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Wise Counsel Interview Transcript: An Interview with Stefanie Goldstein, Ph.D. on Mindfulness and Addiction

David Van Nuys, Ph.D.

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David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by mentalhelp.net. covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

[music]

David: On today's show, we'll be talking about mindfulness in the treatment of addiction with my guest, Dr. Stefanie Goldstein. Stefanie Goldstein, PhD, is a clinical psychologist who integrates traditional psychodynamic psychotherapy with progressive psychotherapeutic interventions such as mindfulness, psychosynthesis and somatic psychology.

Dr. Goldstein is also an addiction medicine specialist and a trained practitioner in psychosynthesis, an integrative form of psychology that focuses on the synthesis, healing and growth of the self. She has worked individually with adolescents, adults, couples and families and has facilitated many process and education groups. She also had a rich and varied training experience working in multiple community mental health and healthcare organizations in the Bay area.

And now, here's the interview...

Dr. Stefanie Goldstein, welcome to Wise Counsel!

Stefanie Goldstein: Thank you! I'm glad to be here.

David: Yeah, that's great. I'm glad to have you too. I'm particularly intrigued to interview you because as you may know, I recently interviewed the internationally known mindfulness teacher, Shinzen Young, on this show and you're bringing mindfulness into your work on addictions. So, I thought speaking to you would be a good follow-up to that show.

Stefanie: Yeah, I listened to that interview. It was really a great interview. The work that I do is more on a practical, everyday, in the therapy room...

David: Exactly, exactly, and that's precisely why I wanted to bring you on. So, maybe we could start off by having you talk about your own spiritual journey and what led you to incorporate spirituality and particularly, mindfulness, into your work.

Stefanie: Sure! So, I think, for me, my interest and intrigue in spirituality really began in high school. I had a dear friend who was really struggling and then eventually dying from bone cancer when I was in high school. He led this journey of questioning and really just struggling with God and yet never giving up on it and it really incited my own spiritual journey at the time and my initial dissertation research was actually on spirituality in adolescence and looking at is it emerging for other teens and how is it manifesting and how are they experiencing it.

And so, for me, it really set me on a journey at that point of just searching, searching for meaning, for what fits for me, to try and make sense of this world. I read a ton of books and began to be interested in Buddhism and my background initially is in Judaism, and finding that both really began to fit for me together. When I graduated from college, I travelled around the world for a year, which also was quite a spiritual journey, in and of itself.

While I was travelling, I did a 10 day Vipassana meditation retreat in Thailand. That was such a profound experience for me, partially because when I arrived, in my ignorance, I didn't know it was going to be silent...

David: Oh my goodness!

[laughter]

Stefanie: So, I got there and they're like, "All right, let the silence begin" and I was like, "What?" Which, at the time, I think actually ignorance was bliss. Had I known, it might have felt too overwhelming and intimidating to actually choose to go. And so, it really deepened my spiritual journey. As I was travelling, I realized I wanted to go back to graduate school and continue my path of becoming a therapist, which is something I always knew I wanted to do.

But realizing and becoming clearer to me that I wanted to somehow incorporate spirituality in that. And I didn't quite know how, I didn't if there were programs that did that, but I knew that that was very important to me because I felt like all aspects of the self were equally important, that it wasn't the therapist and in therapy, it wasn't just about your mind and your emotions, but it was about your heart and your soul.

And so, once I returned from travelling, I began searching programs and I found a few that did that and I ended up going to the Institute of Transpersonal Psychology in Palo Alto, which is really where spirituality is infused throughout the entire program. And I feel incredibly grateful that I got that foundation and education because it ultimately then led me to connect specifically to mindfulness.

One of the things that, personally and professionally, that I love about mindfulness is that it's spiritual and practical. That, sometimes, when you're dealing with mystical aspects of religion or different parts of spirituality, it can get incredibly complicated and intricate and Buddhism and mindfulness certainly can be that way as well, but there are certain things which are just fundamental parts of it, like your breath. Just breathing, we all have to breathe. We wouldn't be here without it.

And so, learning how to use your breath as an anchor can be such a profound tool to help guide us as we go through any trials and tribulations through life.

