PowerPoint Presentation

Mindfulness skills training for adults with learning disabilitiesRussell Botting & Liam Reilly Complex Health Needs Service, Sirona Care and Health, St Martins Hospital, Bath.

What we will cover:Mindfulness Mindfulness practicesMindfulness and PBSWorking with staff teams BreakOur Mindfulness groupsPilot study (Liam) Mindfulness Practise: SoF(Script) Groups 2 and 3Mindfulness Practise: Mindful eating Mindfulness Practise: 3 minute breathing spaceQuestions

Jon Kabat-Zinn MBSRMark WilliamsMBCTBuddha Awakening from habits of body and mind to how things actually areDo not dwell in the past, do not dream of the future, concentrate the mind on the present moment.

Being mindful means that we suspend judgment for a time, set aside our immediate goals for the future, and take in the present moment as it is rather than as we would like it to be.

Mindfulness is Paying attention in a particular way, on purpose, in the present moment and non-judgementallyKabat-Zinn (1996)Learning to pay attention:Moment by momentIntentionallyWith curiosity and compassion Williams (2011)

Cultivated through a range of meditative practicesKabat-Zinn (1990)

Are you driven by the daily routines that force you to live in your head rather than in your life?

How many of you are thinking about something else right now?

Dont think about the pink rabbit

The key to mindfulness lies in learning to simply rest in a bare awareness of thoughts, feelings, and perceptions as they occur. This gentle awareness is known as mindfulness . . . Simply resting in the minds natural clarity--Yongey Mingyur Rinpoche

Evidence-base general population

Mindfulness increasingly popular approach

Evidence for the benefits of accepting experiences rather than suppressing or avoiding them (Kuyken et al., 2010)

Emerging evidence-base for its use in a number of physical health problems (e.g. cancer, aids, pain) and mental health problems (e.g. stress, anxiety, depression)(see Khoury et al., 2013)

MBCT recommended by NICE (2009) for relapse prevention in depression

Mindfulness in adults with LD?

Adults with LD experience higher rates of mental and physical health problems compared to those without LD (Cooper et al., 2007)Adults with LD should have access to the same evidence-based treatments as those without LD (Valuing People, DoH, 2001)Few studies have reported on the use of mindfulness in LD

Evidence Base LDMind-body relaxation used effectively for individuals with LD for decades Uma et al,(1989): Yoga with children with LD, decreased anxiety and increased IQ and adaptive functioningCurrent research mainly from comes from individual case studies and practice based evidence.

Main approaches:Mindfulness based stress reduction (MBSR)

Wider scope of applications/contexts Focus on the landscape of universal vulnerability/sufferingGeneric focus on the range of factors that influence functioning Specificity towards the stress of living with chronic illnesses/general life challengeGreater emphasis on learning and insight emerging through the processLarger group (Noone, 2014)

MBSREight week courseSemi structured groupNo published studies on the adaptation and application of MBSR for LDHas been adapted for parents and carersMindfulness based cognitive therapy (MBCT)Health care intervention Focus on the landscape of universal and specific vulnerability (e.g. depression)Explicit focus on the role of cognitive patterns in creating/maintaining distressSpecificity towards living with heightened vulnerability to depressive relapseFrom first session the underlying theme is how does this working with the challenge of lowered mood? learning is made explicitSmaller group(Noone, 2014)

Mindfulness-based training LDFocus on enhancing functional emotions, behaviours and cognitions.Nirbhay SinghMost commonly taught meditation practice was Soles of the FeetFound decrease in aggression exhibited by adult offenders with LD

Nirbay Singh - The Soles of the Feet practice enables the individual to divert attention from an emotionally arousing thought, event or situation to an emotionally neutral part of the body. The individual is able to stop, focus back on the body, calm down and then make a choice about how to react to the thought, event or situation that triggered response. Participants are encouraged to shift focus to the soles of their feet upon awareness of a particular emotion/thought

14Dialectical Behavioural Therapy (DBT)Marsha LinehanA focus on the present momentAcceptance of the individual in the momentAcceptance is necessary for change.Mindfulness practice and acceptance are distinguishing characteristics of DBTDBT LDSuccessfully adapted for both children and adults with LD who have anxiety, mood and trauma-related disordersCharlton (2006): Adaptation involves simplified language, multimodal presentation of information, use of concrete activities, modelling, more structured, longer therapy sessions Acceptance and Commitment therapy (ACT)Lack of psychological flexibilityLeads to experiential avoidance Encourage client to contact psychological experiences - directly, fully without needless defenseDevelopment of new responses in the presence of the previously avoided event that diminish its regulatory power

