Keeping Mindfulness in Mind (and body): Reflections on introducing MBCT into a large older adult mental health service

1. Keeping Mindfulness inMind (and body):Reflections on introducing MBCT into a large older adult mental health service David Powell Consultant Clinical Psychologist With thanks to Anya Madden Jess Elmer Rebecca Waldron Trainee Clinical Psychologists

2. Possible plan of session • Sit in collective ‘ silence’ for 30 minutes and be open to what unfolds • Rejected in favour of an inferior plan on the grounds that the audience might feel cheated and/or isn’t ready for it

3. Inferior plan There is a prevailing wind blowing mindfulness in your direction – the invitation is to breathe it in The briefest experiential component A reminder of the basic ideas of mindfulness The challenges of practicing and teaching Description of outcomes of a group for older people in Liverpool- if you can do it there you can do it anywhere? Aims & Outcomes of brief training for CMHT staff

4. Audience Consultation • Please indicate if you …… • ‘Know’ little or nothing about it • ‘know’ about it • believe it has something to offer personally………professionally • Personal practice intermittent • Personal practice integrated into life • Use in therapeutic work without personal practice • Use in therapeutic work with personal practice • Facilitate MBCT/ MBSR

5. Briefest experiential component The Bells

6. Some potential meanings of ‘ the bells’( among others ) • Sound softening into silence • An invitation • Signals a shift in your way of being • The start of an adventure • A reminder to be kind and compassionate to self ( and others ) • Stimulus control – conditioned response

7. Brief reminder of the essentials of mindfulness :Usual Definition Mindfulness is the awareness that results from paying attention in a particular way: -on purpose -in the present moment -non-judgementally (Jon-Kabat-Zinn)

8. What is mindfulness?-some service user meanings 2 months after group • Acute awareness of everything you do • If your mind wanders bring it back • Being in the moment • Realising what you are doing • Paying attention and keeping an open mind • Being non-judgemental • Using your mind as for the first time • Concentrate fully on what you are doing

9. What I think MBCT essentially is ? • An intensive course in ‘ meditation’ • Compassion based approach • Living fully and vividly NOW whatever that brings • Aim for greater awareness of thoughts and feelings and greater choice how to react to them Thoughts are decentred ,observed with interest ,rarely challenged . The repeated message is you don’t have to react to them and can shift the attention elsewhere • (Might lead to significant changes in how life is lived )

10. ‘Doing’ vs ‘being’ mode Doing mode: Goal or problem orientated: often focuses on how you want things to be different or how you are not satisfied with the way things are. Trying to get somewhere else often involves forgetting just to be here. Often involves avoiding painful thoughts, feelings sensations

11. Being Being mode: • Attention is intentionally placed on the present moment. Less reference to the past or future • More accepting frame of mind, being as you are right now. learning to be in touch with whatever is here even the painful stuff • Curiosity, interest, focus on NOW • Cultivating the pillars • Kindness and compassion pervade • Important to get a balance between the two modes.

12. ‘Meditations’ used in MBCT Formal meditations include: Eating meditation Body scan Sitting meditation Mindful movement Mindful walking Mountain/lake meditation Loving kindness meditation 3 minute space

13. ‘Meditations’ used in mbct 2 • Informal meditation: People are encouraged to do everyday things more mindfully e.g. eating, having a shower etc. • A more mindful approach to thinking, feeling and physical sensations ( including pain) is encouraged. • It is important to practice a range of meditations as people find certain ones more helpful than others, and this cant be predicted before

14. The seven pillars of mindfulness 1.) Non-judging: We spend much time making judgements- about ourselves, others, and situations. The ability to discriminate is vital in every day living, but often an automatic rush to judgement drives our thoughts, moods and actions 2.) Patience:-speaks for itself- each day brings opportunities for cultivating patience 3.) Trust is about respecting your own experience 4.) Beginner’s Mind: viewing your most familiar surroundings as if for the first time. Adopting the view that each moment is unique and nothing is ever repeated

15. The seven pillars of mindfulness cont’d 5.) Non-striving: one of the goals of the activities is to be able to give up goals! 6.) Acceptance is central. And a great deal of effort is put into how acceptance of what is in the present moment can reduce distress and be a sound base for change , should that be desired 7.)Letting go: So far as possible, neither rejecting nor holding onto experiences whether pleasant or unpleasant .Recognising thoughts as just thoughts and letting them go... making room for what happens next.