David: OK. Well, that's all very fascinating. I think that you are probably one of a new breed of younger psychotherapists coming on the scene who see this possibility for integrating facets of spiritual practices into psychotherapy. Let me shift the focus just a little bit now and ask how did you get involved in working with addictions?

Stefanie: Well, I would say it's both personal and professional. Personally, I have had addictions affect my family. I had a grandparent who struggled with alcoholism, and I've also had two dear friends of mine who have died from overdoses, from accidental overdoses. And so, it's always something that I have been interested in learning more about and knowing more about to make sense of my own personal experiences.

And then, professionally, as I was going through my training, I ended up getting a fellowship with Kaiser Permanente's Chemical Dependency Recovery Program in San Francisco, which is where I became an Addiction Medicine Specialist. I really fell in love with the work because people come in and they're struggling and they're in such a bad place, most often, when they're actually coming to get help. There are so many things they've tried and it hasn't worked, and the transformation that can occur is really quite profound.

In addition, it seemed like a natural fit with my interest and expertise in spirituality and mindfulness because so much of the recovery world is focused around connecting to some sort of higher power, whether it's through something like AA or other ways in which to do that, but really beginning to fill that spiritual void that is often connected with engaging in addictive behaviors. And so, it felt like a really good fit and that's where it took off for me.

And then, my husband, Elijah Goldstein, who is also a psychologist and who also does a lot of work in mindfulness and he's a mindfulness-based stress reduction teacher, we decided to kind of pull our efforts together and do some research and create an audio CD on mindfulness. Really, it's called "Mindful Solutions for Addiction: Relapse Prevention, " which is a psycho-educational CD where the first three tracks talk about what is mindfulness, how it works with addiction. And then, the next three tracks are actually guided, progressive meditations of 5, 15 and 25 minutes.

David: Well, I'll make sure that we have a link to your CD in our show notes. Now, I'm under the impression that you have either studied with, or been under the influence of, Dr. Alan Marlatt, who, in turn, was influenced by Dr. John Cabot Zinn. Maybe you can fill us in a bit about their work.

Stefanie: Sure! So, John Cabot Zinn created a program called "Mindfulness-Based Stress Reduction" which is now in over 250 hospitals in the United States. And he said to the doctors in the hospital, "Give me all the people with chronic pain that you feel like you can't help. That pain is just too profound, and medication and all these others ways have not helped them." And he created a program which incorporates mindfulness medication, psycho education, and yoga, it's an eight week program.

There's been so much research, and so many positives results for people really becoming more aggrandized, changing their relationship to their pain, and really reducing their stress. What has now happened is that people have taken the Mindfulness-Based Stress reduction (MBSR) and created different programs offshooting from that.

There's Mindfulness-Based Cognitive Therapy. Dr. Alan Marlatt from the University of Washington and his colleagues are in the midst of creating and doing research on Mindfulness-Based Relapse Prevention. So it's taking the principles from MBSR and applying them specifically to addiction and relapse prevention. Dr. Marlatt and his colleagues just completed a preliminary study with a two-year grant from the NIDA, the National Institute of Drug Abuse, with really great findings. They are in the process of applying for a five year grant from the NIDA, which they are including RCD as part of their grant, and which will be part of their program as well.

So it's an eight-week program that takes you through psychoeducation, how to work with urges and triggers and uncomfortable and negative emotions, and teaching meditation, and meditation is a part of the program. You need to be meditating 30 to 45 minutes a day, and also yoga. We haven't directly studied with Dr. Marlatt, but we have a relationship with him and we definitely studied his work. We were just recently at the University of the University and gave a talk to his graduate students.

So there's also been other research that has been done, not necessarily with addictions, but with mindfulness and mediation. Dr. Richie Davidson, a neuroscientist, from the University of Wisconsin, has conducted research with brain imaging technology. This is a really simplified way to describe it, but his findings show that people who practice mindfulness meditation tend to show more activity on the left side of the brain, which is typically associated with positive emotions, such as feelings of calm and happiness, versus the right side of the brain, which is typically associated with feelings of sadness, worry, and anxiety. All of those negative or uncomfortable emotions are one of the ways that can trigger and lead us to relapse.

