Transcript No Slide Title

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-judging
Patience
Beginner’s Mind
Trust
Non-striving
Acceptance
Letting go
Learning mindfulness
‘Formal’ methods
Sitting meditations
Movement meditations
Group exchange
‘Informal’ methods
Acting mindfully
In situ exercises
Contemplations
Mindfulness and Neuroplasticity (Lazar et al, 2005)
Clinical applications so far:
Addictions
Anger
Anxiety
Binging
Delusions & hallucinations
Depression
Obsessions
Relationship difficulties
Self harm
Trauma
Clinical uses of mindfulness
• Mindfulness coaching (MC)
• Induced mindfulness (IM)
• Therapist mindfulness (TM)
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
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=
Williams
et al
2000
Ma &
Teasdale
2004
Bertschy
et al
2007
Kuyken
et al
2008
RCT
145
RCT
73
RCT
RCT*
Followup
period
60
weeks
Relapse
assessed?
Symptom
measures?
Yes
Yes
Mindfulness
measure?
No
1 yr
Yes
Yes
No
Life events
>2
episodes
55
1 yr
Yes (not
supported)
?
No
No
>3
episodes
123
15
months
Yes
Yes
No
No (QoL)
>3
episodes
* medication also ended for MBCT patients in Kuyken study
Process
variables?
Patients
Autobiographical
memory
>2
episodes
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
Clinical uses of mindfulness
• Mindfulness coaching (MC)
• Induced mindfulness (IM)
• Therapist mindfulness (TM)
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
Clinical uses of mindfulness
• Mindfulness coaching (MC)
• Induced mindfulness (IM)
• Therapist mindfulness (TM)
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
“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)
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
(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
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)
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
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.
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
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 Inventories
Title
Mindful Attention
and Awareness
Scale (MAAS)
Kentucky
Inventory of
Mindfulness Skills
(KIMS)
Toronto
Mindfulness Scale
(TMS)
Freiburg
Mindfulness
Inventory (FMI)
Five Factors
Mindfulness
Quest’re (FFMQ)
Southampton
Mindfulness
Quest’re (SMQ)
Philadelphia
Mindfulness Scale
(PHLMS)
Authors
Brown &
Ryan,
2003
Baer et
al, 2004
Structure
Single
scale
Items
15
Measures
Continuity
Validity?
High
reliability
4 subscales
39
Observe and
accept best
Lau et al,
2006
1 scale
10
Bucheld
et al,
2002
Baer,
2006
4 scales
30
5 scales
39
Chadwick
et al,
2008
Cardaciot
to et al,
2008
1 scale
16
Observe,
accept,
describe,
act
Postsession
adherence
Effects
plus
awareness
like Kims
plus nonreactivity)
Reactivity
2 scales
20
Awareness
and
acceptance
Limited.
Designed as
orthogonal
Independent
of other
scales
Factors not
stable
Observe and
accept best
Psychotic
populations