BUILDING MINDFULNESS AND MINDFULNESS-BASED SKILLS

Mindfulness is intentionally paying attention to the present moment, without judging it, pushing it away or holding on to it. It is an endeavour rather than an end goal to be achieved. It is a set of skills that can be learnt. This document outlines what mindfulness is and how it can help our mental health: https://www.mind.org.uk/media-a/2891/mindfulness-2018.pdf.

There is evidence that mindfulness can help with a wide range of conditions, including stress, anxiety, depression, addictive behaviours such as alcohol or substance misuse and gambling, and physical problems like hypertension, heart disease and chronic pain. With respect to mental health problems, a systematic review by Potes et al (2018) found mindfulness interventions led to clinical improvements in symptoms of psychosis and depression, cognition, mindfulness, psychosocial and vocational factors. Mindfulness was not taught in early CBT-SFIs, but it has been recommended to be included (Matthews 2013).

In people with a history of suicidal depression, recurrence of depressive features can reactivate suicidal thinking. Mindfulness-based cognitive therapy (MBCT) is aimed at helping patients “de-centre” from negative thinking and is recommended by NICE (2009) to prevent relapse in people who are currently well but have experienced three or more previous episodes of depression. Forkmann et al (2014) investigated the effects of MBCT on suicidal ideation in an RCT of 130 patients with residual features of depression. There was a significant reduction of suicidal ideation in the MBCT group but not in the waiting list control group. The authors conclude MBCT may reduce suicidal ideation in patients with residual features of depression and that this effect may be mediated in part by participants’ enhanced capacity to distance themselves from worrying thoughts. Barnhofer et al (2015) found MBCT for those with a history of suicidal depression can help to weaken the association between depressive features and suicidal thinking, and thus reduce vulnerability for relapse to suicidal depression. Chesin et al (2015) adapted MBCT to enhance patients’ awareness of suicide triggers and appropriate coping strategies (MBCT-S) and found MBCT-S significantly reduced suicidal ideation and depressive symptoms, but not hopelessness. MBCT-S was also acceptable and safe for participants. Chesin et al (2016a) conclude from this pilot study that MBCT-S may improve cognitive deficits specific to suicidal ideation and attempts in depressed patients.

Another study (Anastasiades et al 2017) found mindfulness moderated the mediated effect of depressive symptoms on perceived stress and suicidal ideation. Chesin et al (2016b) reviewed this limited evidence for mindfulness-based interventions (MBIs) for suicidal behaviour and conclude it supports targeting suicidal ideation with MBIs. They found additional studies show deficits that are associated with attempting suicide (namely attentional dyscontrol, problem-solving deficits and abnormal stress response) are improved by MBIs, which strengthens the rationale for using them with individuals at high risk of suicide.

Another important aim of mindfulness is the development of skilful means or being effective which has clear relevance to reducing suicidal states. Suicide is seen by an individual as their only solution for managing intolerable states, and mindfulness can help us tolerate difficult states and enable us to notice when we need to practice strategies for addressing problems. Mindfulness is a gateway skill to living skilfully or what is known in third wave practice as skilful means. However, teaching mindfulness to people who have suicidal thoughts and urges needs particular care and sensitivity. Practising mindfulness is not always pleasant. Mindfulness is not intended to make us feel better but more aware, so if one’s mood is low and you have suicidal thoughts or urges, these may be felt more intensely.

Goodpractice point

Mindfulness can help reduce suicidal thinking and behaviour. However, it is not advisable to teach mindfulness within an SFI unless you are experienced at teaching mindfulness to people with mental health problems and tailoring it to their needs and vulnerabilities. It is also important that you are experienced in practising mindfulness yourself as you can then understand from direct experience how “opening” it can be and how “internal” practices may need to be balanced with activities or practices where you direct your attention outwards.

Teaching mindfulness

Linehan (1993,2015a, b) breaks down mindfulness into “what” and “how’ skills, which is a very useful teaching aid.

Mindfulness “what” skills are:

  • • Observe: Notice your environment and what is around you. And notice what is going inside you. What thoughts, feelings and sensations you are experiencing.
  • • Describe: Use words to describe your experience and what you can observe.
  • • Participate: Become one with whatever you are doing and enter the experience as fully as you can rather than avoiding, suppressing or blocking the present moment.

