Mindfulness skills training for adults with learning
disabilities Russell Botting & Liam Reilly Complex Health Needs
Service, Sirona Care and Health, St Martins Hospital, Bath.
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What we will cover: Mindfulness Mindfulness practices
Mindfulness and PBS Working with staff teams Break Our Mindfulness
groups Pilot study (Liam) Mindfulness Practise: SoF(Script) Groups
2 and 3 Mindfulness Practise: Mindful eating Mindfulness Practise:
3 minute breathing space Questions
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Jon Kabat-Zinn MBSR Mark Williams MBCT Buddha Awakening from
habits of body and mind to how things actually are Do 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.
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Mindfulness is Paying attention in a particular way, on
purpose, in the present moment and non-judgementally Kabat-Zinn
(1996) Learning to pay attention: Moment by moment Intentionally
With curiosity and compassion Williams (2011) Cultivated through a
range of meditative practices Kabat-Zinn (1990)
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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?
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Dont think about the pink rabbit
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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
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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
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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
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Evidence Base LD Mind-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
functioning Current research mainly from comes from individual case
studies and practice based evidence.
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Main approaches: Mindfulness based stress reduction (MBSR)
Wider scope of applications/contexts Focus on the landscape of
universal vulnerability/suffering Generic focus on the range of
factors that influence functioning Specificity towards the stress
of living with chronic illnesses/general life challenge Greater
emphasis on learning and insight emerging through the process
Larger group (Noone, 2014)
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MBSR Eight week course Semi structured group No published
studies on the adaptation and application of MBSR for LD Has been
adapted for parents and carers
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Mindfulness 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 distress Specificity
towards living with heightened vulnerability to depressive relapse
From first session the underlying theme is how does this working
with the challenge of lowered mood? learning is made explicit
Smaller group (Noone, 2014)
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Mindfulness-based training LD Focus on enhancing functional
emotions, behaviours and cognitions. Nirbhay Singh Most commonly
taught meditation practice was Soles of the Feet Found decrease in
aggression exhibited by adult offenders with LD
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Dialectical Behavioural Therapy (DBT) Marsha Linehan A focus on
the present moment Acceptance of the individual in the moment
Acceptance is necessary for change. Mindfulness practice and
acceptance are distinguishing characteristics of DBT
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DBT LD Successfully adapted for both children and adults with
LD who have anxiety, mood and trauma-related disorders Charlton
(2006): Adaptation involves simplified language, multimodal
presentation of information, use of concrete activities, modelling,
more structured, longer therapy sessions
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Acceptance and Commitment therapy (ACT) Lack of psychological
flexibility Leads to experiential avoidance Encourage client to
contact psychological experiences - directly, fully without
needless defense Development of new responses in the presence of
the previously avoided event that diminish its regulatory
power
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ACT LD Brown and Hooper (2009): mindfulness and ACT Taught
young person with moderate/severe LD and anxious/obsessive thoughts
to distance self from literal content Experiential and activity
based nature may be more accessible for people with LD than CBT
based on verbal reasoning skills
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Integrative approaches Robertson (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 injury
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Integrative approach Teaching simple, highly effective,
mindfulness based relaxation practices. Use of modelling and
experiential exercises Self-soothing exercises: yoga poses, deep
breathing (blowing bubbles), guided imagery and expressive art.
Based on preferences, interests, strengths and needs
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Not much research in LD Mainly individual case studies,
practice based evidence Needs to be adapted to individual needs and
strengths as well as general LD adaptation Practical, concrete
exercises most effective and beneficial
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Mindfulness practices
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Cant stop thoughts coming into our head Polygraph
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Tug of war with a monster How powerful thoughts, voices and
experiences can seem Learning to take control. Take them where we
want to go
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Distancing exercises Imagine thoughts speeding away like a
train OR leaves floating down a stream
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Waterfall metaphor Experiencing distressing experiences (pain,
hurt, emotions, voices) Step back from under the water. Notice it,
but dont be overwhelmed by it.
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Breathing exercises Ball 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.
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Noticing exercises Exercises 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 exercise Photo mindfulness (scenery, events,
places) Food mindfulness (e.g. popcorn, raisin) Sounds in the room
(e.g. clocks, cars)
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Mindful body awareness Body 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)
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Grounding exercise Soles 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.
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Applying to everyday life Mindful 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.htm
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PBS Principles Values Person-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 practices Stakeholder participation informs, implements
and validates assessment and intervention practices An
understanding that challenging behaviour develops to serve
important functions for people Theory and evidence base The primary
use of Applied Behaviour Analysis to assess and support behaviour
change Gore et al (2013)
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PBS Principles Process The secondary use of other
complimentary, evidence based approaches to support behaviour
change at multiple levels Gore et al., (2013)
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PBS and mindfulness Doesnt 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.
