Mindfulness skills training for adults with learning d isabilities

1. Mindfulness skills training for adults with learning disabilities Russell Botting& Liam Reilly Complex Health Needs Service, Sirona Care and Health, St Martin’s Hospital, Bath.

2. What we will cover: • Mindfulness • Mindfulness practices • Mindfulness and PBS • Working with staff teams Break • Our Mindfulness groups • Pilot study (Liam) • Mindfulness Practise: SoF(Script) • Groups 2 and 3 • Mindfulness Practise: Mindful eating • Mindfulness Practise: 3 minute breathing space • Questions

3. Buddha ‘Do not dwell in the past, do not dream of the future, concentrate the mind on the present moment.’ Jon Kabat-Zinn MBSR ‘Awakening from habits of body and mind to how things actually are’ ‘Being mindful means that we suspend judgment for a time, set aside our immediate goals for the future, and take in the present moment as it is rather than as we would like it to be.’ Mark Williams MBCT

4. Mindfulness is … …Paying attention in a particular way, on purpose, in the present moment and non-judgementally Kabat-Zinn (1996) Learning to pay attention: • Moment by moment • Intentionally • With curiosity and compassion Williams (2011) Cultivated through a range of meditative practices Kabat-Zinn(1990)

5. Are you driven by the daily routines that force you to live in your head rather than in your life? How many of you are thinking about something else right now?

6. Don’t think about the pink rabbit

7. The key to mindfulness lies in learning to simply rest in a bare awareness of thoughts, feelings, and perceptions as they occur. This gentle awareness is known as mindfulness . . . Simply resting in the mind’s natural clarity --YongeyMingyur Rinpoche

8. Evidence-base general population • Mindfulness increasingly popular approach • Evidence for the benefits of accepting experiences rather than suppressing or avoiding them (Kuyken et al., 2010) • Emerging evidence-base for its use in a number of physical health problems (e.g. cancer, aids, pain) and mental health problems (e.g. stress, anxiety, depression)(see Khouryet al., 2013) • MBCT recommended by NICE (2009) for relapse prevention in depression

9. Mindfulness in adults with LD? • Adults with LD experience higher rates of mental and physical health problems compared to those without LD (Cooper et al., 2007) • Adults with LD should have access to the same evidence-based treatments as those without LD (Valuing People, DoH, 2001) • Few studies have reported on the use of mindfulness in LD

10. Evidence Base LD • Mind-body relaxation used effectively for individuals with LD for decades • Uma et al,(1989): Yoga with children with LD, decreased anxiety and increased IQ and adaptive functioning • Current research mainly from comes from individual case studies and practice based evidence.

11. Main approaches:Mindfulness based stress reduction (MBSR) • Wider scope of applications/contexts • Focus on the landscape of universal vulnerability/suffering • Generic focus on the range of factors that influence functioning • Specificity towards the stress of living with chronic illnesses/general life challenge • Greater emphasis on learning and insight emerging through the process • Larger group • (Noone, 2014)

12. MBSR • Eight week course • Semi structured group • No published studies on the adaptation and application of MBSR for LD • Has been adapted for parents and carers

13. Mindfulness based cognitive therapy (MBCT) • Health care ‘intervention’ • Focus on the landscape of universal and specific vulnerability (e.g. depression) • Explicit focus on the role of cognitive patterns in creating/maintaining distress • Specificity towards living with heightened vulnerability to depressive relapse • From first session the underlying theme is ‘how does this working with the challenge of lowered mood? learning is made explicit • Smaller group • (Noone, 2014)

14. Mindfulness-based training LD • Focus on enhancing functional emotions, behaviours and cognitions. • Nirbhay Singh • Most commonly taught meditation practice was Soles of the Feet • Found decrease in aggression exhibited by adult offenders with LD

15. Dialectical Behavioural Therapy (DBT) • Marsha Linehan • A focus on the present moment • Acceptance of the individual in the moment • Acceptance is necessary for change. • Mindfulness practice and acceptance are distinguishing characteristics of DBT

16. DBT LD • Successfully adapted for both children and adults with LD who have anxiety, mood and trauma-related disorders • Charlton (2006): Adaptation involves simplified language, multimodal presentation of information, use of concrete activities, modelling, more structured, longer therapy sessions

17. Acceptance and Commitment therapy (ACT) • Lack of psychological flexibility • Leads to experiential avoidance • Encourage client to contact psychological experiences - directly, fully without needless defense • Development of new responses in the presence of the previously avoided event that diminish its regulatory power

18. ACT LD • Brown and Hooper (2009): mindfulness and ACT • Taught young person with moderate/severe LD and anxious/obsessive thoughts to distance self from literal content • Experiential and activity based nature may be more accessible for people with LD than CBT based on verbal reasoning skills

19. Integrative approaches • Robertson (2010): Mindfulness-based practices combined with CBT, ACT, mind-body relaxation, and meditative practices. • Positive outcomes when used for individuals and groups with moderate to mild LD in managing anxiety, depression, physical aggression and self injury

20. Integrative approach • Teaching simple, highly effective, mindfulness based relaxation practices. • Use of modelling and experiential exercises • Self-soothing exercises: yoga poses, deep breathing (blowing bubbles), guided imagery and expressive art. • Based on preferences, interests, strengths and needs

21. Not much research in LD • Mainly individual case studies, practice based evidence • Needs to be adapted to individual needs and strengths as well as general “LD adaptation” • Practical, concrete exercises most effective and beneficial

22. Mindfulness practices

26. Mindfulness practices Can’t stop thoughts coming into our head Polygraph

27. Tug of war with a monster • How powerful thoughts, voices and experiences can seem • Learning to take control. Take them where we want to go

28. Distancing exercises • Imagine thoughts speeding away like a train • OR leaves floating down a stream

29. Waterfall metaphor • Experiencing distressing experiences (pain, hurt, emotions, voices) • Step back from under the water. Notice it, but don’t be overwhelmed by it.

