Hong Kong Workshop. April 25, 2015 HELPING CHILDREN COPE MINDFULNESS-BASED COGNITIVE THERAPY WORKSHOP BASED ON ACKNOWLEDGEMENTS CO-DEVELOPER OF MBCT-C

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1 HELPING CHILDREN COPE MINDFULNESS-BASED COGNITIVE THERAPY FOR CHILDREN Randye J. Semple, Ph.D. Keck School of Medicine University of Southern California Semple, 2015; flower & bowl drawings Mahone, 2011 WORKSHOP BASED ON ACKNOWLEDGEMENTS CO-DEVELOPER OF MBCT-C Jennifer Lee, PhD MBSR CONSULTANTS Jon Kabat-Zinn, PhD Ferris Urbanowski, MA Polly Wheat, MD MBCT CONSULTANTS Zindel Segal, PhD John Teasdale, PhD Mark Williams, DPhil CONSULTANTS Lisa Miller, PhD Dinelia Rosa, PhD BOOK ILLUSTRATOR Denise McMorrow Mahone, PhD RESEARCH ASSISTANTS CLINICAL STAFF SCHOOL TEACHERS & STAFF 1

2 MINDFULNESS ACTIVITY TAKING THREE MINDFUL BREATHS INTRODUCTIONS LEARNING OBJECTIVES Describe origins & rationale behind MBCT-C Explain the main objectives of MBCT-C & identify developmental adaptations needed to conduct mindfulness interventions with children Practice & experience some MBCT-C techniques Discuss the importance of one's own practice in facilitating social-emotional resiliency in children 2

3 ATTENTION The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will..... But it is easier to define this ideal than to give practical directions for bringing it about. William James (1890) The Principles of Psychology TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points MINDFULNESS ACTIVITY TAKING THREE MINDFUL BREATHS 3

4 TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points CHILDHOOD ANXIETY (USA) 10% to 20% prevalence $42 to $99 billion/year 50% comorbidity Median symptom onset is 6 years old 2/3 never receive treatment Chavira et al. (2004); Kessler & Greenberg (2002); Greenberg et al. (1999) Kessler et al. (1996); Ringel et al. (2001); Shaffer et al. (1996) CHILDHOOD ANXIETY (HONG KONG) 16% with anxiety levels above normal Slightly higher in boys than in girls 8 10% prevalence (diagnosed disorders) Common comorbidities Major depressive disorder Dysthymic disorder Attention deficit hyperactivity disorder City University of Hong Kong, Happy Seeds Nurturance Project, 2014; Child Assessment Service, Dept. of Health, HK SAR,

5 CHILDHOOD ANXIETY PREDICTS Academic problems Behavioral problems Social skills deficits Substance abuse Criminal activity It s getting worse U.S. DHHS (2004, 2006); Silverman & Moreno (2005) Chavira et al. (2004); Buka et al. (2002); Kessler & Greenberg (2002) SUICIDALITY: HK ADOLESCENTS (AGE 15-19) 28.1% lifetime suicidal ideation 6.2% past-year suicidal ideation 3.1% made a plan in the past year 2.8% made suicide attempt(s) in the past year 0.3% made attempt(s) that needed medical care Centre for Suicide Research & Prevention The Prevalence Study ( ) AGE OF FIRST SUBSTANCE USE (HONG KONG) Alcohol use among students in secondary schools 64.9% ever used 24.2% used in the previous month 2008/2009 Survey of Drug Use among Students Hong Kong SAR: Narcotics Division of Security Bureau Age of Onset < % % % % 5

