Interview with Dan Dickinson

I had the opportunity to interview Dan Dickinson, who works for Kaiser Permanente as Clinical Services Manager in the Department of Addiction Medicine. Dan has a personal mindfulness practice and uses it in his work with clients. He states,

“People with addictions have incredible needs around self-maintenance, self-soothing, [and could benefit from] detachment from thought, just being able to observe thinking. Addiction patients are so much on automatic pilot, based on their drug use. Any sort of difficult feelings that they’re experiencing or their stressors, their automatic pilot will say “go get some sustenance,” from alcohol or whatever drug that they use. So I thought boy, this has some real relevance. I started bringing individual [mindfulness] skills into my practice from then on.”

EED: Why don’t you tell me your personal history with mindfulness in your practice?

DD: I first started practicing, or trying to practice, in the 70s–the early 70s, actually. I thought it was a good idea for me to do and I went to Boulder, Colorado and sat for a summer. And had maybe one of the most miserable experiences of my life. I was not ready for it—I was just not ready. Maybe it was my youth; I don’t know what it was, but it was kind of like I had too much energy to burn, too many places to go, too many things to see, to be able to just sit and pay attention inside.

EED: And this was at Naropa?

DD: Yeah. And so, I really kind of left it for quite awhile; just didn’t really do much with it at all. There’s always been this piece for me around a spiritual quest, were it to be involved in a religion or not, whether to follow up on my original religious background, which was Catholicism, or not—I chose eventually to not. So there’s always been this kind of spiritual quest that I’ve had. And then about twelve years ago I guess it was, I talked to a person that actually works on our staff here who is a rōshi. I asked him a little bit about meditation, about sitting. And we just basically kind of talked about the form. And that night I sat, and I’ve sat each night since then. Each night, or day, since then. I generally sit at night. I can’t back the time off any more than that, so my practice is in the evening. My practice was a solitary practice for a lot of years. I checked in with Leonard from time to time about experiences I was having, and technical parts of the practice, and that sort of thing. Not so much as a teacher, but really as a mentor, in a way.  I then talked to him about two years ago and said, “I think it’s time for me to go further with this stuff. I think it’s time for me to drop into a different level.” I was really surprised to find out that a lot of people don’t sit privately. And that a lot of people consider it very hard to continue on a practice for years just by yourself. I never thought different of it. That was an unusual thing to find out.

EED: You were surprised that your experience was different from the general concept?

DD: Yeah—what I’ve heard from multiple people since is: Gosh, how did you ever keep it up? How’d you ever keep going with it?

EED: For ten years.

DD: Yes. It was just one of those things…one of the things Leonard says is, “Put your ass on the cushion every day. No matter how long you sit, put your butt on the cushion.” And I really did take that in—I thought, OK, that’s a good thing, I can put my butt down every day, and from there we’ll see where it goes.

EED: How long—because I’ve heard that before in my own practice, and I think it’s very powerful, that it doesn’t matter how long, just make sure you get it into your routine. But how long do you average, would you say? Does it completely vary? Like one day, one minute, the next day, two hours?

