Mindfulness skills training for adults
with learning disabilities
Russell Botting & Liam Reilly
Complex Health Needs Service, Sirona Care and Health, St Martin’s
Hospital, Bath.
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
Buddha
‘Do not dwell in the past, do not dream of the
future, concentrate the mind on the present
moment.’
Jon Kabat-Zinn
MBSR
‘Awakening from habits of body and mind to
how things actually are’
Mark Williams
MBCT
‘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-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)
• 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?
Don’t 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 mind’s 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 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.
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)
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
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)
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
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
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
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
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
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
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
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
Mindfulness practices
Mindfulness practices
Can’t stop thoughts coming into our head
Polygraph
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
Distancing exercises
• Imagine thoughts speeding away like a train
• OR leaves floating down a stream
Waterfall metaphor
• Experiencing distressing experiences
(pain, hurt, emotions, voices)
• Step back from under the water. Notice
it, but don’t be overwhelmed by it.
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.
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)
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)
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.
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
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)
PBS Principles
Process
The secondary use of other complimentary,
evidence based approaches to support
behaviour change at multiple levels
Gore et al., (2013)
PBS and mindfulness
• Doesn’t 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
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.
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).
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
responding
• Preparation for the effects of challenging environments
• Promote functional self-monitoring/self awareness
• What happens when
the wolf shows up…
(Noone, 2014)
Staff
Behaviour
Challenging
Behaviour
Staff Stress
Staff Negative
Emotional
Reactions
Staff
Behaviour
Challenging
Behaviour
What evidence is there for using
Mindfulness with carers.
Parents of Children
with Autism
Singh et al., (2006)
70
BASELINE
MINDFULNESS
MINDFULNESSPRACTICE
TRAINING
Parent-Child1
60
50
Aggression
Noncompliance
40
Self-Injury
30
20
3 pairs of mothers and
child
10
0
70
Parent-Child2
60
Children aged 4-6 years
Mothers aged 24-33 years
50
40
30
20
10
Noncompliance
decreased 68-79%
NUMBER OF EVENTS
Aggression decreased
81-89%
0
70
Parent-Child3
60
50
40
30
20
10
0
Self-injury decreased
60%
0
5
10
15
20
25
30
35
40
WEEKS
45
50
55
60
65
70
75
80
Singh et al. (2008)
B/LINE
MINDFULNESS TRAINING
Gerald
4
6 adult offenders
with mild intellectual
disabilities
3
2
1
0
Jason
4
3
2
1
0
Aggressive behaviors
decreased and reached
zero levels for all six
individuals
Paul
4
3
2
1
0
Kent
4
3
2
1
0
NUMBER OF AGGRESSIVE BEHAVIORS
Reductions in
physical restraints,
injuries, PRN
medications
Patrick
4
3
2
1
0
Harry
4
3
2
1
0
0
2
4
6
8
10
12
14
16
18
MONTHS
20
22
24
26
28
30
32
34
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)
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
The pilot group
• 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
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
Mindfulness group feedback questionnaire
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”
– “I’m not sure about the feet one”
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
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 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
Session structure
Session 1





What is mindfulness?
Shifting attention
Soles of the feet / palms of hands practice
Introduction to home practice
Session feedback
Session 4
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 5
Session 3






Switching attention
Soles of the feet / palms practice
Guiding thought back to the present
Feedback on homework
Home practice
Session feedback
Session 6





















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
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
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
Mindfulness Practise :
Mindful Eating
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 postgroup 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 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]
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”
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
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
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
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)
Questions…
Contact: liam.reilly@sirona-cic.org.uk or
russell.botting@sirona-cic.org.uk
Key references
•
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., Chapleau, M. and Paquin, K et al. (2013). Mindfulnessbased therapy: A comprehensive meta-analysis. Clinical Psychology Review 33(6), 763–71.
•
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