6 AGE OF FIRST SUBSTANCE USE (HONG KONG) Alcohol use among students in secondary schools 64.9% ever used 24.2% used in the previous month 2008/2009 Survey of Drug Use among Students Hong Kong SAR: Narcotics Division of Security Bureau Age of Onset < % % % % SUBSTANCE USE: HK ADOLESCENTS (< 21) Peer influence/peer identification Relieve boredom/depression/anxiety Avoid discomfort of its absence Curiosity Seek euphoria/sensory satisfaction Self-medication Under influence of partner Other reasons Narcotics Division, Central Registry of Drug Abuse 59 th Report: Hong Kong, SAR, 2010 SUBSTANCE USE: HK ADOLESCENTS (< 21) Peer influence/peer identification Relieve boredom/depression/anxiety Avoid discomfort of its absence Curiosity Seek euphoria/sensory satisfaction Self-medication Under influence of partner Other reasons Narcotics Division, Central Registry of Drug Abuse 59 th Report: Hong Kong, SAR,

7 STUDENT S DILEMMA (PICK ANY TWO) Good Grades No Sleep No Friends Good Social Life Impossible Fail Every Class Get Enough Sleep MINDFULNESS ACTIVITY 3-MINUTE BREATHING SPACE Awareness Upright, dignified posture. Eyes closed. What is my experience... thoughts feelings body sensations? Identify & acknowledge the experience, even if it is unwanted. Gathering Shift attention to the breath. Use the breath as an anchor to bring awareness to this moment. Expanding Expand awareness to include body as a whole. Be aware of how the body feels in relation to the environment. Adapted from Segal, Williams & Teasdale (2002, 2013) TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points 7

8 Beck & Clark (1988) COGNITIVE THEORY OF ANXIETY Perceived Threat Few skills-training opportunities Attention biased toward threat Avoidant behaviors Perceived ability to manage threat Maladaptive schemas Over-estimates threat & consequences Cognitive distortions Semple, 2015; flower & bowl drawings Mahone, 2011 THINKING THINKING THINKING PARADOXICAL MESSAGES OF CT Explicit message Focused on the content of thoughts Thoughts can & should be changed Changing thoughts reduces anxiety Implicit message Focused on the process of thinking Thoughts are merely events in the mind Changing relationship to thoughts reduces anxiety 8

9 TEACH JUST THE IMPLICIT MESSAGE? It is remarkable how liberating it feels to be able to see that your thoughts are just thoughts and that they are not you or reality... Kabat-Zinn (1990; p ) MINDFULNESS MEANS Mindfulness means paying attention to things as they are in any given moment, however they are, rather than as we want them to be. Intentional Focused directly on present experience Non-judgmental Accepting of self & others Williams, Teasdale, Segal & Kabat-Zinn (2007) WHAT MINDFULNESS IS NOT Self-indulgent A quick fix A distraction or escape from reality Passive or complacent (it s an active engagement) Hypnotic or addictive (however, it can be relaxing) Shutting off thoughts or clearing the mind Religion (although it is part of many religions) Magical or mystical (just a special kind of attention) 9

10 WHICH MOMENT? Anxious thinking Biased attention Past & future focused (memory dependent) Identified with thoughts Ruminative thinking Judgmental & rejecting Mindful awareness Unbiased attention Present focused (sensory dependent) Decentered from thoughts Direct experiencing Nonjudgmental & accepting BEING MINDFUL OF ANXIETY? I realize I ve only been at it for 5 minutes, but mindfulness isn t bringing me the peace of mind I was promised. 10

11 INTEGRATING TWO MODELS COGNITIVE THERAPY Content focused Change MINDFULNESS Process focused Acceptance BOTH ARE Developmentally appropriate Experiential activities Home work Short-term (time limited) THOUGHTS BELIEFS EXPECTATIONS Hooray! I got 2 gumballs! So what? Yesterday I got 3! Just 2 lousy gumballs MINDFULNESS ACTIVITY THOUGHTS ARE NOT FACTS Thoughts are just thoughts 11

12 PRACTICE INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? SAMPLE CHART MAIN TAKE-AWAY POINTS Childhood anxiety is common Early onset anxiety predicts adolescent & adult problems Cognitive therapy & mindfulness are different Decentering may be the common mechanism of therapeutic effectiveness 12

