An Introduction to Mindfulness in End of Life Care Diana Sanders, PhD, Counselling Psychologist BABCP-Accredited Cognitive Psychotherapist Oxford © Diana Sanders, 2013

Aims of the workshop Introduce Mindfulness, MBSR and MBCT o What it is o Development o Research Details of the approach and opportunity to practice and reflect Use and applications in medical settings and end of life care and for us as individuals How to take things forward

Distress in end of life care Common in patients and carers across many stages o Pain – physical and ‘spiritual’ – pain of losses o Low mood and depression o Anxiety o Difficulty adjusting o Fatigue o Sleep disorders o Breathlessness Need for staff to look after themselves, reduce stress and burnout

Distress in oncology patients

What is mindfulness? ‘Mindfulness means paying attention to experience in a particular way: on purpose, in the present moment, and non-judgementally’ Learnt through meditation practices with different focus – taste, body sensations, thoughts, sounds, breath, emotions Mindfulness involves a radical shift in our relationship to thoughts, feelings, body sensations and behaviour that lead to distress and suffering

Quality of attention in mindfulness Curious Interested Non-judgemental Kind Compassionate Slow One thing at a time

Practice 1

Forms of mindfulness in clinical settings Mindfulness-Based Stress Reduction Mindfulness-Based Cognitive Therapy Using mindfulness practices as part of a service or intervention Use in psychological treatments for complex problems – Dialectical Behaviour Therapy

Mindfulness Based Stress Reduction … in the 1970s How can I get this out there… ?

Mindfulness Based Stress Reduction (MBSR) Jon Kabat Zinn, University of Massachusetts with patients with chronic physical illness Development of his interest in meditation as a Buddhist practice to make it secular, acceptable and accessible Large group format, 8 weekly 2 hour sessions plus daily practice Specific practices to enable people to anchor attention in the present

Mindfulness Based Stress Reduction (MBSR) Sitting, walking, stretching, everyday awareness Teaching a way to be aware of thoughts and feelings before they drive emotions and actions Implicit acceptance, compassion, kindness Good outcome for chronic pain Lasting improvements in anxiety Improves emotional distress in medical patients (cancer, MS, organ transplants, fibromyalgia, skin disorders, Parkinson ’ s disease, heart attacks) Helps frail or old people and carers cope with disability and loss of function

The search to prevent relapse in depression – MBCT Mark Williams, Zindal Segal and John Teasdale People who have experienced depression are prone to relapse Small changes in mood or thinking trigger large change in mode of mind Increase in rumination as way to ‘think the self out of emotions’

Thinking and relapse in depression Thinking cannot solve problems it is not designed to solve: too smart for our own good Rumination can lead to relapse People with a different relationship to their thoughts are less vulnerable

Decentring from experience Central to mindfulness and meditation Key process in preventing automatic reactions to mood, thoughts, body Mode of mind essential: not just stepping away from but o Welcoming o Allowing o Compassionate

Aims of MBCT Becoming more aware of body sensations, thoughts and feelings from moment to moment Developing a different way of relating to experience – mindful acceptance and acknowledgement of unwanted feelings, thoughts or body sensations rather than automatic and unhelpful reactions Being able to choose the most skilful response

Format of MBCT Eight weekly two-hour classes One ‘all day’ practice Daily home practice of 1 hour CBT methods of identifying thoughts, feelings, behaviours maintaining depression Psychoeducation about depression and relapse prevention

Effectiveness of MBCT Several trials and meta-analyses halved relapse rate in people with three or more episodes of depression MBCT recommended by NICE as treatment to reduce relapse in depression Extended to wide range of clinical areas

Application of MBCT Anxiety, health anxiety, social phobia, general anxiety, panic Insomnia Fatigue Substance abuse Tinnitus Pregnant women at risk of depression Children, schools, higher education Cancer patients

MBCT/SR in medical settings Mental Health Foundation Executive Summary (2010): Improvements in Chronic Pain o Decreased medication use o Decreased anxiety and depression Cancer patients o Improvement in mood, sleep, energy, quality of life o Decrease stress, anxiety, depression

MBCT/SR in Medical Settings

Practice Pause

How does MBCT work? Factors in depression o Mindfulness o Self compassion o Ability to acknowledge negative experience without being overwhelmed by it Change at neurological level – increase in areas relating to regulation of positive emotion

Learning a different relationship to experience Being versus doing Pain versus suffering Approach and acceptance versus avoidance Compassion versus judging

Practice Are you tired today?