ACT LDBrown and Hooper (2009): mindfulness and ACTTaught young person with moderate/severe LD and anxious/obsessive thoughts to distance self from literal contentExperiential and activity based nature may be more accessible for people with LD than CBT based on verbal reasoning skills Integrative approachesRobertson (2010): Mindfulness-based practices combined with CBT, ACT, mind-body relaxation, and meditative practices.Positive outcomes when used for individuals and groups with moderate to mild LD in managing anxiety, depression, physical aggression and self injuryIntegrative approachTeaching simple, highly effective, mindfulness based relaxation practices.Use of modelling and experiential exercisesSelf-soothing exercises: yoga poses, deep breathing (blowing bubbles), guided imagery and expressive art.Based on preferences, interests, strengths and needs Not much research in LDMainly individual case studies, practice based evidenceNeeds to be adapted to individual needs and strengths as well as general LD adaptationPractical, concrete exercises most effective and beneficial

Mindfulness practices

Mindfulness practicesCant stop thoughts coming into our head

Polygraph

Tug of war with a monsterHow powerful thoughts, voices and experiences can seem

Learning to take control. Take them where we want to go

Distancing exercises

Imagine thoughts speeding away like a train

OR leaves floating down a stream

Waterfall metaphorExperiencing distressing experiences (pain, hurt, emotions, voices)Step back from under the water. Notice it, but dont be overwhelmed by it.

Breathing exercisesBall breathing: Hold a ball in right hand. Inhale as you squeeze the ball and exhale as relax your hold.

Straw breathing: Place straw in mouth. Inhale through nose and exhale through the straw.

Birthday cake: Think about a birthday cake. Breathe in before you blow out the candles, and breathe out when you blow the candles out.

Noticing exercisesExercises to centre yourself, and connect with your environment. Practice it throughout the day, especially any time you find yourself getting caught up in your thoughts and feelings. Leaf/rock exercisePhoto mindfulness (scenery, events, places)Food mindfulness (e.g. popcorn, raisin)Sounds in the room (e.g. clocks, cars)Mindful body awarenessBody scan - Ask to focus on each part of body in turn starting with toes and working up the body. Each time naming a part, ask them to notice how it feels & to move it.

Mindful walk Putting noticing into practice. Facilitator can cue people from time to time ( can pretend to be alien in new body for first time or Dr. Who regenerating into new body)Grounding exerciseSoles of the feet practice - The Soles of the Feet practice enables the individual to divert attention from an emotionally arousing thought, event or situation to an emotionally neutral part of the body.

Applying to everyday lifeMindful music: listen to all aspects of music, notice affect on you, notice physical sensations, notice emotions, allow thoughts to be carried away on music then bring attention back.

Focus on tasks and routines: morning routine (e.g. shower, teeth) or Chores (e.g. ironing)

Focusing awareness physical habit: Noticing how tight you hold a pen, being aware of what happens to your breathing or voice tone in an argument.

Focusing awareness on self when an environmental cue occurs: (Thich Nhat Hanh, 1991) The cues we might use include - Waiting for phone to be answered, waiting to cross the road, walking and getting dressed.

Detailed awareness of the association with cravings or urges such as thoughts, physical sensations and feelings.

Source: http://www.mindfulness.org.au/InAction.htmPBS PrinciplesValuesPerson-centred approaches to the prevention and reduction of challenging behaviour occur within the context of increased quality of life, with an emphasis on inclusion, participation, and the defence and support of valued social roles Constructional approaches to intervention design build stakeholder skills and opportunities and eschew aversive and restrictive practicesStakeholder participation informs, implements and validates assessment and intervention practicesAn understanding that challenging behaviour develops to serve important functions for people

Theory and evidence baseThe primary use of Applied Behaviour Analysis to assess and support behaviour changeGore et al (2013)

PBS PrinciplesProcess

The secondary use of other complimentary, evidence based approaches to support behaviour change at multiple levels

Gore et al., (2013)

PBS and mindfulnessDoesnt wait for the extreme behaviour to occur before an intervention is used. PROACTIVE rather than REACTIVE.The importance of understanding the function of the behaviour.The need to focus on appropriate as opposed to inappropriate behaviours.Collaboration between staff and patients.Focuses on individuals strengths.

PBS principles in relation to mindfulnessPraise helps to reinforce patients use of appropriate behaviour and strengths.

Promotes positive relationship with others.

Staff model appropriate behaviours, clients learn to identify appropriate behaviours for themselves.

Clients self-perception may change for the better.

It helps staff to build more meaningful and positive relationships with patients.

Helps staff to stay motivated and to continuously notice positive change.

Makes for a nicer work environment.

Applying mindfulness to PBSThink about what skills the patient needs to develop to achieve appropriate behaviours and facilitate this in their care.Mindfulness skills could be applied as an intervention

E.g. modelling, performance feedback, rehearsal, teaching of better coping skills.

The care should include some element of self-monitoring for the patient so that they can learn appropriate behaviours. (e.g. mindfulness diary, homework).

