Mindfulness is hot at the moment. Mindful meditation as a way to enhance
life and well-being is popular in lots of communities, and has been gaining research
attention too. Mindfulness-based interventions have also been applied to just
about every health and social care “problem” experienced by humans. The
evidence base is impressive, including strong results from several randomised
controlled trials, and has already resulted in a mindfulness-based intervention
(Mindfulness Based Cognitive Therapy – MBCT - for depression) being recommended
by the National Institute for Health and Care Excellence in England and Wales.
Mindfulness-based interventions in the intellectual
disability and autism fields
Given the reach of mindfulness and its huge popularity, it is not
surprising that practitioners and researchers working with children and adults
with intellectual disabilities (ID) or autism have started to explore the
potential of mindfulness-based interventions with these individuals and their
families and carers. Interest is such that Ramasamy Manikam and I were able to
guest edit a full special issue of the journal Mindfulness on this population
in June 2013. The special issue includes a great collection of papers,
including a free download of our editorial:
Among the evaluations of mindfulness-based interventions in the ID and
autism field, there are examples of randomised controlled trials. For example,
Nirbhay Singh and colleagues in our special issue reported on a RCT of the
Soles of the Feet mediation intervention for adults with mild ID and problems
with anger/aggression (http://link.springer.com/article/10.1007/s12671-012-0180-8).
Also in 2013, Spek and colleagues published a RCT of an adapted version of MBCT
for adults with autism (http://www.sciencedirect.com/science/article/pii/S0891422212002156).
Mindfulness-based intervention for parents and teachers of children with
developmental disabilities has also been evaluated using a RCT design (http://psycnet.apa.org/journals/dev/48/5/1476/).
So, high quality research designs have been applied to testing mindfulness interventions
in the ID and autism fields, and with encouraging outcomes.
Why mindfulness?
It is great to see these results emerging from RCTs, and a range of
other outcome studies published in scientific journals in recent years. At the
same time, I would caution some more thought about why mindfulness
interventions might be suitable for individuals with ID, autism, and their
families and carers. Returning to a topic in one of my earlier blogs (see http://profhastings.blogspot.co.uk/2012/12/who-do-you-believe-model-for.html),
the evidence for interventions can be thought of as developing through a series
of phases. This development does not have to always be linear, but it is very
important to be able to articulate theoretical and other reasons why an
approach to intervention may be worth trying out and testing in large scale and
expensive RCTs. Before we jump on the mindfulness bandwagon, let’s just
rehearse some of the reasons why it was worth making the jump…
First and foremost is a point of principle. If good stuff is happening
in the use of mindfulness for people withOUT ID or autism, then children and
adults with ID and autism should have the same access to the good stuff.
Adjustments may need to be made to ensure this access, but it should be
happening. Thus, at least in the case of MBCT it is a NICE-recommended
treatment for depression in England and Wales. How is MBCT being made available
for people with ID or autism? I suspect that most of the time it isn’t. Someone
should do some research into that access question.
Leaving that core principle aside, what other reasons are there to think
that there is a good match between mindfulness-based interventions and the
needs of people with ID or autism and their families and carers. Here are some
that I have included in recent presentations:
· Individuals with
ID or autism, and their family members (especially parents) face some real and
ongoing challenges, stresses and strains in life. These manifest in increased
risk for psychological problems in individuals themselves and their parents.
The challenges are persistent – some of the difficulties cannot really be taken
away or will take a very long time to be fixed in society at large (e.g.,
poverty, societal negative attitudes). So, one-off “fixes” are not likely to be
helpful. Instead, supports and interventions that help to build resilience are
needed so that people have some skills to cope with new or increased challenges
as they emerge in the future. This is also partly about empowerment – making
sure people have skills to enable them to control their own environments rather
than being continually dependent on others for help and support. Mindfulness is
not about fixing problems, and so is a good match with the need for resilience
to cope with life. In addition, mindfulness-based rely on “training” new skills
or new ways to approach things and in this respect they can be seen as
empowering.
· Already hinted at
is the notion that mindfulness interventions do not come from a pathological
stance but are more focused on positive lifestyle change. Given that ID and
autism are not “problems” in themselves to be “fixed” then again this is a good
match with the orientation of much of the philosophy of services supporting
people with ID or autism.
· There is some
research suggesting that increased dispositional mindfulness (i.e., in general,
you are a more mindful person) and situational mindfulness (especially, more
mindful in the parenting role) are associated with better psychological
adjustment (lower stress, less depression and anxiety) in parents of children
with ID or autism. The implication is that targeting increases in mindfulness
could then be a way of improving outcomes for parents.
· Research evidence
also suggests that coping with stress using avoidance strategies is associated
with poorer psychological adjustment for parents and increased chances of
burnout or work stress for support staff in ID/autism services. Thus, interventions
that reduce avoidant coping are likely to lead to positive outcomes for parents
and staff. Again, mindfulness based interventions tackle avoidance head-on and
encourage engagement with difficult thoughts and emotions (pretty much the
opposite of avoidance).
· Some specific
problems faced by individuals with ID or autism might also be a good conceptual
match with mindfulness-based interventions. In particular, challenging
behaviours can often serve the function of changing aspects of the social environment
that a person with ID or autism finds difficult/aversive. The ability to
regulate emotional responses, and sometimes to increase tolerance for
discomfort could help to reduce the chances of challenging behaviours occurring
(and their associated impacts on others and the person themselves).
Mindfulness-based approaches could be a good way to help people regulate
emotions in particular. In addition, carers find challenging behaviours
aversive to deal with and a real challenge is to work out how to reduce the
chances of carers responding to their own strong emotions and instead to act in
a way that will be less likely to maintain challenging behaviours over the long
term (see http://profhastings.blogspot.co.uk/2013/05/winterbourne-view-will-happen-again-and.html).
Mindfulness-based approaches are likely to be helpful for staff/carers in this
situation.
I could go on with some more ideas, and hopefully you will have ideas of
your own. However, the main point is that we must be able to articulate WHY
mindfulness-based interventions might be a good idea to use in a particular
context in our field. Simply jumping on the mindfulness bandwagon will do a
disservice to the people we work with and their families and carers.
It is also clear that there is a significant research agenda still to be
addressed in relation to mindfulness and ID or autism even before we generate
high quality research evaluations of intervention outcomes. For example, research
on the relationships between mindfulness-related processes and well-being in
people with ID/autism and carers is needed, as is research on how we measure
mindfulness in people with ID and autism. There are also the challenges of what
mindfulness might mean for people with more severe ID – is it still a relevant
concept, in what ways, and what might mindfulness-based interventions look like
for these people.