30. Breathing exercises • Ball breathing: Hold a ball in right hand. Inhale as you squeeze the ball and exhale as relax your hold. • Straw breathing: Place straw in mouth. Inhale through nose and exhale through the straw. • Birthday cake: Think about a birthday cake. Breathe in before you blow out the candles, and breathe out when you blow the candles out.

31. Noticing exercises • Exercises to centre yourself, and connect with your environment. Practice it throughout the day, especially any time you find yourself getting caught up in your thoughts and feelings. • Leaf/rock exercise • Photo mindfulness (scenery, events, places) • Food mindfulness (e.g. popcorn, raisin) • Sounds in the room (e.g. clocks, cars)

32. Mindful body awareness • Body scan - Ask to focus on each part of body in turn starting with toes and working up the body. Each time naming a part, ask them to notice how it feels & to move it. • Mindful walk – Putting noticing into practice. Facilitator can cue people from time to time ( can pretend to be alien in new body for first time or Dr. Who regenerating into new body)

33. Grounding exercise Soles of the feet practice - The Soles of the Feet practice enables the individual to divert attention from an emotionally arousing thought, event or situation to an emotionally neutral part of the body.

34. Applying to everyday life • Mindful music: listen to all aspects of music, notice affect on you, notice physical sensations, notice emotions, allow thoughts to be carried away on music – then bring attention back. • Focus on tasks and routines: morning routine (e.g. shower, teeth) or Chores (e.g. ironing) • Focusing awareness physical habit: Noticing how tight you hold a pen, being aware of what happens to your breathing or voice tone in an argument. • Focusing awareness on self when an environmental cue occurs: (ThichNhatHanh, 1991) The cues we might use include - Waiting for phone to be answered, waiting to cross the road, walking and getting dressed. • Detailed awareness of the association with cravings or urges such as thoughts, physical sensations and feelings. Source: http://www.mindfulness.org.au/InAction.htm

35. PBS Principles Values • Person-centred approaches to the prevention and reduction of challenging behaviour occur within the context of increased quality of life, with an emphasis on inclusion, participation, and the defence and support of valued social roles • Constructional approaches to intervention design build stakeholder skills and opportunities and eschew aversive and restrictive practices • Stakeholder participation informs, implements and validates assessment and intervention practices • An understanding that challenging behaviour develops to serve important functions for people Theory and evidence base • The primary use of Applied Behaviour Analysis to assess and support behaviour change Gore et al (2013)

36. PBS Principles Process The secondary use of other complimentary, evidence based approaches to support behaviour change at multiple levels Gore et al., (2013)

37. PBS and mindfulness • Doesn’t wait for the extreme behaviour to occur before an intervention is used. • PROACTIVE rather than REACTIVE. • The importance of understanding the function of the behaviour. • The need to focus on appropriate as opposed to inappropriate behaviours. • Collaboration between staff and patients. • Focuses on individuals’ strengths.

38. PBS principles in relation to mindfulness • Praise helps to reinforce patients use of appropriate behaviour and strengths. • Promotes positive relationship with others. • Staff model appropriate behaviours, clients learn to identify appropriate behaviours for themselves. • Clients self-perception may change for the better. • It helps staff to build more meaningful and positive relationships with patients. • Helps staff to stay motivated and to continuously notice positive change. • Makes for a nicer work environment.

39. Applying mindfulness to PBS • Think about what skills the patient needs to develop to achieve appropriatebehaviours and facilitate this in their care. • Mindfulness skills could be applied as an intervention • E.g. modelling, performance feedback, rehearsal, teaching of better coping skills. • The care should include some element of self-monitoring for the patient so that they can learn appropriatebehaviours. (e.g. mindfulness diary, homework).

40. Weave your parachute everyday rather than leaving it…(KabatZinn, 1990)

41. How can we use Mindfulness with staff teams? • How can this help clients learning disabilities?

42. Mindful staff: Suggested mechanisms • Mindfulness encourages acceptance of our own actions and others. Leads to stronger alliance between residents and staff. • Non-judgemental acceptance – behaviour not categorised as positive or negative. • Promote idea of psychological resilience and flexibility rather than coping with stress. Allows forcalm attention instead of escalation. • Becoming responsive to each moment. Move from reacting to responding • Preparation for the effects of challenging environments • Promote functional self-monitoring/self awareness

43. What happens when the wolf shows up… (Noone, 2014)

44. Staff Behaviour Challenging Behaviour

45. Staff Stress Staff Negative Emotional Reactions Staff Behaviour Challenging Behaviour

46. What evidence is there for using Mindfulness with carers.

47. Parents of Children with Autism Singh et al., (2006) 3 pairs of mothers and child Children aged 4-6 years Mothers aged 24-33 years Aggression decreased 81-89% Noncompliance decreased 68-79% Self-injury decreased 60%

48. Singh et al. (2008) 6 adult offenders with mild intellectual disabilities Aggressive behaviors decreased and reached zero levels for all six individuals Reductions in physical restraints, injuries, PRN medications

49. Singh et al. (2006) 3 staff teams Mindfulness skills training given to staff increased learning and reduced aggression in adults with intellectual disabilities Decreased aggression in the individuals without directly intervening with the individuals. Increased clients learning potential

50. Mindfulness Skills for Individuals with LD