SDS Seminars Ltd. BPS Approved Certificate in Third Wave CBT. Module 1. Mindfulness. with Dr Fiona Kennedy. Course Materials

Transcription

1 SDS Seminars Ltd BPS Approved Certificate in Third Wave CBT Module 1 Mindfulness with Dr Fiona Kennedy Course Materials

2 BPS Approved Certificate in Third Wave CBT Module 1 MINDFULNESS 2 Day Course Dr Fiona Kennedy Aims For 2 Days Defining Mindfulness Day onefocuses on thinking a littleabout mindfulness, and experiencing a lot of it. It s been said that using mindfulness therapeutically will often fail if therapists do not practice it themselves. Our own personal journey with mindfulness is of great importance, so Experiencing Mindfulness The days will provide many opportunities to practice open awareness, of things in the present moment, both outside ourselves and inside our minds and bodies. Being Mindful Towards Our Clients Holding the client in our awareness without judging, interpreting or rushing to problem solve, in other words, mindfully, allows a deep and rich comprehension of their situation and struggle. From this perspective we can genuinely approach how it feels to be the client, and begin our communication from their own standpoint, rather then our own. Mindfulness As A Therapeutic Tool Several evidence based therapeutic and coaching approaches now incorporate mindfulness as a therapeutic tool. How can we bring mindfulness into our own therapeutic or coaching practice. How to sell mindfulness by giving our clients a reason to use it. Formulating Problems As A Lack Of Mindfulness Many human struggles involve ruminating about the past, worry and panic about the future, and self-judgment. These are all ways of not being mindful. Formulating the problem not as a thing to be overcome but an internal state to be accepted. This opens the way for therapies that emphasise living a meaningful life, rather than just feeling better. Teaching Clients To Use Mindfulness Experience has shown that there are more and less effective ways to take clients on the mindfulness journey. As a skill it needs to be practiced. To be practiced it needs motivation, patience and persistence. Different mindfulness exercises are easy and difficult or perhaps beginner and advanced skills. This part of thetraining will allow participants to try out ways and means of encouraging clients on this journey. Running A Mindfulness Group The second day will include instructions, discussion and role play of running a mindfulness group. This will use the basic structure from a DBT group approach and this dovetail into the 2 day DBT third wave presentation. 1

3 What Is Mindfulness? History, Definitions Current Uses Theory Effectiveness History The Buddha: Western Idea: 2

4 Definitions Intentionally living with awareness in the present moment Wake up from automatic pilot to participate and be present Without judging or rejecting the moment Notice consequences and helpfulness/harmfulness-but let go of suppressing, evaluating, avoiding or blocking Without attachment to the moment Attend to the experience of each new moment, don t ignore the present by clinging to past or grasping for future Definitions At the still point of the turning world. Neither fleshnorfleshless; Neither fromnortowards; At the still point there the dance is, But neither arrest nor movement. And do not call it fixity, Where past and future are gathered. Neither fromnortowards, Neither ascentnordecline. Except for the point, the still point, There would be no dance and only the dance. T. S. ELIOT, Burnt Norton (1935) 3

5 Mindfulness practice The intentional practice of mindfulness and mindfulness skills How? Anywhere, anytime, while doing anything. Pay attention to the moment non judgmentally Meditation Focus attention (open or focus mind) Non judgmentally (without attachment/avoidance) Let go of analysis let the word do the work Carry practice into daily life Outcome Studies The literature on effects of mindfulness training contains manymethodologicalweaknesses, Mindfulness interventions may improve pain, stress, anxiety, depressive relapse, and disordered eating (e.g., Kabat-Zinn, 1982; Kabat-Zinn et al., 1992; Kristeller & Hallett, 1999; Shapiro, Schwartz, & Bonner, 1998; Teasdale et al., 2000). Mindfulness Training as a Clinical Intervention: A Conceptual and Empirical Review by Ruth A. Baer 4