DD: No, no, no, on average I will probably sit from 30 – 40 minutes. That’s the average sitting. It wasn’t that way when I first began; when I first began, there were a lot of technical problems I had, and a lot of frustration, and mis-knowledge, you know, I’d think OK, I’ve got to clear my brain of thought…a lot of things. Like, “I’m not necessarily relaxed.” I had a lot of that kind of crap that filtered into my personal experience with it. But once I got beyond that, yeah, the practice is about 30 to 40 minutes each day. I’ve actually extended it now. I usually will sit for thirty minutes with a five minute walk and then another thirty minutes. That’s been my pattern for about the last two years. And that seems a very easy pattern for me to follow, both physically and time-wise. And at the same time, a couple years ago, I talked to Leonard about kōan study, which I was not familiar with, but I had heard about it in a way. I just started asking some questions, when he kind of explained to me that it wasn’t a concept of figuring things out, but letting things work on you, it really resonated with me. That sounded like something that I could benefit from. It’s not something I have to engage in controlling; not something I have to learn, not something I have to do, or act upon. Which is my life! That’s who I am. I plan my life, I act upon it, I tend to be fairly aggressive with my life. So I kind of said, boy, that really sounds nice. I sat with that for awhile. I joined a sitting group at that time; I began to sit with a group. And really experienced a whole qualitative change. I still love sitting by myself, and I can’t say one is better than the other, but there’s such a different quality in it and I truly do love it. I love the intimacy of sitting with a group, and have since found for myself that by talking, I avoid intimacy. And sitting in silence develops a very intimate relationship with those around me that I’ve never thought about; never experienced. I’ve had intimate experiences with friends and people I know throughout my life, sitting in silence, but it was never an intentional practice; to sit. And that is something that seemed to evolve quickly for me. And then I began formal kōan study, and I still continue to do that. So, I generally do zazenkai once a month; the months that we don’t do zazenkai, we have sesshin; and that’s about three times per year. I try to make two out of three of those a year. Upon retirement, I’m hoping to go three times a year, on a regular basis—and also upon retirement, I’m hoping to be able to sit three hours a day, and just see where that goes. My concern is, I don’t want to trade quality for quantity. That’s really something that’s in my head around that. But actually, meditation has brought me to the place where I’ve chosen to retire. It was during sesshin this summer when it came to me: I don’t need to do this work for my identity. I’m separate from the work that I do. I’m a part of it, but it doesn’t make me who I am. At that point, I experienced a desire to let my sitting lead my life at this point. My life has always been planned; methodical. I plan vacations a year ahead of time.

EED: That works out great as an employee!

DD: Sure, it works well in a business sense—it works great for when I’m at the Center for Health Research; they’re nice qualities to have. But there’s something that I also miss. To use an expression, I’d like my soul to lead my life, rather than a calendar, or a structure. I’d like my structure to come from my soul.  And that’s an experience that I’ve really had in meditation.  I really do bring my life to the cushion, and one of my goals is to take my experience on the cushion back into my life.  I’m always amazed at how my life comes into sitting, and how a sense of clarity and answers come back. It’s really quite neat.

EED: My next question is how this is important to your clinical practice—and in your case, I’m interested in how your practice has changed as a result of this realization you’ve had that you’re separate from it, and also it’s informed the way you work with patients.

DD: Well, you know, I started learning about DBT, gosh, probably ten years ago, before it became really popular. I was really kind of taken by how [Marsha] Linehan had broken down the component parts of meditation practice and taught them as skills. And I thought that was really something that was quite nice. People with addictions have incredible needs around self-maintenance, self-soothing, detachment from thought, just being able to observe thinking. Addiction patients are so much on automatic pilot, based on their drug use. Any sort of difficult feelings that they’re experiencing or their stressors, their automatic pilot will say “go get some sustenance,” from alcohol or whatever drug that they use. So I thought boy, this has some real relevance. I started bringing individual [mindfulness] skills into my practice from then on.  I also deal with a lot of outpatients who have severe depression. I get many patients referred to me for severe depression and who have not really worked well with other therapists. So I felt then that there was a real gift that came through this DBT. But at the same time, I started noticing that DBT had limitations. I thought that some people that I dealt with could actually benefit from doing straight meditation, just going straight into it and not needing to learn the component skills but to embrace the full practice. So I actually began doing that; teaching that with a combination of what I call deflection skills, which is external visualization using different types of sensory stimuli—so, you know, either looking at a picture, or listening to a sound, or whatever the sense is that they seem to be interested in. I don’t use smell, simply because of the number of people I have who have been sexually abused. Smell is such a heavy trigger. I really don’t even go down that road as a sensory experience. Because of the things I was reading, and because of the research that was talking about communication between hemispheres of the brains and that sort of stuff, that the right brain—which seems to be the place—paying attention in the now is something that’s difficult for all my patients. Well, it’s probably difficult for all of us! Not just patients. But for them, particularly. I needed a way for them to be able to communicate with what they’re experiencing in the now. The right hemisphere doesn’t have language, except for art! And so what I ended up doing is I ended up starting to ask people to write haiku for me. I chose haiku because, one, it’s very limited in that, you know, it’s seventeen syllables. It forces a person to boil the experience and thoughts or whatever’s happening down to the kernel.  The other thing is that it’s a form of poetry that doesn’t require rhyming, and that sort of stuff. It’s a form that patients are not so familiar with so they did it without having that self-criticism, or feeling shy that “I’m not doing it right.” And in fact, when they do it, I don’t talk about, you know, if they have six syllables here, or eight syllables there. I don’t care about that. It’s just the limiting factor. The other is, I ask them to write the haiku on the experiences they’re having while meditating.  I’m trying to see if they can give the right hemisphere a language, to be able to kind of access it. It’s a self-reflective piece for them.

