MiT-A for Anxiety and Trauma Disorders

Copyright (c) 2013 Mindfulness Training Australia, All Rights Reserved | [email protected]

MiT For Anxiety & Trauma Disorders

Cameron Aggs Clinical Psychologist & DirectorMindfulness Training Australia Cam @bemindful.com.au In collaboration with the Australian College of Community Services


Overview• Session 1:

– Overview of mindfulness and key concepts– Experiential exercises: 3MBS, 2H and 4B techs

• Session 2: – Mindfulness, Clinical Algorithm and Case Formulation– Mindfulness in the context of trauma and other

anxiety disorders • Session 3:

– Mindfulness-Informed Interventions: Video– Facilitating the 3MBS, 2h and 4B techs


Materials and Process

• Slides • Experiential activities

– Participate as much as you feel comfortable– Volunteering for demonstrations

• Choose a client to keep in mind• Video• Password resources


Beginning with the end in mind

• Mindfulness and the Magic Question

• Safety, Safety, Safety…

• Mindfulness should be embodied (RB2RB)

• Enhancing a willingness to feel into and to safely

experience SIFT experiences

– Importance of the breath

– Relevance of Self-As-Context



• Know your mechanisms!

• Socialise early. Find your entry point. Scaffold.

• Jigsaw metaphor

• Make sure you have access to enough resources to

build the capacities you are seeking to foster

• Make sure you can do what you are asking of your

clients (or are cognisant of how hard it can be!)


Who here can come into a state of presence at will?


4Breaths Technique

Coming into a state of presence:

• Lightly, mindfully watching the breath

• Coordinating with the fingers: Motor-movement

• Rounds of 4

“These 4-Breaths are Mine”

Copyright (c) 2013 Mindfulness Training Australia, All Rights Reserved | [email protected] Copyright (c) 2013 Mindfulness Training Australia, All Rights Reserved | MiT - Mindfulness Informed Therapy

What does mindfulness mean to you ?


“Bringing one’s complete attention to the experiences

occurring in the present moment, in a nonjudgmental or

accepting way”

(Brown & Ryan, 2003; Kabat-Zinn, 1990).

What is Mindfulness?


Our “map”: IAA model of mindfulness

(Shapiro et al., 2006)

Intention

Attention Attitude

Paying attention in a particular way…

Kabat-Zinn, 1994, p4

and non-judgmentally.

on purpose, in the present moment,


Holding in Mind: Intentions

• What do you want from mindfulness?

• This moment…?

• This meditation / workshop / this session…?

• More generally inc this treatment episode?

Tip #1: Mindfulness is an intentional activity


Attending Skills

Placing your attention where you want it…

• Attentional placement:

– Shifting and sustaining attention

• Non-judgmental Awareness

– Inhibiting secondary appraisals

• Noticing and Naming

– Ability to put inner experience into words


The process of mindfulness (the WHAT and HOW)

Noticing and naming with

mindful attitudes (internal & external

experiences)

Letting go (creating space)

Focus/Re-focus attention

Choose an aspect of internal or

external experience to

focus attention on


Attending:

• Using your faculty of attention as a tool: Disengaging from worry and rumination

• Fostering Internal Attunement / Meta-CognItive Awareness: What’s happening for me now..?

• The ability to come into a state of “Presence”


3 Qualities of Presence

• Light: As in buoyant in the Mind– Unencumbered by past and future and fixation

• Relaxed: As in soft in the body– Particularly the belly, chest, shoulders, jaw

• Grounded: The bum in the chair and the feet on the floor– Mind ‘riding’ the breath

Light. Relaxed. Grounded.


Presence…

“The mind if not stirred, will become clear”

Sogyal Rinpoche


Points of ContactBecoming Present:

• Feet on the floor

• Bottom in the Chair

• The breath moving in and out of the body

Grounded inwardly, focused outwardly…


Mindful Attitudes: More than just Attention

The Flavour of Mindfulness: The anesthetic of internal attunement….


Attitudes

GOAL

• Curiosity : • Openness • Acceptance • Love

Metaphor / key principles

• Curious Explorer• “It is already here: Let

me feel it• As an active state• Friendliness

Saying ‘Yes’ to Experience


3 Minute Breathing Space = Making a Space for What is Happening now

Step 1: Taking stock / Gathering the mind

Step 2: Focusing and redirecting the attention

Step 3: Expanding awareness and returning

Hot tip: Bookmark: youtube “3 minute breathing space” (it’s the first one that comes up)

Experiential Exercise: 3MBS:


I-SIFT

• I (me)• Sensations• Images• Feelings• Thoughts


MINDFULNESS: COMPONENTS AND CENTRAL CONCEPTS


Central Concepts• The ubiquity of human suffering

• Internal experiences are transient and change with time

• Thoughts and emotions are not facts

• Though some are very ‘sticky’

• They happen within a larger context: The ‘Space of the Mind’


A Central task

• To disengage from fixation on verbally-

based mental content and fusion with

emotional material


And again…

“The mind if not stirred will become clear” -Sogyal Rinpoche


But!• Before ‘Letting-Go’, of thoughts we must

learn to ‘Be-With’ our primary emotional experiences

Saying ‘Yes’ to experience - Tara Brach

“It’s already here…. Let me feel it”-John Kabat-Zinn


‘Being – With’

• Feeling into …

• Going deeper….