Mindfulness “how” skills are:

  • • Non-judgementally, acknowledging and then letting go of judgements or evaluations.
  • • One-mindfully, doing one thin at a time.
  • • Being effective. Focus on what works and being skilful.

Mindfulness is not relaxation and we’re not trying to feel better or calmer but to be here now. Emphasise that mindfulness is a practical skill used to treat a variety of mental health problems and is no longer specific to any religious practice. “We are all in the same soup or boat”. The aim is to be less caught up in the content of our thoughts; to “unhook” from them. There are two key elements to practising mindfulness:

  • • the action of deliberately focusing our attention (like a mental muscle);
  • • accepting current experience (being in the moment).

Mindfulness is a practice, so we need to notice any thoughts about whether it is working or not working - to be aware of our expectations, assumptions and judgements about the practice and its outcome. We are trying to “unhook” from the expectation of what the current moment should deliver and to focus instead on experiencing it as it is. You can use a metaphor here such as “What happens if you keep watching a souffle?”

Some people are not comfortable with the concept of mindfulness. There may be several reasons for this. The person may feel it conflicts with their religious faith or their previous introduction to mindfulness may not have gone well. Perhaps it has been described as a panacea leading to an inappropriate expectation that mindfulness will make them feel better. Or they simply feel they can’t do it because their mind is busy and distracted. We may need to gently persevere with the practice before experiencing any benefit. If need be, mindfulness can simply be introduced as awareness or being in the moment, or elements of it tried without promoting it as a way of life.

Dunkley and Stanton (2014) provide excellent suggestions for how to teach mindfulness and recommend you:

  • • Model warmth, compassion acceptance and interest.
  • • Be open to questions.
  • • Use personal examples to indicate were all in the same boat.
  • • Model curiosity about what our minds do.
  • • Avoid using a “therapist” voice; try to have a normal tone. Do not speak more slowly or softly as this suggests you are trying to induce preferred, i.e. relaxed states of mind.

Dunkley and Stanton suggest the following tips for teaching mindfulness:

  • • Start simple, vary practice and build on what the client finds helpful; prioritise those practices with the most day-to-day utility.
  • • Encourage exploration of mindfulness - YouTube, apps, books, etc.
  • • Link the practice to your agreed goals.
  • • Shape the three “As”: Attention, Awareness and Acceptance; for example, inserting the phrase “I notice that” I am experiencing anxiety.
  • • Identify obstacles (our untrained “monkey” mind) and normalise these.
  • • Ask for feedback, using it as an opportunity to shape mindfulness.
  • • Vary practices. Mindfulness can be practised in a variety of positions and environments. Avoid creating special conditions, for example, always sitting in a chair or having one’s eyes closed. Move towards your client integrating them into their daily life.
  • • Look for opportunities to generalise to everyday life. Invite clients to give suggestions for how they can and do apply mindfulness in everyday life. Point out situations from your client’s daily life when mindfulness could be helpful and notice and celebrate how and when your client has been mindful, highlighting new learning.

Clients may struggle to learn or practise mindfulness. They may not readily see its application to helping with their problems. The most effective response is to validate these difficulties. Using metaphors to obstacles to mindfulness can be helpful such as “thought traffic” or “monkey mind”. If clients get distressed during mindfulness, use “grounding” with senses or physical practices, such as noticing the floor under our feet.

There are two elements to teaching a mindfulness practice - the chosen focus for attention and your verbal guidance. You don’t want to speak constantly through an exercise but give your client time and space to apply your instruction independently. How much guidance you give will vary depending on the ability of the client and stage of their practice. If you ask your client to close their eyes, do keep yours open so you can observe and monitor how they are getting on (you may close them together initially to model the practice). With any mindfulness practice, one’s thoughts spontaneously go to other matters, such as past memories, upsets or future planning. When that happens, we want to just gently steer our attention back to the task or object of mindfulness. One metaphor for mindfulness practice is steering a boat, which gets pulled by tides and winds. We want to stay at the helm, as calm as we can, gently steering the boat (our direction of travel is the art of focusing our attention). Normalise that our mind wanders and give instructions about how to respond when we notice that. Point out to your client in noticing it they are being mindful.