Doing versus being We are extremely good at ‘doing’ o Involves continual comparison between how things are and how we perceive things ought to be – judgements o Involves being in the past or future – not the present Thinking our way out of problems, emotions and pain does not always work – leads to rumination and perpetuation of distress

‘Being’ mode Allowing and accepting Without judgement In the present moment ‘Nothing to do, nowhere to go’ Direct, immediate experience Thoughts and feelings are passing events in the mind Physical sensations come and go

Pain versus suffering (Burch, 2009) PAIN Pain or Illness or Emotion DESIRE TO GET RID OF PAIN Blocking Taking action to avoid: Addictions – alcohol, food, drugs, smoking, talking, sex Anxiety, fear, anger Over-controlling SUFFERING Drowning Feeling overwhelmed, inactivity, withdrawal, exhaustion, lack of interest, depression, isolation, giving up

Avoidance Part of ‘flight, fight or freeze’ response o Cognitive – don’t think about it o Behaviour – avoiding situations reminding of illness or death o Mood – distracting from all difficult emotions Makes sense to move away from aversive and dangerous situations But …

Approach versus avoidance We cannot avoid pain in life Avoidance backfires when it comes to thought and emotion Avoidance of unwanted experience is central to many psychological difficulties Reduces our ability to make wise choices about how we respond in life

Compassion and kindness Implicit within mindfulness and MBCT/SR Kindness and compassion are an intention rather than (necessarily) producing feelings Having the intention to be kind to oneself is powerful in itself

Practice Body scan

Structure of MBCT Pre-class assessment and screening Eight, weekly two-hour classes Mindfulness practices o The raisin – taste o Body scan – sensations o Sitting meditation – breath, body, sound, thoughts o Yoga – mindful stretching – body in movement o Walking o Three-minute breathing space Enquiry and discussion

Structure of MBCT CBT methods o Linking thoughts and feelings o Pleasant and unpleasant events diary o How mood affects interpretations o Nourishing and depleting activities o Psycho-education o Relapse signatures o Physical barometer Home practice o 45 minutes meditation o Mindfulness of everyday activity o CBT methods Day of silent practice

Themes in classes Classes 1–4: Becoming aware, learning concentration, studying the patterns of the mind Classes 5–8: Wider awareness, working with difficulty, taking mindfulness into rest of life

Reflection Making sense of observation What does this tell us? Experience Meditation practice Daily activities Planning What next? What are the implications? Observation Awareness of mind, body, emotions thoughts Teaching mindfulness

Enquiry in MBCT Being open, curious, present and compassionate Being unfazed by whatever arises Staying with difficult experiences Gives message – can stay with this experience, no need to avoid, withdraw, escape

Teaching MBCT Teaching by embodying qualities o Compassion o Kindness o Interest Teacher as practitioner o Comes from own practice and journey Intention rather than necessarily perfection

Practice The three minute breathing space

Working with difficulty Drop into the body Awareness of body sensations connected to difficulty Breathing into body sensations Ability to step outside habitual responses, especially rumination

Working with intense sensations/pain Gently approach and allow Notice and acknowledge reactions to sensations: o Thoughts o Emotion o Urges to push away, avoid Breathing into sensations Work only at the very edge of sensations

Turning towards difficulty Extended breathing space

Mindfulness in cancer and end of life care Concepts of compassion, reducing suffering, acceptance and living non-judgementally resonate in cancer and end of life care Learning to stay with experience, take a wide perspective, helpful at many stages of treatment and towards end of life Ability to be in the present improves quality and enjoyment of life – treasuring the moments left to live

MBCT for cancer (Trish Bartley, Bangor) Emphasises significance of the group o Shared humanity o Shared process Not group therapy o Not discussing problems per se o Reflecting on direct here and now experience rather than talking about history, etc.

Adaptations to palliative care (Ursula Bates, Blackrock Hospice, Dublin) Groups in day hospice 12 weekly 50-minute sessions Brief practices Adapting all practices to individual Closed versus ongoing groups

Adaptations to palliative care (Elizabeth Baines, Weldmar Hospicecare Trust, Dorchester) 4, weekly, 1-hour sessions Patients and carers Acceptable and valued Need further research on outcomes

Mindfulness in palliative care (Dr Sara Booth, Addenbrooke’s Breathlessness Intervention Service) Used as part of complex intervention Learning mindful awareness of the present to reduce anxiety and stress CD of practices

Mindfulness and End of Life Carers (pilot study by Eileen Palmer) MBCT course with 19 Hospice at Home nurses, West Cumbria Course highly valued Improved well-being, clinical empathy and compassion May reduce staff burn-out and sickness

Impact of mindfulness on clinicians Positive impact on clinical work Means of improving relationships, empathy, compassion Flavour of being present, in the moment Models acceptance of negative experience (Irving et al., 2009; Hick and Bien, 2010)

Impact of mindfulness on therapists Facilitates self-reflection Increased ability to deal with difficult emotion, stress and life’s challenges May lead to more effective work with clients May be a common factor across therapies

Effectiveness in cancer distress Kabat-Zinn team – large database for patients with pain, chronic medical conditions Bartley (2012) – qualitative descriptions Piet (2012) – improvements in depression and anxiety Foley (2010) – improvement in mindfulness, depression, anxiety and distress, increased quality of life No trials as yet comparing MBCT/SR with other treatments for cancer patients

What has mindfulness to offer … In my personal life In my professional life In my work setting

How to take things forward Mindfulness starts with us Developing our own practice at whatever level The breathing space as a core practice Attending 8-week class Workshops, reading, sitting groups MBCT Training Pathway MSt in MBCT