a systematic review and narrative analysis

The use of Mindfulness with
people with Intellectual
Disabilities: a systematic review
and narrative analysis
Erica McInnis, Dougal Hare,
Melanie Chapman, Dene Donalds, Sue Caton &
Duncan Mitchell.
Outline –
‘Shifting from reacting to responding’
• What is mindfulness?
• Relevance to people with ID?
• Does it work?
• Who for? What for?
• How sure can we be?
What is Mindfulness?
“the awareness that emerges through
paying attention on purpose, in the
present moment,
and non-judgmentally to the
unfolding of experience moment by
(Kabat-Zinn, 2003).
Why is it useful for ID?
Job advert:
Wanted: A patient, calm, understanding,
empathetic, energetic, enthusiastic person, who
is able to keep to care plans, protect the rights
of a vulnerable person, ensure the safety of
clients and members of the public & protect the
dignity of stigmatised people.
To work with people who will: bite, throw objects,
scratch, attack you with objects, head bang,
withdraw, spit, run away, break furniture, attack
others, eye gouge, scream, ask continuous
questions & pick own wounds.
Good sense of humour required!
(Noone 2013)
Who for? What for?
• Staff / carers
- For stress
• Family members
– For stress
• People with intellectual
– For clinical problems
Varieties of mindfulness _ Mindfulnessbased Stress Reduction (MBSR)
• Developed in 1980s by Jon Kabat-Zinn
• An 8 week program (2.5 h per week + day of mindfulness+ daily
• Guided mindfulness practices focused mainly on
sensory awareness and body awareness
• Education about stress
• Gentle yoga and movement practices
• Developed for stress reduction of varied patient
groups from chronic pain to anxiety and heart
• Well documented beneficial effects on stress
reduction and well-being (e.g., Hofmann, 2010)
Varieties of mindfulness - Mindfulness
Based Cognitive Therapy
• Developed by Segal, Williams and Teasdale in
• Targeting specific groups of patients with recurrent
major depression while in remission to prevent
• 85% MBSR + elements of Cognitive Behaviour
• Therapy (CBT)
• MBCT halved the rate of depressive relapse in
patients with three or more past episodes
(Teasdale, Segal & Williams, 2000)
Why is mindfulness important in
relation to restrictive practices and
reducing physical intervention?
Staff who practice mindfulness decrease
the frequency of physical interventions and
restrictive practices when dealing with
challenging behaviour.
(Singh,Lancioni,Winton,Curtis, et al.2006)
Why do staff practicing mindfulness
reduce the use of restrictive practices?
• Because staff learn to respond to challenging
situations rather than react.
• Because staff learn this approach it can be
practiced during everyday life, everyday work
experiences and incidents of challenging
behaviour. It reduces the need to use Physical
Intervention and other restrictive practices. It
becomes a way of being.
Difference between responding and
• Reacting is when stressful situations (such as
behaviours which challenge) trigger our physical,
emotional cognitive and behavioural reactions to
stress. This can make a difficult situation worse
• Responding is when during a stressful situation (such
as experiencing behaviours which challenge), we
use mindfulness to create strategies we may have
learnt in our training to deal with the situation in a
positive, professional and respectful way.
Using mindfulness allows us to exert control
over ourselves and influence the sequence
of events at those very moments when we
are most likely to react on automatic pilot.
Before, we would have plunged into the
fight or flight reaction - hyperarousal and
possibly made a very difficult situation
Responding rather than reacting
External and Internal
Stress Events
Perception Appraisal
Fight and Flight
Mindfulness based response
Possible Stress reaction
A Mindfulness based response
• Appraisal of thoughts, feelings and perceived
• Possible arousal, but also an awareness of the
body: muscle tension, breathing, awareness of
the full context of emotion and challenge
• Using training fully is seeing new options
• Quicker recovery of mental and physical
Relevant research
• The use of mindfulness with people with ID and
carers: systematic reviews (Chapman, Hare,
Caton, Donalds, McInnis & Mitchell 2013, Hwang
et al 2013a 2013b)
• Research published since these systematic
reviews (Brooker et al 2013, Chapman & Mitchell
2013, Miodrag et al 2013, Singh et al 2013,
Idusohan-Moizer et al 2013)
• Research looking at ACT and DBT or with lifestyle
change components have been excluded
Does mindfulness work in ID?