16. Why MBCT? • There is a modern western evidence base and a mountain of evidence from centuries of practice in the east that something positive can be contributed to the human condition • Practitioners experience benefits and with a ‘modest zeal’ invite and encourage others to enter and experience what happens

17. Evidence-base of MBCT Growing evidence-base for MBCT. NICE recommends MBCT for relapse prevention in depression. MBCT has been shown to reduce the likelihood of relapse. Various studies show benefits in mental and physical health related conditions: anxiety conditions, chronic illness and pain, cancer, psychosis, pain, skin disease, transplants, stroke, eating disorders, depression and others. There are a a growing community of practitioners in the North West who have used MBCT with older adults. There is growing clinical evidence that older adults can work with and benefit from this approach.

18. How can MBCT help? Developing awareness in the present moment can prevent automatic and often unhelpful ways of thinking and responding to experience. For instance, rumination or avoidance. It can enable people to respond more ‘skilfully’ to unpleasant thoughts, feelings, or situations. By developing greater awareness people are able to identify what is helpful for them. Allows people to learn that they are able to cope and ‘be with’ difficult thoughts and feelings. Live a more ‘ vivid life

19. My practice and its effects • Incorporated into daily life • Helps with difficult thoughts, especially since I no longer feel the need to challenge them • Calmer and can enter even greater calmness with greater ease • Kinder to myself • Softening of mid life ‘phobias’ • Greater awareness and capacity for choice • Even in difficult times the present moment can be convivial • Automatic pilot is a choice for part of the time but a disaster if there for most of the time

20. Service Context Secondary care older adult mental health service, community oriented, covering all of Liverpool Multidisciplinary team consisting of nurses psychiatrists, occupational therapists, psychologists, physiotherapists, speech and language therapist and support workers.

21. MBCT in the service More ‘Routinely’ available as part of our ‘repetoire’ In reality at most 2 to 4 opportunities per year to go into groups- size limited by room/space availability Potentially a fruitful approach that benefits from being delivered in large groups and is therefore an ‘economical’ way of offering a psychological approach Would ideally like all service users fitting wide inclusion criteria to be able to choose MBCT and ‘receive’ it within a reasonable time frame. (criteria offered at end of presentation)

22. Facilitator’s anxious preoccupations • The personal challenge You have the bells you have the scripts you have the room , may even have mats .You have a theoretical underpinning but can you do and live mindfulness?? • The pubic and professional challenge Older people with real and chronic mental and physical health problems never head of mindfulness /never meditated. Can I help them to make the change get it/ try it /use it /feel it helps. Can I convince , even enthuse colleagues

23. Helpful thoughts • There is a very structured plan but I have no idea what’s really going to happen in the groups and the plan may helpfully be scuppered . An unexpected opportunity may come up to shine a brighter light onthis hard to grasp concept ‘Ring the bells that still can ring Forget your perfect offering There is a crack in everything That’s how the light gets in ‘ (Leonard Cohen)

24. Latest MBCT group 9 group members, 3 male, 6 female- one dropped out after first sesion Mean age - 73 years (range 70-80) 3 group members had some previous experience of meditation. Mean number of group sessions attended was 7 Reasons for non-attendance varied, however, in all instances, except for “forgetting”, MBCT trainers were informed prior to the session.

25. Format of the group Optimum size of the group is 10-15 people Sessions last approximately 2 hours but allow at least 2.5 hours 8 sessions in total with a follow up session. Facilitators are expected to do the homework as well as the service users! Group tends to be supportive and encouraging. Often people find it easier to meditate with other people than when they are alone.

26. Engagement Not sure of wider audits but my experience reveals it is possible , and so far usual, to have very small drop out rates – preparation before joining and the experience of the first session being crucial Somehow ‘ openness to new experience’ seems a likely useful predictor of likely engagement It is hard to predict though who will end up incorporating more practice in their life Headline outcome summaries can vary from ‘useless’ to ‘life changing’

27. Usual evaluation processRelevant pre postquestionnaires Focus Group Follow up sessionsKey outcome questionsWhat difference has it made( in the persons own language )Change in problems/symptomsChanges in mindfulnessChanges in ‘ quality of life’

28. Depression Anxiety Stress Scale (DASS) Self report Scores yielded for 3 scales Depression Anxiety Stress Lovibond & Lovibond (1995) Kentucky 5 facet Mindfulness Questionnaire Self report The five factors scored are: Observing, Describing, Acting with awareness, Non-judging of inner experience, Non-reactivity to inner experience Baer et al (2006). Quantitative Measures

29. Quantitative outcomes • Depression Anxiety Stress Scale

30. Quantitative outcomes • Kentucky 5 facet Mindfulness

31. Qualitative( Real ) short term outcomes • Basic thematic analysis of post group focus group • Various probe questions but basic aim is to get group to reflect on own experience in own language