EED: So do you notice, given that there’s less self-criticism and just less pressure in general, with this assignment, that compliance is up? Do you experience patients actually doing their homework more?

DD: I think the thing that’s been the most helpful for me is I don’t really have many expectations around if they do their homework. I just say, “We just need to figure out something that you can do.  Something that you’re willing to carry on in between.” I think one of the things that helps my compliance right off with the meditation was, and I was really surprised by this, but…one of the first patients I tried this with, we practiced here in the room, and I spent, you know, five or ten minutes just sitting here in the office doing it, and I said, “Why don’t you try doing it for, you know, three or five minutes a day at home?” She came back next week and I said, “How’d you do on the homework?” and she said, “Well, yeah, I didn’t really do it.”And I said, “OK, that’s fine.” She came back a week later, and again: “I didn’t really do it.” And I asked, was there maybe something standing in the way? I tried to explore that part. A couple weeks after that, so a month after I gave the assignment, she said: “You know, Dan, I was kind of embarrassed to tell you this at first, but I really do want to say to you that I can’t do this because it’s against my religion.” I said, “Tell me about that.” She said, “Well, I’m a devout Christian. I think doing meditation would be like praying to another god.” I said, “That’s really interesting. That’s incredibly helpful for me to know.” And I moved away from it with her, rather than trying to work through it. What I did do after that point was, I assessed people ahead of time that I do this stuff with. I will present it to them in a different way. With some devout Christians, I will say: “Would you be willing to learn a different form of prayer?” I got incredible compliance with those folks. It was like, boy, here’s someone who’s willing to go into an area that I really find important. And other people that have problems with any kind of religious focus, I’ll say, “We’re going to talk about some awareness stuff. Just some ways of watching ourselves.” So the way I present it is the thing that gives me the greatest benefit. I’ll do some activities such as the ones Kabat-Zinn does around body scans, or the raisin exercise. And for when they go home I’ll say to them, pick an activity and focus in it more deeply in it than you’ve ever focused before. Washing the dishes: feeling the bubbles, smelling the soap, hearing your thumb as it slides across the plate. Kind of, just explore each of the five senses with the washing of the dish. The other thing I developed with this which I think works well is I have a gratitude list. A patient and I put it together—it’s an easy piece of paper. Each day you try to think about and remember something from each sense that you try to feel grateful for. It might be the smell of a small puppy, it might be the smell of fresh bread, the sight of snow falling through the evening looking up at the night sky, the sound of the wind blowing through the corn in the summertime. Try to remember something and notice something during the day and attach that to a sense. This was an attempt to use the mind intentionally to bring forth positive memory rather than negative memory, which comes automatically. That, coupled with the haiku, coupled with the meditation and DBT stuff, really seemed to be a package that seemed to work for a lot of people. So really, compliance—my guess is I’m getting probably well over 50% compliance, and my guess is probably somewhere around 70—80%. I’ve never really tracked it; I probably should have. But my retention rate for patients is extreme. I’ve been able to engage the patients in care that no one has been able to engage and people who for years show up in the ER every other month or get hospitalized every six months.