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PBS principles in relation to mindfulness Praise 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.
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Applying mindfulness to PBS Think 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).
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Weave your parachute everyday rather than leaving it(Kabat
Zinn, 1990)
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How can we use Mindfulness with staff teams? How can this help
clients learning disabilities?
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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 responding
Preparation for the effects of challenging environments Promote
functional self-monitoring/self awareness
What evidence is there for using Mindfulness with carers.
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Parents of Children with Autism Singh et al., (2006) 3 pairs of
mothers and child Children aged 4-6 years Mothers aged 24-33 years
Aggression decreased 81-89% Noncompliance decreased 68-79%
Self-injury decreased 60%
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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
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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
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Mindfulness Skills for Individuals with LD
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Pilot study: Are mindfulness practices, taught in a group
format, acceptable and useful for adults with ID? (Donnelly, James
and Walz, In press)
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Preparation Adapting practices e.g. wording, type of practice
Group location? Involvement of support workers? Length of group?
Letter & information sheet Initial meeting about group
Evaluation - Coping measure, interviews, feedback
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Four-week group run for an hour Four participants (half female)
Recruited from CLDT due to difficulties coping with emotions such
anxiety or anger Two participants accompanied by their support
worker / PA Facilitated by clinical psychology trainee (KJ) and
volunteer The pilot group
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Session structure Orientation introductions, session plan,
group rules Introductory task shifting focus of attention
Mindfulness Training Soles of the Feet Practice Group Discussion
& feedback Discussion about home practice Session Feedback
questionnaire
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Mindfulness group feedback questionnaire
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Participant feedback Helpful aspects: The mindfulness practices
Learning new skills Focusing on things to bring my mind back from
wondering Learnt to think about today not yesterday Sharing with
the rest of the group Making new friends Being with the group Least
helpful aspects: It did bring up the past Im not sure about the
feet one
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Modifications based on feedback Six-week group Focus on the
palms of the hands or soles of the feet Add in another practice Add
in quantitative measure for evaluation Modified 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
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SoF Practise!
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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?
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Groups 2 and 3 Two six-week courses each session 60-90 minutes
Total of 11 participants with mild (n=9) to moderate (n=2) ID group
2, n=5 group 3, n= 6 Facilitated by trainee clinical psychologist
and assistant psychologist Feedback sheet after each session
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Session structure Session 1 What is mindfulness? Shifting
attention Soles of the feet / palms of hands practice Introduction
to home practice Session feedback Session 2 What are negative
thoughts and worries? Shifting attention Soles of the feet / palms
of the hands Awareness of breathing Feedback on homework Home
practice Session feedback Session 3 Switching attention Soles of
the feet / palms practice Guiding thought back to the present
Feedback on homework Home practice Session feedback Session 4
Switching attention Soles of the feet / palms practice Using
practices when feeling anxious Group 3 only Introduction to three
minute breathing space Feedback on homework Home practice Session
feedback Session 5 Switching attention Soles of the feet practice /
palms practice Group 2 only Introduction to three minute breathing
space Group 3 only Practice of three minute breathing space Group 3
only Introduction to mindful eating Feedback on homework Home
practice Session feedback Session 6 Switching attention Soles of
the feet / palms practice Three minute breathing space Group 3 only
Mindful eating Using mindfulness after the group Feedback on the
group
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Mindfulness Practise : Mindful Eating
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Results Scores 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)
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Themes from feedback Mindful self-reflection Today and now is
what matters Try not to worry too much Realising how distracted I
am I like my thoughts today, I've got a lot on my mind this week
Noticing improvements It 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
longer Social aspects of the group Helpful to talk to other people
Enjoyment of mindfulness practices I liked the three minute
practice and I like the stone Focusing on the soles of my feet
[Noted as something liked about the group ]
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Suggested improvements Environmental Noises in the car park
outside. Switching attention was not as easy Session / practice
length The mindfulness [practice] was too long Less time doing the
soles of the feet activity Not long enough More sessions Types of
practices Maybe change an activity
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The challenges Discussion Six-week mindfulness group
significantly improved participants ability to describe their
feelings Participants with ID reported a number of subjective
benefits of mindfulness skills training The social aspect of the
group intervention is experienced as positive Similar themes to
those extracted from research in non-ID samples
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The Royal United Hospital DATE Service Conclusions 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
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Limitations Use of unvalidated measures for evaluation with no
previous testing on ID Small sample size High participant drop-out
No control condition Groups not directly comparable No long term
follow-up
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The story so Future directions Develop and validate a measure
of mindfulness suitable for adults with ID Measure 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 training Extend the number of
sessions to 8 Conduct follow-up Links with primary care psychology
(IAPT)
Key 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.
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Thanks to Steve Noone, Felicity Cowdrey, Linda Walz and Graham
Thew