32. DEVELOPMENTAL ISSUES LEARNING (SKILLS &KNOWLEDGE) COURSE UTILITY TIME Informal and or focuseddiscussion Hard to ‘get’ Hard to ‘do’ Longer term support Relevance Helpful Unhelpful More on difficult days Support Specific skills Course materials Not a panacea Definitions Awareness Acceptance Nonreacting Meditation Themes

33. LEARNING (SKILLS & KNOWLEDGE) Hard to ‘get’ Hard to ‘do’ Definitions Learning (Skills & Knowledge)

34. TIME Informal and or focused discussion Longer term support Relevance Time

35. COURSE UTILITY Helpful Unhelpful/ could be better More on difficult days Support Specific skills Course materials Not a panacea Awareness Acceptance Nonreacting Meditation Course Utility

36. Quotes/Feedback from our current group • “I was really surprised that mindful walking helped me put some of my difficult thoughts to the back of my mind”. • "Loving kindness meditation was useful it improved my mood and helped me generate feelings of loving.“ • “It made me more aware” • “More aware of situations around you, more understanding of others opinions“ • More control of intrusive memories of the past • "Not long enough“ • "Big difference, I’m more calm now" • Waiting for the eureka moment • Want more discussion • Hard to do on the blacker days • Not a panacea

37. Learning objectives for CMHT training To provide a ‘taster’/introduction session. Discuss future training opportunities. To help increase knowledge of mindfulness and MBCT approaches. To give the opportunity to experience mindfulness yourself. To increase confidence in knowing who may be appropriate to refer to the MBCT group and to encourage referral within capacity

38. Brief training of CMHT staff • 43 clinicians working in the CMHT • 27 (62.8%) staff attended the training • 13 Community Mental Health Nurses • 2 Team Co-ordinators • 3 Occupational Therapists • 1 Physiotherapist • 5 Support Workers • 1 Speech and Language Therapist • 2 administrative staff

39. Session format • The training lasted for 90+ minutes and consisted of: • A presentation on what MBCT is; how MBCT can be used to help people with common mental health problems; case examples; the evidence-base for MBCT; referral criteria; and further sources of information. • Practice of Mindfulness meditations (an eating and sitting meditation). • A video of Kabat-Zinn facilitating a MBSR group. • Opportunity for questions and discussion. • Each participant given cd with body scan and sitting meditation

40. Evaluation • Basic knowledge – quiz • Attitude to the approcah • Ability to relate it to service users • Usual post session feedback • Wish for more training

41. Knowledge of mbct

42. Usefulness of mbct

43. Relating it to service users • Percentage of staff who could think of a service user suitable for the MBCT group

44. Relating it to service users • Staff’s reasons for why they think a particular service user would be suitable for MBCT

45. Future training wishes

46. Sources: websites www.shambhala.com- publishers of Mindfulness Practice books www.parallax.org/- resources for Mindful Living www.mbct.co.uk -website on mbct

47. References Follette, V.M., Linehan, M.M., & Hayes, S. C. (2004) Mindfulness and Acceptance. NY Guilford Press Kabat-Zinn, J. (1991) Full Catastrophe Living: How to cope with stress, pain and illness using mindfulness meditation London: Piatkus Segal, Z., Williams, J.M.G & Teasdale, J. (2002) Mindfulness- Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York: Guilford Press

48. One book? Kabat-Zinn, J. (1994) Wherever You Go There You Are: Mindfulness Meditation in Everyday Life. Hyperion, New York

49. MINDFULNESS BASED COGNITIVE THERAPY INCLUSION AND EXCLUSION CRITERIA Inclusion Criteria ( getting wider ) • MBCT Practitioners take the optimistic stance that many people who do not have the exclusion criteria could potentially benefit from the MBCT but, in particular, consider: • People who have had a number of episodes of depression but who are currently relative asymptomatic or have mainly residual symptoms. • Those who have self esteem problems. • Those who have anxiety problems. • Those who tend to worry/ruminate.

50. MINDFULNESS BASED COGNITIVE THERAPY INCLUSION AND EXCLUSION CRITERIA Exclusion Criteria???? • Those who are actively suicidal. • Those who are experiencing hallucinations/delusions/flashbacks or intrusive memories associated with a trauma situation. • Those who have significant levels of cognitive impairment and or challenging behaviour including frontal conditions. • Those who feel fairly sure that they would not be able to commit themselves to attending the group for 8 weeks and/or attempting the homework/practice between sessions.