In addition, a study at the Addictive Behaviors Research Center shows that prison inmates who self-selected into mindfulness meditation showed significantly less relapse rates than the other inmates who did not. So there's a lot of really great emerging research out there, it's really exciting.

David: It is, it's really fascinating to hear about this research and I've also interviewed other people and earlier interviews in this series, who have been using the concept of mindfulness in a variety of psychotherapeutic approaches, ranging from ones that are behavioral in nature, as you already indicated, to ones that are psychodynamic in nature. Mindfulness really seems to be the concept of the hour. It's very interesting to see that it's now getting rooted in studies having to do with the brain. Let me move you into another aspect of your work, because I know that you also draw upon psychosynthesis. I'm familiar with psychosynthesis, but my listeners might not be. Tell us something about that approach, and how you integrate it into your work with addiction.

Stefanie: Sure, well first of all I'm very glad to know that you are familiar with psychosynthesis. When I came to the Institute of Transpersonal Psychology, I was searching for a way to integrate the spiritual aspect and the soul into all of the other parts of the self. When I found the theory psychosynthesis, which was created right around the same time that Freud was coming up, by an Italian psychoanalyst named Roberto Assagioli. As Freud was beginning to break apart the parts of the self, Assagioli came in and said, "How can we synthesize this? How can we take ourselves, and all the parts of ourselves, the parts that we like and we don't like, our mind, body, spirit, soul, emotion. How can we take all of these parts and integrate it into a whole self?" I took action of course during my graduate program and I took an extended two year training in Palo Alto with Anne Gila and John Perman, and Perman studied with Assagioli before he passed away.

Psychosynthesis and mindfulness informs much of what I do. One of the great things about psychosynthesis, is it doesn't take ideas from, but it is very similar to ideas of object relations, where so much of our wounding happens in relationships. So much of our healing can also happen in relationships. Through creating new authentic relationships and internalizing them and having those live inside of us, in addition to the negative ones or traumatic ones we had as children, we really begin to heal us.

David: I seem to recall that psychosynthesis also involved a lot of guided visualization and techniques like that.

Stefanie: Absolutely.

David: Are you using those sorts of approaches in your work with addiction?

Stefanie: Yes, that's also where the mindfulness comes in. It can be a really great adjunct and complement to each other. I do a lot of guided meditations or imagery, because so often we live in heads and it's so hard to get out of our heads, that if we can focus on something else, we can begin to have a different experience, whether it's having a body scan, or doing a medication that focus on our body. Or, if it's taking someone through an imagery of seeing what emerges for them, what is potentially, what they're not aware of, what might be lurking beneath the surface for them, that they're experiencing that hasn't come to their conscious awareness yet. The long answer is yes.

[laughs]

David: What source of addictions are you seeing as most prevalent these days?

Stefanie: It really ranges. The two that have been most on the rise are meth and prescription drugs. The problem with prescription drugs is that they're in all of our medicine cabinets. So they're incredibly accessible and easy for teenagers, adults, to get your hands on and misuse. Not that everyone is, there's plenty of people who are prescribed either vikodin or any of these narcotic pain relievers, or valium, that use it as prescribed, under a doctor's orders, and they're fine. There are people which start to take a little bit more, and take a little bit more, and aren't necessarily telling their doctor that they're doing it, or taking their friends, or on rise is taking pills and then drinking. We've seen a lot of Hollywood actors recently in which the combination of these types of drugs has actually become lethal. In Heath Ledger's example, and there's been a few others as well. I don't think the dangers are quite as known to people because it's not illegal. It's in our medicine cabinets so it's safer somehow. And yet, taken not a doctor's supervision and with combinations of other drugs, can actually be really lethal. It's really important for our listeners who are potentially maybe using a little too much, or using their friends, or whatever the situation is, to really be careful and know that this could potentially cost you your life if you take too many or combine it with other drugs.