• Making a space…


BREAK!


Review…

Mindfulness is the capacity to come into a state of

presence, to not be overly judgmental (non-

catastrophic) about our encounters with suffering, and

to make space for whole range of affectively-engaged

living, with the confidence that SIFT experiences are

passing on through…. and, that we are the conscious,

cognisant space within which that all happens


Correlational ResearchGreater mindfulness associated with higher:

• Healthy self-regulation• Emotion regulation• Positive affect• Quality of life & life

satisfaction• Social skills • Relationship Satisfaction• Academic competence

Mindfulness interventions resulting in greater:

• Feelings of calm/relaxation

• Social skills• Personal and social

well-being• Self-esteem and self-

acceptance• Awareness and

recognition of types of emotions

• Self-efficacy for reducing substance use

• Sleep quality


Mindfulness: Does it Matter?Greater mindfulness associated with lower:

• Depressive symptoms• Anxiety• Stress• Internalizing symptoms• Externalizing behaviour

problems• Worry and rumination• Negative affect• Substance use coping• Somatic complaints• Psychological inflexibility

and thought suppression and control

Mindfulness interventions resulting in lower:

• Depressive symptoms and low mood

• Anxiety• Stress• Internalizing symptoms• Externalizing behaviour

problems• Difficulties with emotion

regulation• Problem behaviours in the

classroom

• Keng, S.L. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review. 31, 1041-1056


What: spectrum of mindfulness-informed interventions

Mindfulness-informed interventions

• Acceptance and Commitment Therapy (ACT)

• Dialectical Behaviour Therapy – adolescents (DBT-A)

• Individualised intervention plan: (e.g. MiT)

Mindfulness-based interventions

• Mindfulness-based stress reduction (MBSR)

• Mindfulness-based cognitive therapy (MBCT)

• Independently developed mindfulness programs (MiCBT)

Embodying and modelling of mindfulness with clients


Modelling Mindfulness, Psychotherapy ProcessMentalising the Clinical Algorithm

Mindfulness Informed Therapy

Mindfulness as metaphor, psychoeducation and

technique


Mindfulness and Psychotherapy Process: Clinical Algorithm

Client Characteristics:

• What is the client’s presenting problem?

• Severity and Level of impairment?

• Stage of Change?

• Client’s theory of Change?

• Character organisation? - Joe Coyne


Mindfulness and Therapist Factors

• Service in which we are embedded

• Theoretical orientation

• Access to training and supervision

• Clinical / Couseling / Case-work assumptions

• Presence of a personal practice

• How we deal with our own suffering

• Access to Resources


Mindfulness and Systemic Factors

• Nature of the Services

• Type and scope of intervention

• Frequency of contact

• Broader social, economic and political

context


My Clinical Assumptions

• The Importance of following the clients lead: What moment is this?

• Live Company: A mind-minded other..• Client engagement as co-regulation• Hypothesis testing: Integrative and client-centered

treatments• Behavioural Activation• Scaffolding:• Importance of Understanding Mechanisms• Entry Point >>>> Consolidating Gains


Self Audit

What I do well:• Patients feel heard, feel felt…• A mind-minded other: ‘Live Company’• Engendering hope• A sense of “We”

What I struggle with: • A consistent psychotherapy frame• Intellectualising


Tailoring individual treatments

• Anxiety specifically and psychopathology generally

initially develop in invalidating developmental

contexts

– Clinical Algorithm

• Skills based vs relationally focused treatments

– Healing nature of attuned relationships

– Emotional processing vs building new capacities


Mindfulness and anxiety….


Mindfulness and Anxiety Disorders

• PTSD

• OCD

• GAD

• Phobias

• Panic Disorder

• Social Anxiety Disorder


Experiential Avoidance: A Primary Target for Anxiety Disorders

• Anxiety disorders are developed and maintained by a complex array of factors including experiential avoidance (EA)

• EA: Defined as an unwillingness to experience unwanted internal events.

• Habitual attempts to anxiety trauma-related thoughts, emotions and memories lead to the core symptoms of Anxiety.

