Mindfulness skills training for adults
with intellectual disabilities
Russell Botting1, Felicity Cowdrey2, Liam Reilly1, Kirsty James2, Graham
Thew2, Katherine Donnelly3, Linda Walz1
1. Complex Health Needs Service, Sirona Care and Health, Bath.
2. Clinical Psychology Unit and Training Centre, University of Bath.
3. Department of Clinical Psychology, University of Exeter.
What we will cover:
• Mindfulness
– What is it?
– Evidence-base for mindfulness
– Mindfulness in ID populations
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Study 1: Pilot study of mindfulness skills training (Group 1)
Study 2: Evaluation of mindfulness skills training (Group 2 and 3)
Discussion and Conclusion
Limitations
Our reflections
Future directions
Mindfulness
• Mindfulness means paying attention in a particular way…
– on purpose
– in the present moment
– non-judgementally
• Cultivated through a range of meditative practices
Jon Kabat-Zinn (1990)
Evidence-base
• Mindfulness increasingly popular approach
• 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)(for a review see Khoury et al., 2013)
• Forms part of DBT, ACT, MBCT and MBSR
• MBCT recommended by NICE (2009) for relapse prevention
in depression
Mindfulness in adults with ID?
• Adults with ID experience higher rates of mental
and physical health problems compared to those
without ID
(Cooper et al., 2007)
• Adults with ID should have access to the same
evidence-based treatments as those without ID
(Valuing People, DoH, 2001)
• Few studies have reported on the use of
mindfulness in ID
Chapman et al., (2013) review
– 11 studies
– Most commonly taught meditation practice was
Soles of the Feet
– Mindfulness generally provided to individuals,
rather than in groups
– Length & manner of training varied
– All studies found improvements after mindfulness
training e.g. reduced aggression/sexual
arousal/weight
Chapman et al., (2013) review
– Participant feedback suggests:
• May initially find practice difficult to understand as
not easy to remember event
• Repeated practice, use of role-play and adding
stimulus to feet helped
• Individuals valued learning to control their own
feelings rather than being told to calm down by
others, and found this reinforcing
Pilot study:
Are mindfulness practices, taught in a
group format, acceptable and useful
for adults with ID?
(Donnelly, James and Walz, In press)
Preparation
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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
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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
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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:
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non-reactivity to inner experience
observing thoughts and feelings
acting with awareness
describing/labelling with words
non-judging of experience
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 ID
– group 2, n=5
– group 3, n= 6
• Facilitated by trainee clinical psychologist and assistant
psychologist
• Feedback sheet after each session
• Home practice CD (Singh et al., 2003 script)
Session structure
Session 1
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What is mindfulness?
Shifting attention
Soles of the feet / palms of hands practice
Introduction to home practice
Session feedback
Session 4
Session 2
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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
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Switching attention
Soles of the feet / palms practice
Guiding thought back to the present
Feedback on homework
Home practice
Session feedback
Session 6
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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
RESULTS
Quantitative results
• No significant difference between the pre-group
and post-group scores on four of the five factors of
the FFMQ-m (p> .05)
• 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)
Themes from qualitative feedback
• Mindful self-reflection
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“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
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“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
• Small sample size
• Use of unvalidated measures for evaluation with no
previous testing on ID
• High participant drop-out
• No control condition
• No long term follow-up
Our reflections
• Variation in personalities and needs influencing the group
process
• Communicating abstract concepts
• Home practice - Was more emphasis needed on what this
was for? What more support needed ?
Future directions
• Develop and validate a measure of mindfulness suitable for adults
with ID
• Measure change in reason for referral (for example, anxiety,
rumination)
• 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
• Paper in preparation….
Questions…
Contact: linda.walz@sirona-cic.org.uk
Key references
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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.
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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.
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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.
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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.
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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.
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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.