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24

Mindfulness-Based Interventions

in an Inpatient Setting

Fabrizio Didonna

Only in quiet waters things mirror themselves undistorted.

Only in a quiet mind is adequate perception of the world.

– Hans Margolius.

Introduction

In the past two decades the use of mindfulness-based interventions in clinical

settings has quickly become more and more common especially in outpatient

treatment and above all with patients whose problems are not extremely

serious and who are not in the acute phase of the disease
(Baer, 2003).

There has been debate about whether or not it is possible and useful to

use mindfulness therapy with serious, chronic psychiatric pathologies in the

acute phase
(Baer, 2003; Segal, Williams, Teasdale, 2002,
see also Chapter 18

of this volume). There is, however, some evidence that acceptance and

mindfulness-based treatment programs can be usefully adopted in clinical

inpatient settings and for challenging problems, especially for suicidal adoles-

cent inpatients
(Katz, Gunasekara, & Miller, 2002; Katz et al., 2000)
patients with borderline personality disorder (BPD)
(Barley et al., 1993; Bohus et al.,

2000),
psychotic patients
(Bach, P., & Hayes, S. C., 2002; York, 2007;
Gaudiano & Herbert,
2006),
and to enhance treatment team process (Singh, Singh, Sabaawi, Myers, & Wahler,
2006).

Keeping in mind that mindfulness approaches (e.g., MBSR, MBCT, ACT)

easily lend themselves to applications in a group-therapy setting and on

account of an excellent cost-efficient ratio resulting from this sort of appli-

cation, these kinds of interventions are particularly suitable in psychiatric

inpatient settings and especially in units specialised in the treatment of spe-

cific forms of psychopathology. This form of treatment seems to obtain

good compliance and appears to be well tolerated even by patients with

high levels of distress or disturbance
(Mason & Hargreaves, 2001).
As will be detailed later in this chapter, mindfulness-based intervention has many

attributes that make it highly suitable for use in short-term inpatient treat-

ment. Nevertheless, there are some difficulties and obstacles involved in

using mindfulness treatment in an inpatient setting. These challenges are

mostly non-existent in outpatient treatment so mindfulness-based interven-

tions must be re-organized and follow a specific format when used for hospi-

tal patients and environments.

447

448

Fabrizio Didonna

Based on the personal experience of the author in implementing and

planning mindfulness-based treatments for hospital programs for psychiatric

patients, this chapter aims to show how it is possible to successfully imple-

ment mindfulness interventions within an inpatient unit in a Mental Health

Service for severe and challenging problems by rationally integrating them

with established inpatient treatments and protocols. More specifically, the

chapter will clearly outline the obstacles and challenges related to these

inpatient mindfulness-based protocols and propose some guidelines to over-

come them.

Why Should a Mindfulness-Based Program

Be Implemented in an Inpatient Setting?

There are several reasons that make mindfulness-based training a cost-

efficient intervention in the context of an inpatient treatment program. First

of all, clinical experience and empirical observation suggest that, in general,

the more serious the problems of patients admitted to inpatient units, the

greater the need to provide an environment that promotes mindfulness prac-

tice. These patients require a more intense degree of practice than that which

characterizes outpatient settings, for example, at least on a daily basis, and

more help in learning how to carry out the exercises and in understand-

ing how they relate to and can be useful in helping them learn to man-

age their problems. During hospitalization, if all the treatment staff share

a mindfulness-based model, patients can live in a
mindful therapeutic set-

ting
: patients can feel a sense of calm in an environment that is free from

judgements and pressure and that demonstrates tolerance, emotional valida-

tion and empathy. The style of communication and messages from therapeu-

tic team, therefore, need to be consistent with mindfulness-based principles

(acceptance, presence, here and now, non-judgement, etc.).

Normally in an inpatient setting, the ward milieu can be considered a

“safe place” in which patients feel safe, accepted, protected and cared for.

Indeed, very often patients begin to improve shortly after admission even

before they start any sort of treatment. This atmosphere is needed in order

to allow severely disturbed patients to become familiar with and effectively

use mindfulness practices, often for the first time in their lives. In this setting

they can do regular mindfulness practice without being disturbed by the fac-

tors that they often can find in their own personal environment (e.g., family

conflicts, expressed emotion, feeling of loneliness, psychological or physical

violence, etc.).

Unlike outpatient mindfulness training, in which participants may often

have difficulty finding the time, spaces and willingness to do meditation prac-

tice on a regular basis, especially individuals with challenging problems (e.g.,

BPD, depression, OCD), during hospitalization patients can be assisted in

doing intensive and regular practice. Because of the specificity of the pro-

gram, planned inpatient treatment involves daily practice, which is assisted

by the nursing staff and psychological professionals. Furthermore, in an inpa-

tient setting, patients have more opportunities to find moments and spaces

for mindfulness practice because most of their time during inpatient treat-

ment is to be used for therapeutic reasons.

Chapter 24 Mindfulness-Based Interventions in an Inpatient Setting

449

Another advantage of this kind of treatment in an inpatient setting is the

chance to use mindfulness-based interventions in vivo with the patients’

problems when they arise, explaining and showing the effects and impor-

tance of acceptance, non-judgement, and decentering attitudes when anxi-

ety, sadness, anger or any other emotion or problematic states arise.

