Mindfulness in Therapeutic Interventions

1. Mindfulness in Therapeutic Interventions Chris Mace MD FRCPsych Coventry and Warwickshire Partnership NHS Trust and University of Warwick, Coventry CV4 7AL, UK C.Mace@Warwick.ac.uk

2. 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)

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

4. Qualities of Mindfulness(Kabat-Zinn, 1990) Non-judging Patience Beginner’s Mind Trust Non-striving Acceptance Letting go

5. Learning mindfulness ‘Formal’ methods Sitting meditations Movement meditations Group exchange ‘Informal’ methods Acting mindfully In situ exercises Contemplations

6. Mindfulness and Neuroplasticity (Lazar et al, 2005)

8. Clinical applications so far: Addictions Anger Anxiety Binging Delusions & hallucinations Depression Obsessions Relationship difficulties Self harm Trauma

9. Clinical uses of mindfulness Mindfulness coaching (MC) Induced mindfulness (IM) Therapist mindfulness (TM)

10. Mindfulness coaching in therapy Mindfulness-Based Stress Reduction Mindfulness-Based Cognitive Therapy Mindfulness-Based Relapse Prevention Mindfulness-Based Relationship Enhancement Dialectical Behaviour Therapy Acceptance and Commitment Therapy Compassionate Mind Training

11. Components of Mindfulness-Based Stress Reduction(MBSR) (Kabat-Zinn, 1990) • Body scan • Movement and simple yoga • Sitting meditations • Group discussion • Self-ratings

12. 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

13. “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)

14. MBCT: Randomised outcome studies

15. Risk of relapse after MBCT (3+ previous episodes) Ma & Teasdale 2004

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

17. 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)

18. Linking MBCT to mindfulness • Michalak et al (2008) report: • Increase in MAAS post MBCT; • Negative correlation relapse probability with MAAS scores

20. Farb et al, 2007

21. 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

22. Mindfulness in DBT ‘What’ skills • Observing • Describing • Spontaneous participation ‘How’ skills • Non-judging • One mindedness • Effective action

23. Clinical uses of mindfulness Mindfulness coaching (MC) Induced mindfulness (IM) Therapist mindfulness (TM)

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

25. Acceptance and Commitment Therapy (Hayes, Strosahl & Wilson, 1999) 6 ‘core processes’: • Acceptance • Cognitive defusion • Being present • Self as context • Values • Committed action

26. Clinical uses of mindfulness Mindfulness coaching (MC) Induced mindfulness (IM) Therapist mindfulness (TM)

27. Therapist Mindfulness Qualities of attention: evenly hovering saturation wholeheartedness Awareness of: what is felt in the body the way words are used the unfolding relationship

28. “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)

29. 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-)

31. Grepmair et al results (both studies) Symptoms GSI ** and 6 subscales of SCL-90** Experience of process (final – initial) clarfication** problem solving*(*) relationship Perceived personal change total VEV score** ** = intergroup difference p < 0.01

32. (Grepmair et al, 2007)

33. Impacts of Therapist Mindfulness Therapist Skills Empathy? Working alliance? Client Outcomes Symptoms? Process? Therapist Health Illness? Resilience?

34. Paper at: www.rcpsych.ac.uk(go to: ‘publications’) Mace,C (2007) Mindfulness in psychotherapy: an introduction. Advances in Psychiatric Treatment 13 147-154

38. 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

39. T1 (Pre-group) T3 (Post-group) T5 (3 month follow-up) Measure Mean SD Mean SD Mean SD MAAS 2.82 0.82 3.51 0.93 4.08 0.80 DERS 3.38 0.56 3.10 0.69 2.41 0.79 Mindfulness and emotion regulation (Martin, Mace, Riggs & Liebling-Kalifani)

40. ANOVA across T1, T3 & T5 Measure F - statistic p value MAAS F(2, 10 ) = 8.07 p = .008** DERS F(2, 10) = 31.18 p < .001** Correlation between MAAS and DERS scores after MBCT End of treatment r = - 0.83, p = .021 3 month follow-up r = - 0.89, p = .01.

42. 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.

43. 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.

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