Mindfulness in Therapeutic Interventions

Mindfulness in Therapeutic Interventions

Chris Mace MD FRCPsych

Coventry and Warwickshire Partnership NHS Trust and University of Warwick,

Coventry CV4 7AL, UK

[email protected]

Mindfulness“Mindfulness means …. paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally" Kabat-Zinn (1994)

“…. The clear and single-minded awareness of what actually happens to us and in us, at the successive moments of perception” Nyanponika Thera (1986)

“…..keeping one's consciousness alive to the present reality" Thich Nhat Hanh (1991)

“…..awareness of present experience with acceptance”Germer (2005)

Mentalization :“the capacity to think about mental states as separate from, yet potentially causing actions” Bateman and Fonagy 2004 p.70

Qualities of Mindfulness(Kabat-Zinn, 1990)

Non-judgingPatienceBeginner’s MindTrustNon-strivingAcceptanceLetting go

Learning mindfulness‘Formal’ methods

Sitting meditationsMovement meditationsGroup exchange

‘Informal’ methodsActing mindfullyIn situ exercisesContemplations

Mindfulness and Neuroplasticity (Lazar et al, 2005)

Clinical applications so far: AddictionsAngerAnxietyBingingDelusions & hallucinationsDepressionObsessionsRelationship difficultiesSelf harmTrauma

Clinical uses of mindfulness

• Mindfulness coaching (MC)

• Induced mindfulness (IM)

• Therapist mindfulness (TM)

Mindfulness coaching in therapy

Mindfulness-Based Stress ReductionMindfulness-Based Cognitive TherapyMindfulness-Based Relapse PreventionMindfulness-Based Relationship EnhancementDialectical Behaviour TherapyAcceptance and Commitment TherapyCompassionate Mind Training

Components of Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn,

1990)

• Body scan• Movement and simple yoga• Sitting meditations• Group discussion• Self-ratings

MBCT for depression(Segal, Williams & Teasdale

2002)• Modification of MBSR• Research on depressive rumination• Seeks change of processing mode• Emphasis on mindfulness of thinking• Prophylaxis for chronic depression:

– 3 or more episodes– Replication of RCT findings

“This involves moving from a focus on content to a focus on process, away from cognitive therapy’s emphasis on changing the content of negative thinking, toward attending to the way all experience is processed”

Segal, Williams and Teasdale (2002, p.75)

MBCT: Randomised outcome studies

Authors Type Size

n= Follow-up period

Relapse assessed?

Symptom measures?

Mindful-ness measure?

Process variables?

Patients

Williams et al 2000

RCT 145 60 weeks

Yes Yes No Autobio-graphical memory

>2 episodes

Ma & Teasdale 2004

RCT

73

1 yr

Yes

Yes

No

Lif e events

>2

episodes Bertschy et al 2007

RCT

55

1 yr

Yes (not

supported)

?

No

No

>3

episodes Kuyken et al 2008

RCT*

123

15

months

Yes

Yes

No

No (QoL)

>3

episodes * medication also ended for MBCT patients in Kuyken study

Risk of relapse after MBCT (3+ previous episodes) Ma & Teasdale

2004

Risk of relapse after CT (mean 1.4 episodes) Fresco et al 2007

Relapse in chronic depression

• Known risks:– Number of episodes &– Severity of episodes (Kendler, 2001)– Residual symptoms (Fava, 2000)– Reactivity to mood provocation and decentering (Segal et al

2006; Fresco et al, 2007)

• Investigated mediators with MBCT:– Overgeneral memory (Williams et al 2000)*– Metacognitive insight - MACAM (Teasdale et al 2002)*– Mindfulness (Michalak et al 2008)

Linking MBCT to mindfulness

• Michalak et al (2008) report: – Increase in MAAS post MBCT;– Negative correlation relapse

probability with MAAS scores

Farb et al, 2007

Dialectical Behaviour Therapy

(Linehan, 1993)• For Borderline Personality Disorder• Reduces self-harm (several RCTs)• Theory of 3 minds• Change skills

– Interpersonal effectiveness– Emotion regulation

• Acceptance skills– Distress tolerance– Mindfulness

Mindfulness in DBT‘What’ skills

– Observing– Describing– Spontaneous participation

‘How’ skills– Non-judging– One mindedness – Effective action





Inducing mindfulness• ACT?• Gendlin’s ‘focusing’• Cloninger’s quiet therapy• Ogden’s Sensorimotor Therapy• Shapiro’s EMDR• Etc…..