EED: What percentage of your patients, would you say, are dual diagnosis?

DD: All of them. They have to be, by nature.

EED: To get services?

DD: Well, we’re addiction medicine, so they have to have at least that diagnosis. Maybe not 100%, because I do have a few folks that are just straight chemical dependency. But probably 85% of my folks are co-occurring. From what I understand from the literature, it’s pretty consistent—about 65% of people with addictions have a co-occurring mental health disorder. The one category which I think is maybe overdiagnosed is Axis II, personality disorders. I think a lot of people who are diagnosed with an Axis II diagnosis, it’s just active addiction. You know, it affects their personality! It affects how they work and form relationships and that sort of stuff. By the nature of the disease, I think a lot of people who’ve been diagnosed with personality disorders, maybe the therapist didn’t see the addiction.

EED: This is a pretty quickly growing approach. What percentage of your patients would you say you use mindfulness with?

DD: To some extent, maybe 75%.

EED: You must use it because you find that there’s better outcome than not using it.

DD: Yeah.  It gives patients ways to tolerate stressful things in their lives. Basically, I find it buys more abstinence time, which allows us to work on mental health conditions more effectively.

EED: Do you think that the presumably better outcomes, in terms of more or less “permanent” abstinence, was a result of the approach itself, or the result of what that abstinence allows you to do?

DD: I think three things. One is, I think I do see people that are able to commit permanent abstinence. I see people who commit to longer periods of abstinence. And the third thing is, I think I see people who have actually reduced their [substance] use down to a much less harmful level. I consider all of those to be successful outcomes. It took me a long time, having grown up in the addictions field thinking that abstinence is the only way—that includes antidepressants—it’s extreme.

EED: Do you think the field in general is changing how they view outcomes?

DD: I think it is changing, but there are a lot of clinicians that have a hard time with opiate replacement. It’s like, still, “drug-free is the only way to go.” And yet research is really clear that opiate replacement is much better than drug-free. And I understand [this resistance]; I had to work through it myself. I started doing this thirty five years ago, and it was very much an abstinence-based thing.

EED: What are the drawbacks you see in clinicians who don’t have a background in mindfulness themselves in using this approach?

DD: I definitely see major drawbacks. The research work that Kabat-Zinn did which was followed up by the research work that Linehan did which was followed up by the research work that Teasdale, Segal and Williams did around depression, was that they tried using therapists or clinicians to just teach mindfulness practice without their own practice, and they really had marginal results. And one after the other, Kabat-Zinn required all his clinicians to have a mindful practice. And then when Linehan was having problems, she called up Kabat-Zinn and he said, “Well, this is something I found,” and she did the same switch. It immediately started producing better outcomes. And then Teasdale, Williams and Segal did the same thing. Called up Linehan, she advised them—

EED: —It seems like a lineage thing! Like a dharma heir

DD: —Yeah, it is! But so the research has been really clear that there have been marginal, theoretical approaches, and then all of a sudden you change the clinician profile from one who isn’t doing it to one who’s versed in this thing, and it takes off. So, I think that’s real clear in the experience. The other thing I think is that a lot of the issues that patients talk about…if you don’t have a personal practice, it’s not clear what technical assistance you can give them on that practice. If somebody’s saying, well, I’m having a hard time counting my breath to ten…the fix is, count to one. And that’s something you may not get if there is no practice. The truth is, there really is only one breath after all. Or you’re not willing to go to the same depths. A patient starts talking about an experience they’ve had in meditation. If you haven’t had something similar to it, it’s very difficult to be willing to work with them at that level! So I think there’s a real danger. There’s also a real danger in throwing this practice out to all populations. I think it would be crazy to deal with this with psychotic populations. That doesn’t make a lot of sense. Like the example I gave with using the sense of smell with people who have been sexually abused. So I think there are some real limitations to it and it should be used not across the board. The approach should be directed toward patients who would be most likely to benefit from it.