David: I've seen some really scary things on TV about methamphetamine. I've not worked with anyone who suffers from that addiction, and I don't knowingly know anybody who is hooked methamphetamines. Based on what I've seen in the media, it almost sounds like it's impossible to get off of. What's been your experience with that?

Stefanie: I wouldn't say impossible, because I would never want to put that message out there, because I believe anything would be possible. I would definitely agree that it is one of the hardest drugs for people to kick, essentially, and how you see that is that there's not a lot of people in recovery who are trying to recover from that and it's not because there's not that many meth users. It's because it's that hard. I mean, it really grabs someone and just arrests them and keeps them so consumed by it. It's really one of the scariest drugs we have out there because it has such a strong hold over people.

David: Well, I know that you're able to talk a bit about how addiction affects the brain. And so, maybe this conversation about meth is a good place to bring that in. Just what is it that goes on in the brain in relation to addiction?

Stefanie: So, there's a couple of things. One, is we all have this neurotransmitter called Dopamine. Dopamine is really associated in our brain with our pleasure system. When we eat a good meal; see a sunset; look into our lover's eyes; Dopamine is released. It's what makes us feel good, that kind of like, "Ahhh... That was a nice feeling."

One dose of cocaine can produce 10 times the amount of Dopamine that eating your favorite meal produces or looking into your lover's eyes.

David: Wow!

Stefanie: People vary in their innate sensitivity to Dopamine. Some of us are born with more Dopamine receptors; some of us are born with less Dopamine receptors. Those of us born with less Dopamine receptors are much more susceptible to developing an addiction because once they try a drug or alcohol, that surge of Dopamine is like nothing they've ever experienced before. All of a sudden, their brain's like, "Ohhh... I want more of that", and it begins to remember the situation in which this drug was occurring. So, where you were, the smells, the people you were with. All of these things start to become triggers because your brain remembers, "I want to feel this again. So, what's going on right now that I can remember, that I might be able to feel this way again if I'm in this situation again?"

It's one of the ways in which addiction can run in families because it can be hereditary, the amount of receptors that we have to Dopamine. In addition, a researcher, Kevin McCauley, out of the Institute of Addiction Study in Utah, is beginning to find where exactly in the brain, addiction is located.

It was thought for a long time that it would be in the prefrontal cortex because our prefrontal cortex mediates delayed gratification, executive functioning, such as judgment, reasoning, problem-solving. And yet, what they're finding is that it's actually in the most primitive part of our brain, which is the midbrain.

The midbrain deals with the next 15 seconds. So, basically, intense hunger, if you're in danger and you need to protect yourself, that really just raw, primitive part of ourselves that's all about survival. And so, what begins to happen is the more and more that we use a drug or alcohol... And by drug or alcohol, this really could be eating, this could be gambling, this could be shopping, emailing... I mean addictions come in all different forms and sizes.

I mean, in this interview, we've been talking more about drugs and alcohol, but just to really widen that, then it really could be any of those kinds of addictions. So, the more that we start to use, the more we begin to ignore our survival mechanisms, like to eat, in order to get the high.

We begin an addiction, essentially, can equate to a broken pleasure system. So, all of a sudden, when we were initially using in order to get that surge of Dopamine and feel high, the more that we use, the less we get high and the more we have to use in order to just feel normal, in order to not withdraw from whatever substance you're using.

So, it's really incredibly powerful. It's also, I think, very liberating to find that researchers are finding where in the brain that addictions are located because so often, when we think about someone who's addicted, the images that come up are someone who's dirty and homeless and a bad person who robs and steals. Yes, there are those people, but there are so many more because one of the craziest things about addiction is that it doesn't discriminate.

It doesn't matter how much money you make, who you are, what color of the skin you have, what country you're born from, none of those things matter, it can touch any single one of us. And so, all of that shame that often comes with being an alcoholic or being a drug addict that our society sort of places upon people, finding out that this is actually happening in the brain can be really liberating.

David: I wonder if you could give us a quick overview of the kinds of concrete steps you might use in your addiction work. In other words, how would you combine mindfulness, cognitive behavior therapy and psychosynthesis? Maybe there's a case that comes to mind that you could kind of quickly step us through the actual steps that you took?