6 Outcome Studies Gross, C. R., M. J. Kreitzer, et al. (2011). (MBSR) as a treatment for chronic primary insomnia. RCT N=30 primary chronic insomnia randomized 2:1 to MBSR or pharmacotherapy (PCT) MBSR=pharmacotherapy on: sleep onset latency, sleep quality andsleep efficiency Mindfulness-based stress reduction versus pharmacotherapy for chronic primary insomnia: a randomized controlled clinical trial." Explore (NY) 7(2): Outcome Chiesa, A. and A. Serretti (2011). MBIs for pain and depressive symptoms in patients with chronic pain. Systematic review 10 studies to July 2009 MBIs reduce pain symptoms and improve depression improvements in psychological measures such as coping with pain following MBIs further research in larger better designed studies is warranted. "Mindfulness-based interventions for chronic pain: a systematic review of the evidence." J AlternComplement Med17(1):

7 Outcome Dobkin, P. L. and Q. Zhao (2011). 83 chronically ill patients mindfulness related to reductions in depression, stress, medical symptoms and increased sense of coherence Future research is needed to identify which factors lead to an increase in mindfulness. Increased mindfulness--the active component of the mindfulness-based stress reduction program?" Complement Ther Clin Pract 17(1): Some Theory Grant, J. A., J. Courtemanche, et al. (2011). Meditative practice, has been associated with pain reduction, low pain sensitivity, chronic pain improvement, and thickness of pain-related cortices. Zen meditation is more akin to 'no appraisal' than 'reappraisal'. This implies the cognitive evaluation of pain may be involved in the pain-related effects observed in meditators. "A non-elaborative mental stance and decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen meditators." Pain 152(1):

8 Theory Using MRI and a thermal pain paradigm We show ZEN practitioners reduce activity in executive, evaluative and emotion areas during pain (prefrontal cortex, amygdala, hippocampus). Meditators with the most experience showed the largest activation reductions. Meditators activated primary pain processing regions (anterior cingulate cortex, thalamus, insula). Theory Lower pain sensitivity predicted by reductions in functional connectivity between executive and painrelated cortices Suggests functional decoupling of the cognitiveevaluative and sensory-discriminative dimensions of pain allowing practitioners to view painful stimuli more neutrally. Possible to self-regulate by reducing higher-order evaluative processes, as demonstrated here by the disengagement ofanterior brain systems in meditators. 7

9 Four Therapeutic Systems That include mindfulness training as a component. Mindfulness based stress reduction (MBSR; Kabat- Zinn, 1990), Mindfulness based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002; Teasdale & Barnard, 1993) Dialecticalbehavior therapy (DBT; Linehan, 1993), Acceptance and commitment therapy (ACT; Hays, Strosahl, & Wilson,

10 The Pigeon And The Cowboy Ways To Be Unmindful Ruminations re past: (if only) guilt, shame, anger, hatred, revenge 9

11 Ways To Be Unmindful Ruminations re present: (I wish) Envy Bitterness discontent I can t I don t I won t Ruminations re future: (what if?) Negative predictions Catastrophising Anxiety Ways To Be Unmindful Hopelessness 10

12 Experiencing The Present: Ways To Be Mindful Turning the mind Accepting the present Observing Describing Participating Non-judgemental stance Wise Mind Wise Mind Rational Wise Mind Emotional Mind Mind 11

13 Video Discuss salient learning Why Is Mindfulness Important? Exercise: How would your client s life be If s/he accepted their situation/feelings? 12

14 When acceptance is better than change: When trying to change it makes it worse; When it can t be changed Cognitive Avoidance Thought Suppression The Green Rabbit Chocolate: Behavioural Rebound Distress tolerance (mindful focus) 13

15 How To Stop Banging Your Head On A Brick Wall Client avoidance Client resistance See saw Alternatives To Your Usual Treatment Practice Therapist mindfulness Accepting one s own emotions and urges 14

16 Reasons To Be Mindful 1,2,3 1. Reduce avoidance 2. Empower client 3. Empower/relieve/relax therapist Transference Protective distancing position Therapist burn out position T C T C PB PB Tentative holding position Collaborative working position T T C PB C PB 15