• Target = Affect Regulation Capacity


Mindfulness and Treatment Planning

• Establishing a platform of accurate attunement and

(therefore) safety

• Assessment inc client theory of change

• PsychoEducation

• Mindfulness as Metaphore / Deepening the Narrative

• Experiential


Assessment, psycho-education and experiential techniques

Throughout the psychotherapy journey point is the same:

“ We can become curious about your experience together, that your what you are going through is understandable, and that this is a safe place to feel into those parts of your inner experience that are you find frightening, and which you avoid, and/or have been experienced in isolation. Through gaining mastery in here we can help you to generalise it out-there (and visa versa)…


Mindfulness and CBT

• Moreso than changing maladaptive beliefs, the target

of MiT is changing ‘maladaptive’ ways of avoiding

anxiety-provoking stimuli: ie avoidance.

• Its also about the provision of a relationship that can

feel into and cope with that which is more often

excluded from awareness


Mindfulness and CBT

Promoting the willingness to stay with it for ‘one-

more moment’ in the service of values-based

living


Mechanism 1: Exposure

Safety Exposure H* / Emotional Processing

Repeated Exposure Mastery / H*

• Biological mechanisms• The Breath: Entering the relaxation response • IA: Decreasing stress and strain (bracing) in the body

*H = Habituation


Exposure

Psychological Mechanisms

• Experiential contact: Feelings can be felt, memories can be integrated into coherent narrative– Ie inner experiences can be felt, named, and

shared• One-moment at a time: The benefits of staying

present• Acting with Awareness: Availability of safety cues in

the world• Curious Explorer: SIFT


Exposure

Relationally

• The Therapy Relationship is safe: – Live Company: A Mind-Minded Other– Accurate Attunement: Following Lead– Containing, Reframing, Exploring, Debriefing– At the client’s pace


Mechanism 2: Decentering

• Self-as-Context

• Meta-cognitive Awareness

• ‘Thoughts are not facts’: Undermining

thought/action fusion

• ‘Being-Mode’

• Agency


Potentiating Mechanism 3: Compassion

• Mindfulness and Self-Attunement

• Friendly Self-Object

• Self-Efficacy

• Potentiating mechanism for Acceptance

• Revolution in self-concept and attachment

security: Self is Good, Safe and Loveable


Interventions

• 2-Hands

• Therapist behaviours: Reframing

• The psychotherapy Narrative / psychoeducation

• Mini thought experiments:

• 4-breaths

• POC – with modifications

• 3MBS- with modifications


Mindfulness Practice: 2 Hands

• Place one hand is on the chest and the other hand on the abdomen.

• Breathe and notice:–Where is the breath moving?– Is the breath deep or shallow? Fast or

slow?–Which hand is moving more?

• Rate our of 100%


POC: Points of Contact – Inward focus

Noticing the feeling of your feet on the floor, bottom in the chair and your breathing…

For clients:

• Engenders safety (groundedness and an ‘inward focus’• De-stabilising aspect of mindfulness practice• Deepens the impact of the therapy relationship,

potentiates the therapy hour

For the therapist:

• The how of ‘Therapeutic Presence’• Enables frustration tolerance


4Breaths Technique

Coming into a state of presence:

• Lightly, mindfully watching the breath

• Coordinating with the fingers: Motor-movement

• Rounds of 4

“These 4-Breaths are Mine”


3 Minute Breathing Space = Making a Space for What is Happening now

Step 1: Taking stock / Gathering the mind

Step 2: Focusing and redirecting the attention

Step 3: Expanding awareness and returning

Working With Discomfort: Exposure to negative affect modification: Presenter demonstration

Experiential Exercise: 3MBS:


Safety – Modification • Severity of impairment assessment • Working Alliance assessment • POC Exercise: Agency• Eyes Open Modification• Relational Exercises


Practice!

• Coach each other through an exercise of your choosing

• Provide a rationale: Link to assessment and ongoing socialisation process

• Encourage partner (You are fostering a trajectory to end in a sense of Mastery)

• Provide feedback• Swap


Clinical Markers **

• Viewing, trauma-related thoughts and feelings from a nonjudgmental perspective

• Increase their contact with the present moment: The trauma is not now.

• A felt awareness that thought suppression, avoidance etc is unnecessary and counter productive

• Behavioural Activation / Acting with Awareness: Moving on into a values congruent future


Mindfulness as Assessment

• Assess trauma type and severity

• What is the clients theory of change, level

of impairment etc?

• Mindfulness and a sense of agency and

safety

–Modifying Points of Contact exercise


Potential Experiential Mindfulness Trajectory

2 Hands > P.O.C > 4 Breaths > T.E.’s

3Rs > 3MBS > Body Scan >

Breathing Meditation > Sitting with

discomfort


Potential Experiential Mindfulness Trajectory

2 Hands > P.O.C > 4 Breaths > T.E.’s

3Rs > 3MBS > Body Scan >

Breathing Meditation > Sitting with

discomfort


Psychoeducation: IAA terms

Intention

Attention Attitude

Focusing/refocusing on the here and now

Noticing and naming

Letting go and creating space

Checking in

Curiosity

Kindness

Willingness

Choosing

Slowing down

Remembering

Knowing why


Psycho-Education: Knowing your Mechanisms!