EED: Would you go so far as to say that mindfulness-based therapy is contraindicated when used by a non-practicing professional?

DD: Not necessarily.

EED: That would go too far.

DD: Yeah. Because I think that there are certain skills that can be taught, can be learned, that would be universally helpful. Would they be able to get the same potential out of the practice? Probably not. But yeah, most of the skills that we’re teaching are probably not dangerous, I don’t think. Unless, again, you’re using them with a person who’s been abused, or who’s psychotic, but with the general population we’re dealing with—anxiety, depression, addiction—I think most of the skills around mindfulness are probably pretty safe skills, and generally could be taught. But it’s more of a skills approach and psychotherapy type of process that you’re into.

EED: Why do you think the approach is growing so much in usage?

DD: One is, I think periodically we just do that in these fields. Codependency for a long time was a big dance; adult children of alcoholics was another big dance that you had to go to. Psychodrama was a big dance for awhile that we had to engage in. And so to a certain extent, I think mindfulness is just one more. The other thing that I think, though, that’s probably more likely, is most of us kinda get frustrated that we’re not as effective as we’d like to be. And gosh, here’s a new approach that’s actually showing something that’s been fruitful. And the more we learn about brain chemistry, neurobiology, it really lends itself to saying “Hey, there’s something here.” I think it’s just the right time. But I think we’re grasping for something that makes us better clinicians and is showing some fruitfulness for us.

EED: Do you think the field is heading in a certain direction?

DD: Yes, but I don’t know what the direction is! {laughs} You would have a better sense of where it’s heading than me, perhaps! It’s just sitting and watching, experiencing where the field is today, and seeing where the field is next week. I hope the field continues to be going in a direction, because we’re still not as effective with people as we’d like to be. I don’t think clinicians, any of us, are good enough at being able to move to where the patient needs us to be as quickly and as gracefully as we should be able to. We all kinda get into our niches and the way that we do things, and we ask the patient to come there with us rather than being versed enough and having enough flexibility to go to them.

EED: What do you think are the shortcomings in traditional western psychotherapy or addictions practice that this approach addresses?

DD: Well, one is, it’s easy. Another is, it’s very much a skill that it can be practiced. Another is that it’s a skill where even if a patient’s willing to do it only a couple minutes a day, they can learn something from it. So in very small increments, it can be worked with. I think the natural issues of relaxation, maybe being able to sleep better for some folks, just as a release of tension or a respite from the stress of some people’s lives, I think when patients experience that for the first time, it’s like an immediate buy-in to therapy. “Gosh, if I can get this in two minutes, what can I get if I really start thinking about working on these issues for myself?” So it really is a nice tool that way.

EED: Do you think that it works especially well in settings where resources are limited—which is almost all settings?

DD: Yeah, it doesn’t take too much to sit on the floor, or in a chair, or lay on your back. That’s one thing, you can teach it to people with all sorts of physical limitations so long as you’re not getting too hung up on the form of a certain particular way—

EED: Dōgen!

DD:         Yeah! In fact, Linehan, when she goes to sesshin, buys one of those cheap plastic chairs at K-Mart, the ones that come in forest green or white? She buys one of those and just throws it away when she’s done because she can’t sit on the floor!

EED: Well, knees, you know?

DD: Oh yeah, and backs can be bad…but it’s a form that you can do in so many ways. I don’t know anyone who couldn’t do it. The other thing is that people with greater skills or people who aren’t more limited, it may be easier to manage in some ways. For people who aren’t used to thinking in those ways, it’s maybe easier to access it through some of the component skills. It’s soothing to patients—particularly the manualized stuff. “For this condition, we’re going to use this skill.” It’s like a recipe.  You know, you want the brownie, you’ve got to put in the chocolate first…you know, it really does help that. It makes it a simplistic, concrete approach. I think we get too abstract with our patients half the time.

EED: Right. Because we spend years thinking about this stuff, they just walk into an office.

DD: Right.

