John occurred in both the home and the therapy setting. At first, John initiated very little conversation. In my observations, I noticed that John was easily distracted, sought out negative attention, and acted out towards his family in the home. First, it was important that I find out what his thoughts were and provide education about how negative self-perceptions often lead to maladaptive behaviors. In the beginning of therapy, I focused on self-awareness in hopes that it would decrease his tendency to act out or turn to negative thought patterns that made using alcohol a simple way to address his stress and fear. It seemed that John was aware that people around him wanted to help him but that in order to receive this help; he would have to shift his approach to making changes in his life. My approach was not to explore the unconscious underlying conflicts with John but instead help John change his own internal schemas. To achieve this goal, once John had had moved from the precontemplation stage to the contemplation stage of therapy, we moved into mindfulness technique preparation and development. This involved the aid of externalities such as hot baths and quiet reading, and later through the use of relaxed stretching such as yoga for a minimum of 20 minutes per day and then meditation practices. Each class, whether regular exercise or yoga, ended with a 10-minute deep relaxation period with John lying supine. Progressive relaxation, visualization, and meditation techniques were also introduced during this time, with a focus on external and internal practice. This reflected the literature findings that stated that yoga which is practiced outside “was associated with greater feelings of revitalization and positive engagement, decreases in tension, confusion, anger, and depression, and increased energy” (Coon et al., 2011). While some physical activity can lead to a more positive outlook due to the cessation of specific symptoms, other forms of activity may increase potential for socialization or endorphin-related mood changes (Coon et al., 2011).As we moved into mindfulness techniques, John’s internal dialogue was changing, which was a healthy indication that my treatment of John was progressing. John commented on how he felt that he was not a “normal” person, but that he wanted to change his future. It was during these sessions that I attempted to expose his faulty cognitions by having him generate alternative thoughts to his current thoughts. Mindfulness techniques would serve several purposes, which include strengthening John’s ability to deal with stressful situations. In this manner John would no longer have to feel that he was vulnerable; rather, he would experience control over his impulses. Some of the techniques that were taught to John included the use of “I” statements, such as “I feel,” or “I believe,” or “I think,” thought stopping, counting backward from 10 to 1, breathing control techniques, and use of positive imagery. I gave John assignments that would help him master these techniques. Many of the stress management techniques helped John overcome periods of crisis; these techniques were used therapeutically and eventually incorporated in mild stressful situations. John’s actions were indicative of an overt behavioral change. We had progressed to the point that John was able to incorporate healthy thought patterns. In doing, he was able to deal with situations that caused him discomfort. He these new stress management techniques to keep him from reverting to crisis mode and he utilized these management techniques to move him out of crisis mode into a more healthy thinking. John had progressed in his treatment to the point of being able to offer specific feedback to parts of his therapy and I was pleased with his progress. He uses his focus on mindfulness as a means to manage his frustration as opposed to threats and acting out against people around him, and his reliance on substances as a means to manage stress seems to be alleviated for the most part. He admits to having used alcohol during the intervention process but notes that it has decreased significantly, and on our last meeting he had not used alcohol in over a week, which shows how this process is going. To this end, one might consider the outcomes of this process successful. The outcome of the intervention relative to the goal identified with the client was to work towards abstinence is therefore a positive one, but these processes need to be maintained over the long term in order to determine just how successful this process was. A maintenance phase for this intervention would be to begin to help John try out different yoga and meditation programs to find a studio or exercise club where he would gain a social group interested in the same goals. This would help him solidify his experiences and come to develop his own ways of using the skills that he has used by interacting with others and building a social foundation in which to continue and commit to these processes outside of a therapeutic relationship. Combining the maintenance phase for this intervention with John’s entrance into a 12-step program is the aim of this intervention. Another part of maintenance, after John enters the 12-step program, may be to augment his yoga work with other forms of physical health in order to build his self-esteem and focus on new future goals. As noted by Whitelaw, Swift, Goodwin, and Clark (2008), the connection between the type of exercise and its relationship with mental health may be connected to both self-esteem and self-concept. What this means is that there is a need to recognize the relationship between what people think they should do, what they want to do, what they are doing, and their overall mental health and quality of life. In other words, people who are not exercising as often as they believe that they should are more likely to derive a benefit from