It is good practice to ask your client for feedback after a mindfulness practice in order to monitor your client’s comprehension and skill level, identify any obstacles and problem-solve these. Dunkley and Stanton suggest you: [1]

When teaching, we are practising a specific skill but we also want to draw from this some general learning about the mind - noticing our mind states means we are more than the content of our minds. We are not our thoughts. Everything is subject to change.

Introductory mindfulness practices:

Keep early practices short. Starting with sensory practices is usually the easiest way for people to learn such as:

  • • Observing and participating in tastes, smells, sounds, sight or touch is generally easier for people than practices such as mindfulness of thoughts.
  • • Mindfulness items you can use: stones, shells, conkers, feathers, pieces of fabric, buttons, leaves. Choose an object which is common and fairly neutral. Notice all its features - texture; colour, etc. Experience the sensation of touching the object. Consider the function of that object and what the object does for you.
  • • Focus your attention on your feet touching the ground. Focus your attention on your body touching the chair you sit in. Consider how you are connected to and supported by it.
  • • Mindful single or simple common activities such as making and drinking tea; washing up; bathing; stroking pets.

Mindfulness of the breath

This is the main meditation technique for training the mind to focus, decentring from thoughts and grounding. Mindfully count your breath or say silently to yourself “breathing in” as you breathe in and “breathing out” as you breathe out. Gently bring your attention back to your breath and body sensations. It can also be difficult, especially for patients with anxiety disorders who hold their breath or over-breathe. Simplifying it by adding the task of naming in and out breaths or counting breaths can be helpful. Include dialectics when teaching, i.e. we are not aiming to change the rate of breathing and it may well change.

Generalising mindfulness skills to daily life

Homework practices start with building on these, with the person practising them in their own home or other settings. You can also start to build practices which are more activity-based such as going for a walk or a jog (also building behavioural activation which can help improve mood), focusing on this experience and your immediate environment. Using mindfulness when in challenging emotional or suicidal states is the hardest practice of all and therefore the last application to address. If your client needs to develop more willingness and acceptance, mindful emotional exposure may be helpful (e.g. someone struggling with unresolved grief or anticipated grief). However, this may be difficult for someone to tolerate until they have a certain level of skill in mindfulness practice and feel familiar and comfortable with it.

Applying mindfulness to your client's individual needs and goals

Based on your formulation and understanding of your client skills, you may want to include practices such as emotional exposure or opening to painful emotions. The client will need to be “signed up” to acceptance as an agenda and have established capacity to use their safety plan. You will then need to explain the rationale for this. Avoidance may work in the short term, but then prevents us from building resilience.

Surfing urges and defusingfrom thoughts

Research studies demonstrate that suppressing a thought (Wegner et al 1987; Clark et al 1991; Wegner 8c Gold 1995) or sensation such as pain (Cioffi 8c Holloway 1993) tends ultimately to intensify it. For example, Wegner et al (1987) conducted experiments to assess the effects of thought suppression called the “white bear” experiments. In one experiment people were shown a film about white bears and then given a sorting task which required concentration. They were divided into two groups. The first group was instructed to suppress the white-bear thoughts. The second group was given no instruction to suppress these thoughts. Both groups were asked to hit a button every time they thought of white bears while doing the other task. The initial suppression group reported a significantly higher rate of “white bear” thoughts during this time.

There are a number of visual metaphors for the mind and thoughts within it, such as clouds in the sky or leaves on a stream or items on a carousel or conveyer belt. For example, you can introduce the image of a conveyor belt as a metaphor for the mind, and watch thoughts and feelings coming down the conveyor belt or carousel. Place thoughts as we catch them on the conveyor belt and let them fade as they move on. I often describe the aim of this practice as having more space around thoughts, to let them be just that; not to control or change our thoughts but for the thoughts to have less power over us. These are known in ACT as defusion exercises. Another mindfulness practice is to name types or categories of thoughts, such as “worry” thoughts, planning or analysing. This can also be helpful in defusing from their content and help us take them less personally. Validate and normalise how we all have unhelpful thoughts.