EED: How do you think mindfulness-based relapse prevention works with diverse populations?

DD:         Diverse in…what do you mean?

EED: Anything—like populations have been marginalized racially, ethnically, maybe even underresourced financially, or women?

DD: Actually, I talked about that with a woman who runs an addiction program for battered African-American women with children. We talked about doing some work together, upon my retirement. I would do some volunteer work with her. But I don’t know that I’m going to do it. One of the things that we talked about and theorized on was that I may not be the person to do this work with them. There may need to be some cultural relevance in there. Particularly with battered African-American women, a white guy may not be the best teacher. But who knows? Other folks may be OK with that. So, you know, maybe the skill needs to be taught by someone who’s more culturally aware and can do the cultural bridge. I think this stuff is kinda different enough for most people’s experience where you can kinda say, that wouldn’t work for me. Maybe if it’s coming from someone with more authority within that culture.  I’ve been able to bridge the cultural differences that have come out of religious backgrounds pretty well. I get no reaction for that reason now; it just doesn’t happen. It’s intriguing for me to think about how it may be done for someone who’s hard of hearing or maybe doesn’t have access to one of the five primary senses. Would it be easier or harder? I don’t know…

EED: As you’re talking, the question is coming up for me…to my knowledge, people in helping fields who themselves practice mindfulness: it’s not a very diverse community, I don’t think.

DD: No. And it may be in other places, but we’re talking Portland, Oregon here.

EED: No. Or even the Northwest. But thinking about it, I can’t recall meeting too many people [amongst the American Buddhist community] anywhere who are Black, or Latino, or something like that…so is that going to be a problem as far as the field growing, do you think?

DD: You know, I don’t know. I just don’t know. I know there is a lack of African-American or Latino [clinicians]. I think this practice would be very easy to work within a Native American culture, because there are already foundations for mindfulness within that culture.

EED: Do you think…I guess I’m theorizing right now, just listening to you, that it would be beneficial to try to grow the mindfulness-based therapeutic field within diverse communities. So, social workers who do work with, for example, DV survivors who are Black women—there could be someone who could say, you know, I can teach that, and I’m a Black woman myself.

DD: It’d be nice to see what the research does. If the research says there were cultural dynamics or limitations within this practice.  I’d tend to think not, but I’ve never seen anything studied. I think studying mindfulness as a phenomenon is fairly new to begin with. My guess is to start breaking it down into cultural populations…maybe it’s too early. Maybe it’s a little too much of a challenge right now? We’d have to have some of the more basic questions answered first. Maybe I’ll call Carla Green about that. She’s a person I work with at the Center for Health Research who does a lot of research.

EED: Yeah, let me know. It is an interesting question. For some reason I’ve never…I know it’s been discussed before, the lack of the diversity within the American Buddhist community. But thinking about it, if that’s true, that probably means there are probably less people of color and women teaching it to others.

DD: Yes. I think there is also a socioeconomic gap. The American Buddhist culture is fairly affluent and highly educated.

EED: Maybe it’s exposure or something. But if there are no Black women practicing, and that’s obviously an exaggeration, but then there are no Black women to teach it to other Black women. And that’s just an example.  …What do you think are some of the big questions or controversies facing people who are going to integrate mindfulness into their clinical practice?

DD: I think one of the big ones is going to be developing your own practice.  When I have shared the research that people who have their own practice are better at communicating the practice, I’ve received a lot of resistance around that. Defensiveness. As a professional…when we talk about doing more of this in our department, when I bring up the concept that if we really want to do this and have a fair shot at being effective, we need to get a cadre of clinicians who are actually doing this practice for themselves to be able to then work with it. That’s going to be our best chance at seeing if this can be a successful approach in our department. And actually, we’ve done that. Suzanne Cooper has been practicing mindfulness for quite some time.

EED: And now she’s doing a group over here in Portland.

DD: Yes, that’s pretty cool.

Thanks, Dan, for your generous gift of time and energy!

Leave a comment

Filed under Interviews

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s