Stefanie: OK. So, when working with someone who is struggling with addictions, whether, like I said earlier, it's eating or drinking or drugs and alcohol or gambling, one of the first things I would do is to help the person bring awareness to what Dr. Marlatt calls and what we all, I think, know is that auto pilot, that idea that we go through life doing things that we know how to do without any awareness.

I mean, how many times have we driven somewhere and arrived and not even remembered driving? Or, been eating our food and finished a meal and not even really tasted it yet. And so, it's really beginning to bring awareness to your own experience. Part of why we do that is because these things are easy to do. We know how to eat, we know how to drive. We don't necessarily need to think about it.

And yet, if we're not thinking about it, if we're consciously aware in those moments, it can lead us to a relapse or it can lead us to engage in addictive behavior without consciously choosing. We can, all of a sudden, find ourselves in a bar halfway through a bottle of vodka without even having chosen to have done that.

And so, it's really important to begin to know what's going on for you and really learn how to become present in the moment. I would do that through guided meditations, reflecting back to people when they're telling me an experience and I can maybe sense that they're not really present or they weren't really aware of what was going on and really beginning to bring that awareness into their consciousness more.

It takes practice. It's not something that once you learn you've been unaware, now you can flip a switch and be like, "All right! I'm aware now." It takes practice and often, it starts by realizing it after the fact. And then, you can begin to realize it a little sooner and maybe towards the end of engaging in the addictive behavior and then towards the middle and then as you continue on, you can realize that before you would get engaged and you can actually then choose what you want to do.

David: OK.

Stefanie: Then I would probably move into really talking about cravings and urges. Dr. Marlatt defines a craving as a desire to experience something. So, really more of a mental process. You're driving around, it's a beautiful day, you think in your head, "Oh, wouldn't it be nice to go to a café and have a glass of wine." Where an urge is a sudden impulse to engage in whatever the addictive behavior is. So, drinking, shopping, gambling.

So, really, it's almost like a visceral experience that takes you over and it's like, "Ahh... I've got to have a drink." And so, beginning to identify what triggers your urges and cravings.

There are three sorts of main ways that urges triggers our craving and then they're more specifically for each person. So, the first one is a lack of insight into the body feeling state. As I have said earlier, many of us live just in our heads and we're often unaware that we even have a body or how our emotions can transform and connect into our body. And so, beginning to have that awareness, beginning to take that pause, that moment, to check in with yourself when you're experiencing something.

Maybe you were at work that day and you finished a project and your boss told you to redo the whole thing and you're feeling these feelings of frustration that you don't really want to feel, so you put them aside. And then, all of a sudden, later in the evening, this intense urge comes on to have a drink and you find yourself in the bar wasted, when you had said earlier that wasn't what you wanted to do.

Well, had in that moment, you stopped and taken a breath and said, "OK, what's going on for me right now? OK, I'm sensing that I'm experiencing some frustration, some anger, some disappointment, maybe some shame." And then, taking another breath and tuning into your body, "Where am I feeling in that in my body?" My chest feels a little tight and constricted. My shoulders feel tense. And just sitting with it, not trying to then make that go away.

One of the key and most important parts of mindfulness is that it's tuning in to the present moment without our lenses of judgment. That it's just being with whatever is, which is an incredibly profoundly difficult thing to do. And yet, if we can just be with ourselves, wherever we're at, and not try and change it or stuff down the parts that we don't want to feel or ignore the parts we don't want to feel, it can begin to liberate us from them.

And then, the next thing, I would say, is the way urges and cravings are triggered is our defensive and distorted styles of thinking. These are things such as denial, catastrophizing. Really, the idea that we're not seeing reality as it actually is, we're putting some sort of lens on it. So, denial.

David: This is where the cognitive behavioral part comes in, right?

Stefanie: Yeah. This is where the more cognitive behavioral piece comes in, exactly. So, this would be providing psycho education so that someone can begin to see how they are, what their distorted styles of thinking are, so that they can begin to really normalize it and see it from a little bit more clear of a perspective. It's kind of like, I like to use the metaphor of a camera lens, where if you're super zoomed in, all you see is that little, tiny speck that you're focused on.