Explain that thoughts are not facts. This can be illustrated with an example of an emotionally charged thought alongside a comical thought. For example, we can have the thought “I’m worthless” and we can have the thought “I’m a purple cat”; both are thoughts which don’t make them true. Use personal examples where you have had a thought, noticed it and let it go. The tug-of-war metaphor is helpful in explaining defusion and how we can let go of the struggle we can get into when we experience “charged” thoughts (thinking it and not wanting it). This metaphor suggests that if we insist on struggling with a thought, then the thought may continue to control us (Harris 2019). In ACT we describe dominant, pervasive or persistent thoughts (as suicidal ideation can be) as “sticky thoughts”. When using ACT techniques with someone contemplating ending their life, it is important we don’t trivialise their struggle, as could be done for example, if we said, “that’s just a thought”. The extent to which we are irreverent or challenging will depend on the strength of our working alliance with a client. If you have good working alliance, then humour and even irreverence can be helpful and release tension at times.

Mindfulness of challenging thought states is the most demanding or advanced application or practice and without considerable building of foundation skills, people can feel unable to do it. In a short SFI you are unlikely to have time to build that practice unless the client already practises mindfulness and understands the dialectical balance of awareness that is skilful when our mood is low. Although mindfulness isn’t about being successful at anything (rather endeavouring to be mindful and accepting that one often isn’t), it is important when working with people who have suicidal thoughts not to add experiences which may be demoralising for them. If and when the person has some faith in mindfulness and understands this ebb and flow of being more or less attentive, then mindfulness of thoughts can be introduced, but not initially with any aim to let go of suicidal thinking. Rather, one introduces the practice with other, more everyday thoughts. Again, I would only progress to more challenging thoughts if the person was confident in the practice and understood that mindfulness is not pushing thoughts away.

Discuss how your client responds to suicidal thoughts and urges. Often people try to suppress urges by distraction or “fighting them”. With mindfulness, we endeavour to step aside and watch the cravings, impulses and urges. Ask your client whether there have been times they did not give in to an urge when it arose. Did the urge pass? The main message is that urges do not have to be acted upon. Invite your client to do a behavioural experiment such as deferring acting on an urge and exploring the outcome of that.

Exercise: Experiencing the changing nature and impermanence of urges

Start mindfulness of breathing. Wait for any sense of discomfort, e.g. restlessness, an itch. Note the desire to move and resist it. Notice thoughts that arise, e.g. “I wish this itch would go”... “It is driving me crazy”... Say to yourself, “this too will pass” - in a calm tone ... “This too will pass”. Gently bring your attention back to your breath and bodily sensations. Note the changing position, shape and quality of the discomfort over time. Be interested in feeling it as precisely as you can. Notice how the shape and intensity change with the cycle of the breath. Is it stronger during the in-breath or during the outbreath?

Exercise-. Holding arms out in front of you and surfing the urge to put them down. Another practice is to sit completely still for five minutes, resisting any urges to move, blink or swallow.

Any of these mindfulness-based skills could be helpful in an SFI: [2]

  • • Build mastery or positive experiences;
  • • Interpersonal skills (if you are in relationship crisis);
  • • Reducingvulnerability (eating,sleeping,exercise; taking medication).

Sleep hygiene.

Address sleep disturbance

People who die by suicide have higher rates of sleep disturbance, insomnia and hypersomnia as compared with matched controls (Bernert & Joiner 2007; Goldstein et al 2008), and this is over and above differences due to depression. Unlike other suicide risk factors, sleep complaints may be particularly amenable to treatment. So do assess your client’s sleep pattern and address strategies that will help improve their sleep (see Linehan 2015b, p. 259), including, if need be, medication, especially in the context of depression or a mood disorder.

Note we want to coach clients to use a balance of acceptance and change skills. These are easily available in manuals and self-help websites such as www.getselfhelp.co.uk or https://dialecticalbehaviortherapy.eom/.The DBT community have published a range of DBT skills workbooks. There is a general manual of all the DBT skills (Linehan 2015a, b; McKay et al 2019) and specific manuals for anger (Chapman 8c Gratz 2015), bulimic disorders (Astrachan-Fletcher 8c Maslar 2009) or bipolar disorder (van Dijk 2009).