Self-Compassion

DefusionPositive Affect

Acceptance

Interoceptive Exposure

Agency

RelaxationAttention Switching


Mindfulness & Metaphor • Using metaphors to illustrate and explore mindfulness concepts

– Keep it simple and Don’t overload with too many or varied metaphors

Metaphor Target area

Clouds in the sky Self as Context: Interoceptive Experiences are safe

Leaves on a stream / River Bank

Internal experiences are constantly changing + Observer Self

Training the Puppy

Gentle and Firm orientation to attentional control. Forming a relationship with the self

Narrowing focus – widening lense

Attention is a tool

‘Turning Towards’, Saying ‘Yes’

Mobilising acceptance in behavioral terms

Train of thought Internal experiences are constantly changing

Making space / feeling into…

Mobilising acceptance in behavioral terms


Clinical Uses for Meditation

• Selling meditation: Finding a way of talking about

meditation that makes sense.

• Constraining gains: starting with FBB +4B

• To focus a session: Do at Beginning

– Establish a narrative for this early on and stick with it.

• As treatment: Emotional processing, attention training,

synergies with schema-focused and cognitive work


• As homework: Start with diaphragmatic breathing (Crawl and/or two breaths) prior to doing guided meditations

• Using meditation like a Personal Trainer. Discourse: Building neural circuits

• Trajectory: – Start with Body scan (relaxation– > breathing meditation (attention regulation),– > noticing thoughts and feelings (meta-

cognitive awareness – > guided imagery (creating a safe place)– > sitting with discomfort (interoceptive

exposure / emotional processing


Meditation-Check list: Learning Opportunities

Attention• Thoughts will continue to be there and that is okay• You can learn to let go of thoughts

Attitude• My feelings are okay as they are

Experiential• The present moment can be a nice place to be• Your ally is close at hand: Diaphragmatic breathing:

Long, deep and slow • Feeling it at a physical level


In-session meditation:Emotional Processing

• Discuss a worry - Find the bottom line /what is the essential

message?

– Eg. “I am not good enough”

• Guide a meditation starting with relaxing into FBB

• Evoke the message: “Imagine it like a radio station….”

• Notice feelings and body sensation. Special attention to belly

and chest.


Using MetaphorsClouds in the Sky

Mentally “placing” internal experiences (usually thoughts) on the object and allow it to move (or not move) as it naturally wants to.

– Does … (object) stick around? – Does it feel ok if … (object) is not moving on?

– Background (sky) is ‘observing self’/‘self-as-context’– Noticing that the background can observe the objects that move

through it– Are you the … (object) or the … (background)? [‘self-as-context’

rather than ‘self-as-content’]

If the child has the capacity, you can link other internal experiences (e.g., feelings) to other objects/events that occur in the background

– Are you still able to be … (the background) even when … (feeling) is also happening?


No Pest Control(reactions happen)

• Imagine your distressing or unwanted thoughts, feelings, body sensations are like … cockroaches…

• Being able to let the experience be…– Not feeling bad that it is here – Not trying to get rid of it – Not running away from it– Not letting the cockroaches control how you act – Not trying to make the experience positive (e.g., a

butterfly)

• Being ok with the experience coming and going… like cockroaches running around you...

• Being able to notice the experience and still being able to chose what to do


Nature of Attention

Spotlight

• Shining light on where you want to focus your attention

Puppy on a leash• Like a puppy attention

naturally wanders (jumps around)

• It takes time to train a puppy (attention) to be able stay in the one place for any length of time

• Getting angry at the puppy doesn’t help

• Be kind to your wandering mind


Train of thought• Thoughts don’t stop and they often jump from one

topic to another.

• The train of thought can be fast or slow

• Creating Space: “Are you standing on the platform or

are you riding on the train?”


Thought Parade



• Mindfulness and the Magic Question• Safety, Safety, Safety…• Mindfulness should be embodied (RB2RB)• Enhancing a willingness to feel into and to safely

experience SIFT experiences– Importance of the breath– Relevance of Self-As-Context



• Know your mechanisms!

• Socialise early. Find your entry point. Scaffold.

• Jigsaw metaphor

• Make sure you have access to enough resources

to build the capacities you are seeking to foster

• Make sure you can do what you are asking of your

clients (or are cognisant of how hard it can be!)


Thank You!

More information at www.bemindful.com.au

Email me: [email protected]