Weave your parachute everyday rather than leaving it(Kabat Zinn, 1990)

How can we use Mindfulness with staff teams?

How can this help clients learning disabilities?

Mindful staff: Suggested mechanisms

Mindfulness encourages acceptance of our own actions and others. Leads to stronger alliance between residents and staff.Non-judgemental acceptance behaviour not categorised as positive or negative.Promote idea of psychological resilience and flexibility rather than coping with stress. Allows for calm attention instead of escalation. Becoming responsive to each moment. Move from reacting to respondingPreparation for the effects of challenging environmentsPromote functional self-monitoring/self awareness

What happens when the wolf shows up (Noone, 2014)

Staff BehaviourChallenging Behaviour44Staff BehaviourChallenging BehaviourStaff Negative Emotional ReactionsStaff Stress45Use scenarios to reinforce each point

How is staff behaviour influenced by a multitude of personal and interpersonal factors.Avoidance of situation/behaviour leads to an increase in stress which impacts on behaviour

Reflecting with peers can lead to negative reinforcement of behaviours you werent here, you should have seen it

Dashed line challenging behaviour (either experienced or discussed) directly effects the level of stress experienced by staff. Their emotional response to that person is then defined by that challenging behaviour.What evidence is there for using Mindfulness with carers.Parents of Children with Autism Singh et al., (2006)3 pairs of mothers and child

Children aged 4-6 yearsMothers aged 24-33 years

Aggression decreased 81-89%

Noncompliance decreased 68-79%

Self-injury decreased 60%

Singh et al. (2008)6 adult offenders with mild intellectual disabilities

Aggressive behaviors decreased and reached zero levels for all six individuals

Reductions in physical restraints, injuries, PRN medications

Singh et al. (2006)3 staff teams

Mindfulness skills training given to staff increased learning and reduced aggression in adults with intellectual disabilities

Decreased aggression in the individuals without directly intervening with the individuals.

Increased clients learning potential

Mindfulness Skills for Individuals with LD Pilot study:

Are mindfulness practices, taught in a group format, acceptable and useful for adults with ID?

(Donnelly, James and Walz, In press) PreparationAdapting practices e.g. wording, type of practiceGroup location?Involvement of support workers?Length of group?

Letter & information sheet Initial meeting about groupEvaluation - Coping measure, interviews, feedbacke.g. making wording more concrete, being explicit about not answering questions aloud, length of practice, which practice to use repeat one or vary?

Four-week group run for an hourFour participants (half female)Recruited from CLDT due to difficulties coping with emotions such anxiety or angerTwo participants accompanied by their support worker / PAFacilitated by clinical psychology trainee (KJ) and volunteerThe pilot groupWe had four participants come along to the group in total. 2 of them brought PAs or support workers along with them to two sessions.

53Session structure Orientation introductions, session plan, group rulesIntroductory task shifting focus of attentionMindfulness Training Soles of the Feet PracticeGroup Discussion & feedbackDiscussion about home practiceSession Feedback questionnaire

The format of the current group is based principally on the initial sessions of a typical group-based mindfulness training course (Segal, Williams, & Teasdale, 2002), in which participants are guided to pay purposeful attention to each moment and to develop skill in re-focusing attention while accepting the minds tendency to wander. We have chosen to focus this training on a task that has been used successfully with individuals with a learning disability by previous workers in this are, namely, a meditation on the soles of the feet (Singh et al., 2003). This practise encourages participants to focus their attention on an anxiety or anger inducing incident, and then to let their mind shift attention towards a neutral or calming stimulus. Singh and colleagues have demonstrated that this practise can be an effective tool for reducing anxiety, anger and hostility and coping with difficult situations when they occur (Singh et al., 2011; Singh et al., 2008; Singh, et al., 2003).

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Mindfulness group feedback questionnaire

Participant feedbackHelpful aspects:The mindfulness practicesLearning new skillsFocusing on things to bring my mind back from wonderingLearnt to think about today not yesterdaySharing with the rest of the groupMaking new friendsBeing with the group

Least helpful aspects:It did bring up the pastIm not sure about the feet one57Modifications based on feedback

Six-week groupFocus on the palms of the hands or soles of the feetAdd in another practiceAdd in quantitative measure for evaluationModified Five Factor Mindfulness Questionnaire (FFMQ-m)One item from each of the five factors: non-reactivity to inner experience, observing thoughts and feelings, acting with awareness, describing/labelling with words and non-judging of experience

SoF Practise! Groups 2 and 3:

Is a modified protocol acceptable and useful for adults with ID and does the group program lead to an increase in self-reported mindfulness?