13 MINDFULNESS ACTIVITY MINDFUL STRETCHING BREAK MINDFULNESS ACTIVITY TAKING THREE MINDFUL BREATHS TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points 13

14 AIMS OF MBCT-C Enhance awareness Bring attention to the present moment Identify thoughts, feelings & body sensations Observe (rather than judge) experiences Decentering from internal experiences Choose how to respond Being aware that choices always exist Act with self-compassion & empathy for others CORE COMPONENTS Attention Present-focused awareness Decentering Mindfulness Emotion regulation Equanimity Self-compassion Empathy Behavioral self-management Mindful choices Semple, 2015; flower & bowl drawings Mahone, 2011 AGE-APPROPRIATE CHANGES Memory Capacity for attention Verbal fluency Abstract reasoning Family interrelatedness 14

15 MEMORY & ATTENTIONAL CAPACITY 12-weeks, 90-minute sessions Short activities (3-10 minutes) Broad variety of activities Repetition of core themes Rules for mindful behavior Written session summaries Home practice assignments VERBAL FLUENCY & ABSTRACT REASONING More explicit guidance through inquiry Activities focused on individual sensory modes Creative expression encouraged Games & stories included Frequent physical activity FAMILY INTERRELATEDNESS Parental orientation session Written session summaries & practice activities Family encouraged to participate at home Ongoing dialogue between therapist & parents Parental review session 15

16 STRUCTURAL ADAPTATIONS 6 to 12 children per group (1 or 2 therapists) 12-week program, 90-minute sessions Written session summaries & weekly homework 2 parent sessions (introduction & follow-up) MBCT-C for individual child psychotherapy FUNCTIONAL ADAPTATIONS Therapist is active participant Variety with creative repetition Short hands-on activities Sensory focus Mindfulness of Thoughts, feelings & body sensations Judging vs. describing Choice points TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points 16

17 MINDFULNESS ACTIVITY 3-MINUTE BREATHING SPACE Awareness Upright, dignified posture. Eyes closed. What is my experience... thoughts feelings body sensations? Identify & acknowledge the experience, even if it is unwanted. Gathering Shift attention to the breath. Use the breath as an anchor to bring awareness to this moment. Expanding Expand awareness to include body as a whole. Be aware of how the body feels in relation to the environment. Adapted from Segal, Williams & Teasdale (2002, 2013) OVERVIEW OF MBCT-C Your own preparation Logistics Orientation (sessions 1-3) Middle phase (sessions 4-10) Termination (sessions 11-12) 3-month follow-up EMBODYING MINDFULNESS Attend to your own practice Ground your teaching in your own experience Foster acceptance, curiosity & openness Invite participation (emphasize freedom to choose) Share your own experiences Offer encouragement & acceptance Discover your own voice (don t read scripts) 17

18 MINDFULNESS IN RELATIONSHIP Let go of goals & expectations Don t tell, don t yell, don t judge Cultivate a relationship of authenticity, mutual respect & connection Consistently demonstrate mindfulness & compassion through your own speech & behaviors Form a shared intention to cultivate experience MAKING MINDFULNESS MEANINGFUL Make it relevant to what s happening in their world Appropriate role models (celebrities, athletes) What is in it for them? Less stress & anxiety Better physical health Better performance (academically, in sports) Better relationships with family members & peers Guidelines for Mindful Behavior 1. We agree to act and speak to other people with care and kindness. 2. We can remember not to talk when another person is talking. 3. We can remember to raise our hand to share our ideas with the group. 4. We agree not to talk during mindful awareness practices so as not to disturb others. 5. We agree that if anyone does not wish to take part in an activity, one person at a time may sit in the Quiet Space. 18