• 11 studies exploring the use of mindfulness with
people with ID
• 3 studies exploring the use of mindfulness with
• 2 studies exploring the use of mindfulness with
Mindfulness interventions for people with ID
• Soles of the Feet - teaches people to divert
attention to an emotionally neutral part of the
body if they experience emotionally arousing
thoughts, events or situations (Singh et al 2003 2013; Idusohan-Moizer et al, 2013)
• Mindful Observation of Thoughts – visualising and
observing thoughts as clouds passing through
awareness (Singh et al 2011b)
• Mindfulness programmes – participation,
observation and description exercises to promote
non-judgemental attitudes and acceptance,
awareness of surroundings and thoughts and
breathing (Chilvers et al 2011); MBCT programme
(Idusohan-Moizer et al, 2013)
Yes it works!
Key findings – people with ID (1)
All studies found improvements over medium-long term:
• Physical and verbal aggression (Singh et al 2003, 2007a,
2008b, 2013, Adkins et al 2010, Chilvers et al 2011, Singh et
al 2011c)
• Increases in self control (Singh et al 2003, 2008b),
compassion towards self and others (Idusohan-Mozer et al
• Improvements in psychological wellbeing, anxiety and
depression (Adkins et al 2010; Idusohan-Mozer et al 2013;
Miodrag et al 2013)
• Reductions in inappropriate sexual arousal (Singh et al
• Physiological changes – declines in cortisol and sAA levels
(Miodrag et al 2013)
Key findings – people with ID (2)
As a result this has led to reductions in:
– interventions such as physical restraints and
seclusion (Singh et al 2003, 2008b, Chilvers et
al 2011)
– medication (Singh et al 2003, 2008b)
– staff and resident injuries & staff absences
(Singh et al 2003, 2008b)
Key findings – people with ID (3)
People with ID :
• Value learning to control their own feelings rather than being
told to calm down (Singh et al 2011b)
• Find mindfulness procedures difficult to understand if they
cannot easily remember or visualise past events (Singh et al
2007) or understand abstract concepts and instructions (Singh
et al 2011b)
• May drop out if they find content difficult to understand or do
not like meditation practice. Amount of paper work, including
diaries can be overwhelming (Idusohan-Moizer et al 2013)
• Vary in their ability to initiate mindfulness meditation without
prompting (Adkins et al 2010) and to use it in their lives
(Singh et al 2011c)
Key findings – people with ID (4)
• Role of carer support (Idusohan-Moizer et al
• Many positive reports of experiences of
mindfulness training (Chapman & Mitchell 2013;
Idusohan-Moizer et al 2013)
Findings – staff (1)
Impact on people with ID
Observed happiness of people with ID increased
more when supported by the staff member trained
in mindfulness (Singh et al 2004)
Reductions in:
• Use of physical restraints (Singh et al 2009)
• Verbal redirections (Singh et al 2009)
• PRN medication Singh et al 2009)
• Incidents of physical and verbal aggression
(Singh et al 2009)
• Peer injuries (Singh et al 2009)
Findings – staff (2)
Impact on staff (Brooker et al 2013)
• Staff positively evaluated the programme
• Associated with significant increases in positive
affect and mindfulness facet of observing
• Reductions in – extrinsic job dissatisfaction
• Decreases in: negative affect, perceived stress,
anxiety and negative emotional symptoms.
• Enhanced awareness of signs and sources of
• Positive changes in behaviours and interactions
with clients and colleagues
• Positive changes in self-care attitudes
and behaviours
Findings – family members
• Reduction in child’s aggressive behaviours (Singh et al
• Improvements in interactions between child with
learning disabilities and their siblings (Singh et al 2007)
• Improvements in mothers’ ratings of parental
satisfaction, parental stress and mother-child interaction
(Singh et al 2007)
• Parents need to be disciplined in meditation practices
and exercises (Bazzano et al 2010)
Findings – family members
• Mindfulness training led to transformational change
rather than rules or techniques to use, and a more
holistic view of their child (Bazzano et al 2010)
• Parents responded in a calm, positive manner that preempted maladaptive behaviour and encouraged
positive social behaviour by children (Bazzano et al
BUT Caution!…
• Study quality rated as weak
• Many studies by same research team
• Small sample sizes – single subject
experimental design
• Few randomised controlled trials
• Generalisability to people with moderate and
severe learning disabilities or from different
cultural backgrounds
• Which components of mindfulness lead to long
term change and how?
• Few U.K studies
• More clarity about which approach used
Dr Erica McInnis
[email protected]
Dr Dougal Hare
[email protected]
Dr Melanie Chapman
[email protected]
Mr Dene Donalds
[email protected]
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