Groups 2 and 3

Two six-week courses each session 60-90 minutesTotal of 11 participants with mild (n=9) to moderate (n=2) IDgroup 2, n=5group 3, n= 6 Facilitated by trainee clinical psychologist and assistant psychologistFeedback sheet after each session

Session structure Session 1What is mindfulness?Shifting attentionSoles of the feet / palms of hands practiceIntroduction to home practiceSession feedback

Session 2What are negative thoughts and worries?Shifting attentionSoles of the feet / palms of the handsAwareness of breathingFeedback on homeworkHome practiceSession feedback

Session 3Switching attentionSoles of the feet / palms practiceGuiding thought back to the presentFeedback on homeworkHome practiceSession feedbackSession 4Switching attentionSoles of the feet / palms practiceUsing practices when feeling anxious Group 3 only Introduction to three minute breathing spaceFeedback on homeworkHome practiceSession feedbackSession 5Switching attentionSoles of the feet practice / palms practiceGroup 2 only Introduction to three minute breathing spaceGroup 3 only Practice of three minute breathing spaceGroup 3 only Introduction to mindful eatingFeedback on homeworkHome practiceSession feedbackSession 6Switching attentionSoles of the feet / palms practiceThree minute breathing spaceGroup 3 only Mindful eatingUsing mindfulness after the groupFeedback on the groupMindfulness Practise : Mindful Eating

ResultsScores on the describing item (I'm good at describing how I feel) were significantly higher post-group than the pre-group scores (p .05)

No significant difference between the pre-group and post-group scores on four of the five factors of the FFMQ-m (p> .05)

Themes from feedback

Mindful self-reflection Today and now is what matters Try not to worry too much Realising how distracted I amI like my thoughts today, I've got a lot on my mind this weekNoticing improvementsIt is getting easier I think The session has been very helpful for me. I find it easy now we do we do it a bit longerSocial aspects of the groupHelpful to talk to other people Enjoyment of mindfulness practicesI liked the three minute practice and I like the stoneFocusing on the soles of my feet [Noted as something liked about the group]

Suggested improvements

Environmental

Noises in the car park outside. Switching attention was not as easy

Session / practice length

The mindfulness [practice] was too longLess time doing the soles of the feet activityNot long enoughMore sessions

Types of practices

Maybe change an activity

The challengesDiscussionSix-week mindfulness group significantly improved participants ability to describe their feelings Participants with ID reported a number of subjective benefits of mindfulness skills trainingThe social aspect of the group intervention is experienced as positiveSimilar themes to those extracted from research in non-ID samples

The Royal United Hospital DATE ServiceConclusions

Group mindfulness interventions are acceptable and useful for adults with ID

Mindfulness can be adapted for adults with ID

Group format particularly well suited to adults with ID

Mindfulness may helps clients with ID feel more able to identify and express emotions

Limitations

Use of unvalidated measures for evaluation with no previous testing on IDSmall sample sizeHigh participant drop-outNo control conditionGroups not directly comparable No long term follow-up

The story so Future directions

Develop and validate a measure of mindfulness suitable for adults with IDMeasure change in reason for referral (for example, anxiety, ruminsation)Use initial assessments to aid modification of practices Add in additional practices earlier on (for example, mindful eating, breathing space)Involve support network more - staff trainingExtend the number of sessions to 8Conduct follow-upLinks with primary care psychology (IAPT)Questions

Contact: liam.reilly@sirona-cic.org.uk or russell.botting@sirona-cic.org.ukKey references Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., Chapleau, M. and Paquin, K et al. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review 33(6), 76371.

Robertson, B. (2010). The adaptation and application of mindfulness-based psychotherapeutic practices for individuals with intellectual disabilities. In R. Fletcher (Ed.) Psychotherapy for individuals with intellectual disability. Kingston, NY: NADD.

Singh, N. N., Lancioni, G.E., Winston, A. S. W., Adkins, A. D., Singh, J. and Singh, A. N. (2007). Mindfulness training assists individuals with moderate mental retardation to maintain their community placements. Behaviour Modification, 31(6), pp. 800-814.

Singh, N. N., Lancioni, G.E., Winston, A. S. W., Singh, A. N., Adkins, A. D. and Singh, J. (2008). Clinical and benefit-cost outcome of teaching a mindfulness-based procedure to adult offenders with intellectual disabilities. Behaviour Modification, 32(5), pp. 622-637.

Uma, K., Nagarathna, R., Nagendra, H. R., Vaidehi, S. and Seethalakshmi, R. (1989). The integrated approach of Yoga, a therapeutic tool for mentally retarded children: a one-year controlled study. Journal of Mental Deficiency Research, 33, pp. 415-421.

Donnelly, K., James, K., and Walz, L. Group-based mindfulness practice training for individuals with a learning difficulty: A pilot study. Clinical Psychology Forum (In press)

Chapman et al., (2013) The use of mindfulness with people with intellectual disabilities: A systematic review and narrative analysis. Mindfulness, 4, 179-189.

Thanks to Steve Noone, Felicity Cowdrey, Linda Walz and Graham Thew

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