17 Mindfulness 3 Choose something you usually do on automatic Do this withawareness When? Where? Behaving Mindfully: 1. Non-judgmental Stance Identifying judgments in your clients perspectives: Shoulds, oughts Rephrasing non judgmentally 16

18 2. Observing And Describing Say it just as it is: I can t, Itwon t work, It s impossible, Re-phrasing realistically 3. Participating Committing to action in parallel to pain Throwing yourself into the present 17

19 4. Staying in the moment Turning the mind from past/present/future rumination FOFBOS BreathFeet Reasons to be mindful 1,2,3 1. To act your values 2. To achieve your goals 3. To dowhatworks (beeffective) 18

20 Values Based Work In my close relationships I want to be... In my work I want to be... As a parent I want to be... In my spiritual life I want to be... How To Introduce Mindfulness To Clients Mindfulness metaphors, Relate these to particular client circumstances 19

21 Why Use a metaphor? Can communicate difficult to hear point Can lighten emotion Produces imagery, increasing memorability In-session And Out Of Session Practice Targeting when and how to be mindful Setting homework mindfulness tasks Reminding andre-phrasing 20

22 Using Mindfulness In Challenging Situations Convincing clients not to judge success by feeling better Managing crises: Mindful breathing Mindful observation Building Mindfulness Into Clients Everyday Lives Practicing skills in all different settings, the mindfulness habit 21

23 Exercise: How might today affect your practice? Evaluations, Goodbye Til Tomorrow! 22

24 Day 2 Mindfulness Feedback andreview of yesterday Wise mind What skills Observe Describe 7 Core Mindfulness Skills Participate How skills Non-judgmentalness One mindfulness Effectiveness 23

25 Wise Mind Rational Emotional Wise Mind Mind Mind Cool Rational Task-focused Wisdom Middle path Hot Mood-dependent Wise Mind Practice Stone on the lake: floating down Spiral stairs Inbreath wise outbreath mind Inbreath ask Wise Mind a question outbreath listen for answer Solar plexus/centre forehead Expanding awareness Dropping into breath pauses Other ideas? 24

26 What Skills OBSERVE Notice body sensations Pay attention Control attention Wordless watching Observe in and outside Describe Put words on Label Unglueinterpretations/opinions from facts If you can t observe it through your senses you can t describe it 25

27 Participate Throw yourself into present activities Become one with whatever you re doing Act intuitively from Wise Mind Go with the flow Observing Practice Observe with your eyes Clouds, nature, people, faces, features, leaf Observe sounds Stop and listen; listen to speech; music Observe smells Smells around you, food smells, bath smells, flowers Observe taste and eating Eating slowly, lollipop licking, part of meal Observe urges Urge-surf, notice urges to avoid, body scan, swallowing urge 26

28 Observing Practice Observesensations oftouch Stroke upper lip, walking, sitting, touch something, Observe breath Abdominal breathing, pauses, nose sensations, breath while walking, while listening to music Observe thoughts As they come into your mind, pauses, sky and clouds, soldiers, helicoptering, worries (or shift focus), conveyor belt, river and leaves, railway track Imagine your mind is A chessboard, a stage, a TV screen, a book Observeby expanding awareness 3 things at once, the space around you, the sheets, a tree Describing What You See Cloud patterns On bench, passers by An object from nature Describe what a person has just said to you, check A person s face when they seem angry, afraid or sad What a person has done or is doing now Other ideas? 27

29 Describing Thoughts And Feelings A Feeling Of Anger Is Arising Within Me I Feel X And My Thoughts Are Y When You Do X I Feel Y Describe As Many Thoughts As You Can While Feeling A Strong Emotion Describe Your Feelings As An Object Label Thoughts As Judgments Label The Mind Which Send The Thoughts And Feelings Describe Thoughts And Feelings As Helpful Or Unhelpful Describe Your Breath I am inhaling 1 I am exhaling 1 to 10 As above, then extend exhalation I am extending breathingout I am inhaling and following the inhalation from beginning to end I am exhaling and Other ideas? 28