Acceptance and Commitment Therapy (Hayes, Strosahl & Wilson,

1999)6 ‘core processes’:

– Acceptance– Cognitive defusion– Being present– Self as context– Values– Committed action





Therapist MindfulnessQualities of attention:

– evenly hovering– saturation– wholeheartedness

Awareness of:– what is felt in the body

– the way words are used– the unfolding relationship

“Evenly hovering attention” (Gleichschwebendeaufmerksamkeit)

“...consists in making no effort to concentrate the attention on anything in particular ...maintaining in regard to all that one hears the same measure of calm, quiet attentiveness... one's 'unconscious memory' is to be given full play… one has simply to listen… . Without (it) the physician is in danger of never finding anything but what he already knows”.

(Freud, 1912, pp 111-2)

Impact of therapist mindfulness (Grepmair et al 2007 & 2008)

• 2 studies of German inpatients• 18 female therapists

– 9 had meditation training;– other 9 did not

• All gave brief talking therapy only • Measures of:

– experience in therapy (weekly)– general adaptation (post therapy)– symptoms (SCL-90-R) (pre- and post-)

Grepmair et al results (both studies)

SymptomsGSI ** and 6 subscales of SCL-90**

Experience of process (final – initial)clarfication**problem solving*(*)relationship

Perceived personal changetotal VEV score**

** = intergroup difference p < 0.01

(Grepmair et al, 2007)

Impacts of Therapist Mindfulness• Therapist Skills

– Empathy?– Working alliance?

• Client Outcomes– Symptoms?– Process?

• Therapist Health– Illness?– Resilience?

Paper at: www.rcpsych.ac.uk

(go to: ‘publications’)Mace,C (2007) Mindfulness in

psychotherapy: an introduction.

Advances in Psychiatric Treatment 13 147-154

http://www.rcpsych.ac.uk/

Projective testing and ‘stages of mindfulness meditation’

(Brown & Engler 1986)

• Successful beginners– Absence of association– Immersion in perceptual features

• Insight– Rich associations

• Advanced– Lack of reaction– Description of energetic patterns

• Mastery

Mindfulness and emotion regulation (Martin, Mace, Riggs &

Liebling-Kalifani)

0.792.410.693.100.563.38DERS

0.804.080.933.510.822.82MAAS

SDMean

SDMean

SDMean

Measure

T5(3 month follow-up)

T3(Post-group)

T1(Pre-group)

p < .001**F(2, 10) = 31.18DERS

p = .008**F(2, 10 ) = 8.07MAAS

p valueF - statisticMeasure

ANOVA across T1, T3 & T5

Correlation between MAAS and DERS scores after MBCTEnd of treatment r = - 0.83, p = .021 3 month follow-up r = - 0.89, p = .01.

Cognitive defusion in ACT - I This exercise is to help you see the difference between

looking at your thoughts and looking from your thoughts. Imagine you are on the bank of a steadily flowing stream, looking down at the water. Upstream some trees are dropping leaves, which are floating past you on the surface of the water. Just watch them passing by, without interrupting the flow. Whenever you are aware of a thought, let the words be written on one of the leaves as it floats by. Allow the leaf to carry the thought away. If a thought is more of a picture thought, let a leaf take on the image as it moves along. If you get thoughts about the exercise, see these too on a leaf. Let them be carried away like any other thought, as you carry on watching.

Cognitive defusion in ACT - II

At some point, the flow will seem to stop. You are no longer on the bank seeing the thoughts on the leaves. As soon as you notice this, see if you can catch what was happening just before the flow stopped. There will be a thought that you have ‘bought’. See how it took over. Notice the difference between thoughts passing by and thoughts thinking for you. Do this whenever you notice the flow has stopped. Then return to the bank, letting every thought find its leaf as it floats steadily past.

Self-report InventoriesTitle Authors Structure I tems Measures Validity? Mindful Attention and Awareness Scale (MAAS)

Brown & Ryan, 2003

Single scale

15 Continuity High reliability

Kentucky I nventory of Mindfulness Skills (KI MS)

Baer et al, 2004

4 sub-scales

39 Observe, accept, describe, act

Observe and accept best

Toronto Mindfulness Scale (TMS)

Lau et al, 2006

1 scale

10 Post-session adherence

I ndependent of other scales

Freiburg Mindfulness I nventory (FMI )

Bucheld et al, 2002

4 scales 30 Eff ects plus awareness

Factors not stable

Five Factors Mindfulness Quest’re (FFMQ)

Baer, 2006

5 scales 39 like Kims plus non-reactivity)

Observe and accept best

Southampton Mindfulness Quest’re (SMQ)

Chadwick et al, 2008

1 scale 16 Reactivity Psychotic populations

Philadelphia Mindfulness Scale (PHLMS)

Cardaciotto et al, 2008

2 scales 20 Awareness and acceptance

Limited. Designed as orthogonal

Documents

Mindfulness in Therapeutic Interventions