doing more exercise. Conversely, people who are doing too much physical labor either at work or at home may feel that they are not fulfilling their self-concept and thus may be negatively affected by that particular form of physical activity. This is why, as Whitelaw et al. (2008) point out, there is a universal mental health benefit to leisure activity. Given these challenges, it will be important for John to begin to see his yoga and meditation practice not as ‘work’ associated with therapy, but instead something that he does to build his own self-concept as a healthy person, associated with leisure.DiscussionThere are few changes to this intervention plan that I would make after reflecting on the results of this evaluation, since it seems to have achieved the goals that John and I set out together, but there are limitations in this approach that suggest that this intervention may not be appropriate in every case. The literature has demonstrated that there is a need for further examination into the meaning of existing data, especially based on demographic variables linked to gender, chronic conditions including clinical depression, and self-rated health status (Whitelaw et al., 2008). To this end, this intervention may not be as valuable to some people with slightly different challenges as John related to their substance abuse. For example, for some individuals, the intervention is supplemented with other interventions such as traditional therapies so that they can explore the ways in which their abuse of alcohol developed, or supplemented with pharmacological therapies if depression or anxiety is part of the equation. In terms of psychotherapy it may be argued that while mindfulness merges well with many different therapies, it is perhaps its practices that are of the highest therapeutic benefit, in that it is helpful in that it gives individuals freedom to find themselves and what is important to them, so that they allow themselves to live better lives.The limitations of this evaluation, both in general and in relation to validity and reliability, are connected with the fact that it is overtly qualitative rather than quantitative. John was not yet ready to measure his alcohol dependence or intake, in that the point of this intervention was to get him to that point. One cannot therefore measure whether this form of mindfulness-based cognitive behavior therapy is effective at reducing relapse in John over extended periods of time after formal treatment or engagement in this intervention has ultimately ceased. In summary, the overall effectiveness of my intervention with this client was significant. The concept of a patient like John taking great part in and leading their own therapy, and not simply subjected to instruction, or required to deliver monologue with an eventual diagnosis as a result, is an uplifting one. Because of the therapy’s ultimate goal for the patient to begin to act as their own therapist once they have become versed in the practice of cognitive and behavioral analysis and change, one can assume that successful patients will face lower rates of relapse of their conditions, or in the case of persistent conditions with an biological basis, less severe relapses that may be less frequent as well. Research Article CritiqueAlterman, A. I., Koppenhaver, J. M., Mulholland, E., Ladden, L. J., & Baime, M. J. (2004). Pilottrial of effectiveness of mindfulness meditation for substance abuse patients. Journal of Substance Use, 9(6), 259-268.In the journal article, “Pilot trial of effectiveness of mindfulness meditation for substance abuse patients,” Alterman, Koppenhaver, Mulholland, Ladden & Baime (2004) present a study on a comparison of the experiences of 18 randomized substance-abuse recovery house patients who received eight weeks of mindfulness meditation in contrast to 13 patients who received standard treatment. The study examines mindfulness skill development in the context of substance-abuse recovery and counseling care. The problem posed by Alterman et al. (2004) is clearly stated and the argument and rationale for the study are both convincing and clearly articulated. The target of the intervention was to build coping skills and relapse prevention skills through the application of specific cognitive behavioral skills, in particular that of mindfulness. The primary terms and concepts, such as the difference between mindfulness and other forms of therapy used in this study were clearly defined, and the authors’ assumptions were made clear.The methodology of the study consisted of a mixed-method comparative pilot framework in which two sets of interventions were applied. One group received mindfulness meditation in addition to standard treatment, while the second group received standard treatment alone. The sample included both substance-dependent men (n~14) and women (n~17), all of whom were residents of a recovery house located in Philadelphia (USA) and who had been in treatment for up to two months at the time of the study. The sample was not assembled randomly, but instead was a convenience sample consisting of random assignment within the two groups. The mixed-method research design included evaluations of each participant’s status, consisting of measures of substance-abuse-related problems, as well as measures of positive psychological states. These measures were conducted at the point of entry into the study and at two follow-up points, specifically eight weeks and five months after the intervention started. These were conducted with existing valid and reliable measures, which were appropriate for the research protocol given the case. No independent and dependent variables, research questions, or hypotheses were presented in the article, although given the nature of the study it was evident that the authors were hypothesizing that there would be a connection between the efforts of mindfulness practice and