19 Semple, 2015; flower & bowl drawings Mahone, 2011 Semple, 2015; flower & bowl drawings Mahone, 2011 BELLS OF MINDFULNESS Semple, 2015; flower & bowl drawings Mahone,

20 MINDFULNESS ACTIVITY LISTENING TO THE SOUNDS OF SILENCE 3 LINES OF INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? Semple, 2015; flower & bowl drawings Mahone,

21 MINDFULNESS OF THE BREATH & BODY MINDFULNESS OF EMOTIONS MINDFULNESS OF THE SENSES 21

22 MINDFULNESS OF JUDGMENTS MINDFULNESS OF CHOICE CHOICE POINTS Are you happy? No Yes Do you want to be happy? Great! No Yes Keep doing what you re doing. Try something different. Semple, 2015; flower & bowl drawings Mahone,

23 MINDFULNESS OF SILLINESS GENERAL SESSION OUTLINE: PREPARATION Therapist s personal practice Bells of mindfulness Being Present board (optional) Complete 1 st Feely Faces scale (optional) Brief recap of previous session Review session agenda Review prior week home practices GENERAL SESSION OUTLINE: ACTIVITIES Bells of mindfulness 3-minute breathing space (1 st practice) Sensory-based mindfulness practices Inquiry & dialogue Mindful body practices 3-minute breathing space (2 nd practice) 23

24 GENERAL SESSION OUTLINE: CONCLUDING Read a poem together Complete 2 nd Feely Faces scale (optional) Review session summary Review session handouts Review home practices Bells of mindfulness TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points LUNCHTIME PRACTICE Bring awareness to the food Bring awareness to the sensations of eating See the beauty & wonder Practice gratitude 24

25 MINDFUL EATING PRACTICE As best you can, mono-task eating your lunch A. Bring mindful awareness to the experience Tastes smells textures sights sounds B. Bring mindful awareness to thoughts Are they descriptive? Judgmental? Past or future focused? C. Bring mindful awareness to emotions Observe how long it takes to forget about A B & C TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points LUNCHTIME PRACTICE REVIEW 1. Did you remember to be mindful? 2. What was that experience like for you? 3. How was bringing awareness to the simple act of eating different than what you do every day? 4. How might this practice be helpful to you in your everyday life? 25

26 LAYING THE GROUNDWORK Session 1 Introduction Getting to know each other Being on autopilot Orientation to mindfulness Structure of the program Guidelines for group practice LIFE CAN BE COMPLICATED ARE WE NAVIGATING ON AUTOPILOT? 26

27 MINDFULNESS ACTIVITY FINDING MINDFULNESS IN A CUP PRACTICE INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? BUILDING THE FOUNDATION Session 2 Barriers to practice This is not easy, so why do it? Mindful breathing Mindfulness of the body 27

28 DISCOVERING INNER WORLDS Session 3 Who Am I? Exploring internal experiences with playfulness & curiosity Thoughts, feelings & body sensations CONSTRUCTING REALITY MINDFULNESS OF THE SENSES 28

29 MINDFUL TASTING Session 4 A taste of mindfulness Thoughts are not facts Thoughts are not the same as events MINDFULNESS ACTIVITY RAISIN MINDFULNESS PRACTICE INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? 29

30 MINDFUL HEARING Session 5 Mindful hearing I Thoughts create our worlds 3-minute breathing space MINDFULNESS ACTIVITY DOYOU HEAR WHAT I HEAR? PRACTICE INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? 30

31 MINDFUL HEARING Session 6 Mindful hearing II Recognizing reality Practicing mindful expression of emotions MINDFULNESS ACTIVITY SOUNDING OUT EMOTIONS MINDFULLY PRACTICE INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? 31

32 MINDFULNESS ACTIVITY MINDFULLY MOOOVING SLOOOWLY MINDFUL SEEING Session 7 Practice looking Seeing what we don t see Judging vs. noting Judging changes seeing Session 8 Attention building Discovering choice points Redirecting attention CHOICE POINTS Are you happy? No Yes Do you want to be happy? Great! No Yes Keep doing what you re doing. Try something different. Semple, 2015; flower & bowl drawings Mahone,