30 Participating Practice Awareness of connection to the Universe Dance to music Sing along Jump out of bed and dance or sing Go to a church and join in singing Play karaoke Throw self into what someone is saying Go running and focus Become 1 on inbreath, become 2 on next etc Become a word Learn to improvise Other? How Skills Nonjudgmentally See, don t judge, accept each moment, discern helpful/harmful, don t judge your judging One-mindfully Rivet self to now, one thing at a time, let go distractions, concentrate your mind Effectively Keep goals in mind, focus on what works, play by the rules, act skillfully, let go of wilfulness and sitting on hands 29

31 Nonjudgmentalness A judgmental thought is arising in my mind Count judgmental thoughts Replace: state facts, consequences, feelings Observe judgmental body language Change judgmental body language Recount an event nonjudgmentally Imagine a person you are angry with. Try to become her/him. See from their point of view. Imagine understanding them When judgmental practice half smile/willing hands One - Mindfulness Awareness while: Making tea/coffee Washing dishes Cleaning house Taking slow-motion bath Meditating Other? 30

32 Observe when getting angry/hostile; ask is this effective? Observe self when wanting to be right. Give it up and go for effective Noticewilfulness: is this effective? Drop wilfulness, practice effective instead When feeling angry/urge to be ineffective, practice willing hands Other? Effectiveness Feedback What process did you feel you needed to work through? What blocks did you observe In client In self 31

33 The Mindfulness Journey Outside-inside Concrete-abstract Formal-informal Easy-difficult Cool-hot (emotions) Running A Mindfulness Group: week content 1 Orientation: Goals and Guidelines 2 Wise Mind Mindfulness what skills Goals of mindfulness training Ground rules Pros and Cons Wise mind observe 3 What skills describe 4 What skills participate 5 Mindfulness How Skills Non-judgmental stance Intro Ice breaker Mindfulness exercises Clarifying motivation Homework review diary Teaching Practice Feedback homework 6 How skills One moment 7 How skills participate 8 Review, evaluate, goodbye Strengthening practice, network building, boosters 32

34 Behavioural Teaching Principles Successive approximation Errorless learning Positive reinforcement ofspecific behaviours Validation Self-disclosure Modelling Generalisation: specific to all situations Monitored practice (diary) Functional analysis of unwanted behaviour (not doing practice, saying I can t do it ) Taking Feedback On Mindfulness Exercises Opportunity for client/s to learn mindfulness is: Repeated re-focusing of attention Willing acceptance Observing mind (wise mind) Opportunity for client/s to learn mindfulness is not: Not relaxation Not to feel better Not to stop thinking/blank mind 33

35 Setting Homework & Review SMARTER Specific Measurable Achievable Realistic Time bound Evaluate Review Troubleshooting Dealing with problems Validate Observe, describe Don t judge Guess function Problem solve 34

36 Managing Disruptive Behaviour Examples of disruptive behaviour Gentle correction Individual work Embedding the Learning Booster sessions Apps Forums Other? 35

37 Evaluating How to measure progress? Client goals MH measures Mindfulness/EA questionnaires Five Facet KIMS AAQ-II AFQ-Y CAMM See mindfulness tips and resources for more details on these 36

38 BPS Approved Certificate in Third Wave CBT Module 1 Mindfulness Mindfulness Tips and Resources Physicalising exercise Passengers on the bus Demons on the boat Anxiety is a hole with a rope to pull you in Ice cube exercise Taking feedback: Awareness Attention Acceptance Present moment awareness: instant mindfulness: Where are the soles of my feet? Visiting my breath? Acceptance stories Useful little book Free mindfulness resources:

39 REFERENCES FOR MINDFULNESS MEASURES Baer, R. A., Smith G. T., & Allen, K. B. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment, 11, Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, Bond, F. W., Hayes, S. C., Baer, R. A., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20, BOOKS Dunkley and Stanton Teaching Clients to Use Mindfulness Skills Williams and Kabt-Zinn (Eds) Mindfulness