lower substance abuse. While extraneous and confounding variables were not controlled by the design, the authors indicated quite specifically that the participants in the study were relatively severe substance abusers with a history of poor societal skills, and to this end, they were residents of a recovery house rather than a regular treatment program. What this means is that this sample may not have been the ideal group of individuals to take through a study such as this because they represent an extreme population that may or may not demonstrate positive outcomes associated with any recovery program, let alone one such as this. While measures were administered consistently to each group, it is not clear from the article the specific differences in the two study groups’ practices, as only mindfulness tasks are detailed. While all of the sessions were monitored by a recovery house counselor under a single lead counselor, there is no indication as to whether the sessions for both groups were run by the same counseling team, and therefore the experiences of each group may have been significantly different given individual differences in the ways in which counselors run sessions. In addition, with such a small group of individuals, the validity of the sample data may be called into question even though the construct validity of the instruments are sound and the statistical tests used to measure these were accurate. In other words, it is important to turn a critical lens to the way in which the data has been framed. With a small sample size, and patients who are at the more complex end of the substance-abuse spectrum, it is not necessarily possible to determine the statistical significance of their experiences. While statistical tests were likely interpreted correctly, based on the small sample of data presented, these could not necessarily reach significance no matter how correctly the authors of the study conducted the research. At the same time, the study authors do not identify problems of control that were not addressed by the design or analysis in their article, and do not mention limitations of the study other that the sample characteristics. Despite all of this criticism, due to the fact that this was a pilot study, it is likely that these results were expected on a practical level, and therefore the alternative conclusions considered by the study team, namely that a bigger study would be likely to yield considerably different results, are also likely to be accurate. The implications of this research on the client, John Doe infers that mindfulness meditation in addition to standard treatment may not be the best approach for individuals with more intensive substance abuse challenges. At the same time, what is also clear from this study is that the authors came to the conclusion that under certain circumstances it could prove to be beneficial, especially since there were indications that patients’ overall medical health might be bolstered by this type of intervention. The article demonstrates the need for future research to determine the benefits of alternative techniques, such as meditation and yoga techniques with the emphasis on attempting to calm the body and mind. These techniques were used in both studies to strengthen one’s ability to deal with stressful situations and manage impulsivity and the relationship of impulsivity to substance abuse. Increasing a patient’s overall medical health could be seen to create the foundation for a long term change within a patient’s psychological welfare, which is an important goal in the process of recovery. To this end, the Alterman et al. (2004) study was vastly beneficial in understanding the possible positive implications of this kind of counseling practice in the recovery process of John Doe. ReferencesAlterman, A. I., Koppenhaver, J. M., Mulholland, E., Ladden, L. J., & Baime, M. J. (2004). Pilottrial of effectiveness of mindfulness meditation for substance abuse patients. Journal of Substance Use, 9(6), 259-268.Beck, J. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York: Guilford Press.Coon, J. et al. (2011). Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environmental Science and Technology, 45(5), 1761–1772.Giorgi, A. (2002). The question of validity in qualitative research. Journal of Phenomenological Psychology, 33(1), 1-18.Kelly, B. (2008). Buddhist psychology, psychotherapy and the brain: A critical introduction. Transcultural Psychiatry, 45, 5-30.Kiluk, B., Nich, C., Babuscio, T., & Carroll, K. (2010). Quality versus quantity: Acquisition of coping skills following computerized cognitive-behavioral therapy for substance use disorders. Addiction, 105(12), 2120-2127.Kirsch, I., Lynn, S., Vigorito, M., & Miller, R. (2004). The role of cognition in classical and operant conditioning. Journal of Clinical Psychology, 60(4), 369-392.Marlatt, G.A. (2002). Buddhist philosophy and the treatment of addictive behavior. Cognitive and Behavioral Practice, 9, 44-50.McGovern, M., Fox, T., Xie, H., & Drake, R. (2004). A survey of clinical practices and readiness to adopt evidence-based practices: Dissemination research in an addiction treatment system. Journal of Substance Abuse, 26, 305-312.Walters, G. (2002). Twelve reasons why we need to find alternatives to alcoholics anonymous. Addictive Disorders and Their Treatment, 1, 53-59.Weiten, W. (2004). Psychology: Themes and Variations. Belmont, CA: Wadsworth/Thomas.Whitelaw, S., Swift, J., Goodwin, A. & Clark, D. (2008). Physical Activity and Mental Health: The Role of Physical Activity in Promoting Mental Wellbeing and Preventing Mental Health Problems. Edinburgh: NHS Health Scotland. Witkiewitz, K., Marlatt, G., & Walker, D. (2005). Mindfulness-based relapse prevention foralcohol and substance use disorders. Journal of Cognitive Psychotherapy, 19(3), 211-228. ................
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