33 MINDFULNESS OF SEEING Semple, 2015; flower & bowl drawings Mahone, 2011 WHAT KIND OF ANIMAL IS THIS? HOW MANY TRIANGLES? 33

34 WHAT DOES THIS SAY? A BIRD IN THE THE HAND NOW WHAT DOES THIS SAY? A BIRD IN THE THE HAND WHICH RED DOT IS BIGGER? 34

35 WHICH RED DOT IS BIGGER NOW? CAN WE SEE TOO CLEARLY? Semple, 2015; flower & bowl drawings Mahone, 2011 MINDFUL TOUCHING Session 9 Touch the world with mindfulness Control the responses, not the events Choose to be here now 35

36 MINDFULNESS ACTIVITY BEING IN TOUCH PRACTICE INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? MINDFUL SMELLING Session 10 What the nose knows Advanced practice - judging vs. noting Moving toward & away 36

37 MINDFULNESS ACTIVITY JUDGING STINKS! PRACTICE INQUIRY 1. What was that experience like for you? What did you notice in your thoughts your feelings your body sensations? 2. How is bringing awareness to this experience different from what you do every day? 3. How might this practice be helpful to you in your everyday life? EXPANDING MINDFULNESS Session 11 Life is not a rehearsal Integrating the senses Accessing mindfulness in everyday life 37

38 MAINTAINING MINDFUL AWARENESS Session 12 Living with presence, compassion, and awareness Compassion, commitment & continuing practice Graduation ceremony MINDFULNESS ACTIVITY REMEMBERING TODAY S JOURNEY Childhood anxiety Integrating cognitive & mindfulness approaches Making mindfulness child-friendly Components of MBCT-C Walking through the 12 sessions Summary & take-away points 38

39 THREE PROGRAMS ONE MODEL Mindfulness-based Cognitive Therapy for Children (MBCT-C) Therapist conducted Clinical treatment for mood & anxiety problems Mindfulness Matters! Teacher conducted Regular classroom curriculum Mindful Learning Mindful Living (ML 2 ) Therapist conducted Therapeutic classrooms RESEARCH CONCLUSIONS Feasible to implement in clinics & schools Acceptable to children, parents & teachers Accessible to children via sensory modes Elicited creativity, playfulness & purpose Fewer attention problems Lower test anxiety improved school performance Reduction of anger & emotional reactivity Semple, Lee, Rosa & Miller (2010); Lee, Semple, Rosa & Miller (2008); Semple, Reid & Miller (2005); Semple et al. (in preparation) LESSONS WE TEACH Attunement with the internal world of thoughts, feelings & body sensations Self-awareness enhances emotional resiliency Mindfulness promotes acceptance of what is Acceptance leads to growth & development Clarity brings awareness of choice points Choices create freedom 39

40 THE WISDOM OF CHILDREN Mindfulness lets me see when I m going to get in trouble and just breathe instead. Mindfulness is not letting thoughts get in your way when you can be doing something better. Mindfulness makes my life easier. BEFORE AFTER [Attention] [Justice] ACCEPTANCE LEADS TO CHANGE Present-focused attention curtails autopilot Mindfulness increases: Awareness of choice points Consideration of response choices Consideration of response outcomes Creates opportunities to choose more skillful responses & adaptive behaviors 40

41 KEY TAKE-HOME POINTS The heart of mindfulness is attention Mindfulness increases awareness Awareness promotes change Judging is not the same as experiencing Thoughts are just thoughts Choices only occur in this moment Mindfulness lets us be happy (in spite of life s challenges) MINDFULNESS The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will..... But it is easier to define this ideal than to give practical directions for bringing it about. William James (1890) The Principles of Psychology 41