So, mindfulness really helps us to take a step back and bring that lens to a broader perspective so that we can see more of the situation, we can get a better perspective, we can have more choice in what we're doing. And so, some of the other distorted styles of thinking are minimizing, "I only had a few drinks. I was OK to drive." Or, rationalizing, which is as we all do. I mean, these are certainly not just specific to addictions. We all do these for varying reasons.

Or blaming, "You would drink too if you were married to her." Bargaining, trying to cut a deal that you'll quit when such and such happens. Or, catastrophizing. So, assuming the worst possible outcome, which can get bigger and bigger. Or "all or nothing" thinking, that if you have one sip of wine, your entire recovery is ruined, rather than looking at it as a slip and knowing that you can step back into your recovery.

Then, finally, the third way that urges and cravings are triggered is our automatic negative interpretations of events. This is something that I actually find that people have a hard time totally being able to understand. It's the idea that events in and of themselves are neutral. It's our interpretation of the event is what gives it meaning.

An example that I like to use is if you think about the conflict in the Middle East, it can be looked at from both sides. So, you take someone from an Arab country who comes in to Israel as a suicide bomber and walks into a pizza parlor and sets off the bomb. While the Arabs that are from the same faction sees this person as a martyr, and that really what they have done is furthering their cause and it's for the good of their people and they truly believe this. And then, you ask Israelis and it's the worst thing that ever happened.

You can really begin to see that the event is the event, but how different people interpret it, is what gives it meaning. That's a really extreme example, but as walk through our daily lives, we go on a date with someone and they don't call back immediately the next day and we can interpret that as they didn't like us and I'm not good enough. When, if fact, maybe they were busy.

We don't often know, and yet our minds can run with all the possible automatic negative interpretations.

David: Sure.

Stefanie: And all of these three things, when we're not aware, when we're in automatic pilot, can lead to us engaging in our addictive behavior, without us being aware, without that conscious choice.

David: OK. Well, I think we're probably running short on time here. I wonder, for anybody who might be suffering from an addiction themselves or have family members, I am going to refer them to your CD and your website. I wonder if there's any reading that comes to mind that you would recommend?

Stefanie: Well, there is. I think Thomas Bien has written a book called "Mindful Recovery" which I would certainly suggest also. And then, any of Dr. Marlatt's work, which tends to be a little bit more focused towards therapists. So, I would say for the therapists out there, to definitely check out Dr. Marlatt's work and to look for "Mindfulness-Based Relapse Prevention" coming more in your area.

Then, Thomas Bien's book, "Mindful Recovery" and also our CD, which is "Guided Meditations in Psycho Education", which can be found on our website which you had said you'll post on your website?

David: Yes.

Stefanie: Also, for the listeners out there, it's www.drsgoldstein.com. You can purchase our CD through our website and it's also on Amazon.com.

David: OK! Well, Dr. Stefanie Goldstein, thanks so much for being my guest today on Wise Counsel.

Stefanie: Thanks, David. I really enjoyed it.

[music]

David: I hope you enjoyed this interview with Dr. Stefanie Goldstein. You can find out a lot more about Dr. Goldstein by visiting the website she shares with her husband, Dr. Elijah Goldstein at www.drsgoldstein.com. You'll find links there to their audio CD, "Mindful Solutions for Addiction and Relapse Prevention" as well as other helpful materials.

You will also find inspirational poetry on their site, such as this selection from the Sufi poet, Rumi, which is titled "The Guest House."

"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.

He 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."

[music]

You've been listening to Wise Counsel, a podcast interview series sponsored by MentalHelp.net. If you found today's show interesting, we encourage you to visit MentalHelp.com where you can add a comment or question to this show's web page, view other shows in this series or simply page through the site, which is full of interesting mental health and wellness content.

Access this show's page and show archive information via the Podcast Box on the MentalHelp.Net home page. If you like Wise Counsel, you might also like Shrink Rap Radio, my other interview podcast series, which is available online at www.shrinkrapradio.com.

Until next time, this is Dr. David Van Nuys and you've been listening to Wise Counsel.