As is the case for all group therapeutic interventions in inpatient programs

mindfulness-based group therapy is a cost-efficient intervention in that it can

make optimal use of the staff and maximize the often limited resources of

the mental health units. It has also been noticed that inpatients, during the

sessions together with individuals suffering from different disorders (hetero-

geneous group), can share a sense of
common human suffering
with each

other regardless of the diagnosis), and this is one of basic principles of mind-

fulness. Patients in group therapy can realize that suffering is an imperma-

nent normal condition that can be present in people with different ages,

cultures, and social status and that the suffering has a common origin (e.g.,

the three causes of suffering, see Introduction, Chapters 1 and 2 of this vol-

ume). This understanding can be reached by sharing of a mindfulness-based

problem formulation, which offers a simple and uniform approach across

diagnoses and gives the individual a clear and non-accusatory way of under-

standing how their breakdown has occurred.

There is also some evidence that when mindfulness-based mentoring is

provided to professionals involved in inpatient programs, it can be an effi-

cient and effective intervention for enhancing and maintaining the perfor-

mance of treatment teams in adult psychiatric hospitals.
Singh et al. (2006)

investigated changes in treatment team functioning in an adult inpatient psy-

chiatric hospital after the implementation of a mindfulness-based mentoring

intervention. Their results showed that with the introduction of mindfulness-

based mentoring, treatment team performance was enhanced, patients’

attendance at therapeutic groups and individual therapy sessions was max-

imized, and patient and staff satisfaction with treatment team functioning

increased substantially, with patient satisfaction showing greater gains than

staff satisfaction.

Another important point is that hospital units and wards are normally

staffed by multidisciplinary teams characterized by very different orienta-

tions. A mindfulness-based approach is a trans-epistemological perspective,

which can be easily used by professionals from different therapeutic ori-

entations (psychodynamic, cognitive-behavioral, existentialist, etc.). What is

important is that all the professionals in the treatment team share the same

mindfulness view of suffering and of mind functioning and, if possible, have

a regular meditation practice. For this reason, in order to implement an effec-

tive mindfulness-based program in an inpatient treatment, it is important to

highlight the fact that all therapeutic staff need to be trained in mindfulness

and that supervision is required on a regular basis.

Features and Difficulties of an Inpatient

Mindfulness-Based Group

Providing mindfulness training for severe and acute disorders is not an easy

task and, compared with outpatient treatment, it requires that first those

providing the training clearly understand the obstacles and challenges that

450

Fabrizio Didonna

characterize inpatient units. First of all, the disorders of hospitalized patients

are much more severe, comorbid, and chronic than those of outpatients,

and inpatients are often in an acute phase, especially at the beginning of

the inpatient treatment. They may also have a seriously disturbed relation-

ship with the body (often because of traumatic experiences or psychotic

problems), which is usually an important focus in mindfulness exercises,

and feel extreme fear of loosing control during the mindfulness exercises.

Furthermore, during hospitalization patients are usually on medication. This

can often create some problems with patients during group sessions because

of the side effects of the medication. Thus, during the exercises they may fall

asleep or have several physical symptoms that can make concentration or

participation during sessions difficult or even impede it.

Another important point is that in inpatient treatment, because of the

intensity and the relatively limited duration of the stay, there is a rapid

turnover of patients. This fact can make it difficult to provide group inter-

ventions in which participants start with a group of people and finish with

the same one, as is, on the other hand, more so the case in outpatient groups.

There is an ongoing change in the makeup of the group and this can lead to

lack of homogeneity in each meeting with regards to the level of learning

and understanding of the participants. Indeed, each session can be the first

session for some patients and this often makes it difficult to provide more

advanced exercises to the patients who have been in the hospital and in the

group for longer periods of time.

These problems mean that the standard mindfulness-based group format

must be adapted to the specificity of the severe mental health problems of

patients admitted to the unit and to the features of an inpatient treatment

program.

Features and Advantages of Heterogeneity

in Mindfulness Groups

Another typical feature that we normally find in inpatient mindfulness

groups, and which is often considered an obstacle for the process and out-

come of treatments, is
heterogeneity
. This is related in particular to the kind

of the disease, level of severity, age, and socio-cultural level. The author’s

clinical experience with hundreds inpatients suggests that heterogeneity can

actually be turned into a resource if we are able to understand and exploit

some of the advantages of heterogeneous groups.

Heterogeneity and the atmosphere of mindfulness-based groups tend to

deactivate the “agonic/competitive modes” (which activate anger, shame,

etc.) are normally activated in other more homogeneous settings (e.g., skills

training groups for borderline patients). For many patients, participating in a

group with people of different ages, status and kinds of disorder allow them

to de-identify themselves from the “
pathological role and identity
” that they

often have. In groups this discourages the expression of typical pathological

modes and behaviors (anger, acting-out, expressing emotions or avoidance),

which are often connected to the identification of the patients with their

own disorder. This phenomena is often observed, for example, in BPD or