DBT also places emphasis on practising willingness which may be helpful in an SFI. For example, when negotiating reducing access to means, we may ask someone if they would be willing to give up the means or willing to practise some emotional exposure (initially feeling worse by having less ready access to means), in the interest of their safety and survival. ACT, another mindfulness-based therapy (Hayes et al 1999; Harris 2009, 2019), emphasises developing flexibility and this is also helpful to attend to in an SFI. Lack of flexibility will most definitely contribute to people seeing suicide as a solution. In short, it can be helpful to invite people to intentionally practise either willingness or flexibility as part of their journey past suicidality.

Distress tolerance skills

Distress tolerance is the ability to tolerate and survive crisis situations without making things worse. Also, these skills teach us how to accept and fully enter into a life that may not be the life we hoped for or want. They include crisis survival skills to enable us to tolerate painful events, urges and emotions and reality acceptance skills to help us reduce suffering by acceptance. One of these skills is self-sooth which helps to calm us when we are feeling overwhelmed both physically and emotionally. They help to regulate our emotions. It is what parents do when they pat their child’s back or rock them to sleep. People with states of acute mental distress by definition have not been able to effectively self-sooth, and it is worth spending some time exploring that. What have they tried? Does it ever work? If not, what might make it less or more effective? Did they give it sufficient time or participate fully? Activities which are most soothing affect as many senses as possible. You can make a self-soothe box like a hope box. You could include:

  • • something to smell, such as essential oil (peppermint or lavender or rose).
  • • something to touch. Stress balls are great for this; they’re satisfying to touch, and easy to put force into and relieve some stress.
  • • something to look at a beautiful place for example (be careful not to evoke sadness and loss for happier times).
  • • something to hear and listen to - a particular CD or wind-up music box.
  • • perhaps even something to taste.

You also want a range of self-soothing activities depending on the circumstances. What is workable in a public place or at home will be different, when you’re alone or in company.

Emotion regulation skills

When our emotions feel overwhelming, it’s difficult to think clearly and address problems effectively. To bring down very high levels of emotion we want to:

1. Calm the body

You can do this by putting your face in very cold water and/ or slowing down your breathing. Activating the parasympathetic nervosa system and vagus nerve has been described as putting your foot on the brakes rather than taking yourfoot off the accelerator - i.e. it is more effective for slowing the car engine (or stress or threat response) .There are a number of breathing practices which activate the parasympathetic nervosa system and vagus nerve; square (i.e. even) or rectangular (longer outbreaths) breathing, or soothing rhythm breathing or diaphragmatic breathing. See for example Dr Alan Watkins https://youtu.be/Q_fFattg8N0 or https://mi-psych. com.au/soothing-rhythm-breathing/. In DBT, patients are taught to STOP and TIP (Linehan 2015b, pp. 327,329).

2. Calm the mind

With simple mindfulness practices or counting

3. Block unhelpful action urges

Ask yourself, what is the emotion urging you to do? and then do the opposite.

4. Address problems that need to be tackled (now or later)

This is the spirit of being effective or doing what works. Is there a problem which needs tackling (when you are ready)? See Linehan (2015b, pp. 230,231); see 3.6 problem-solving (page 157).

Emotional suppression plays an important mediating role in both suicidal ideation and suicide attempts, irrespective of levels of depressive symptoms (Kaplow et al 2014). Kaplow et al suggest effective suicide preventive interventions may need to include techniques to reduce emotional suppression in those who have been exposed to adverse life events. There may be particular emotional states linked to suicide drivers such as unresolved grief which indicate emotional exposure will be helpful to enable a client to learn they can tolerate that which their mind tells them is intolerable. This YouTube clip expresses this very simply as well as providing education about the naming of functions of emotions: https:// youtu.be/SJOjpprbfeE.

Mindfulness of emotions

See https://cdn.gottman.com/wp-content/uploads/2018/10/Compressed6- Steps-to-Mindfully-deal-with-difficult-Emotions-Social.jpg.

  • [1] adopt a light, interested tone; • ask what the client noticed during practice; • highlight when client is mindful; • label types of internal experience; • link practice to everyday life.
  • [2] Beginners mind; • Wise Mind; • STOP &.TIP; • Opposite-to-emotion action; • Self-soothe; • Surfing urges; • Skilful occupation; • Pros and cons; • Checking the facts (Does my emotion or its intensity actually fit thefacts? How warranted is it?);
 
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