Clinical Handbook of Mindfulness (123 page)

“doing” mode to a “being” mode, etc.). Some other skills and attitudes taught

in mindfulness groups are not being guided during mindfulness exercises by

an objective, not striving to attain a particular state (e.g., relaxation, happi-

ness, peace, etc.) and developing awareness of how a problem can manifest

itself in and through the body.

An Example of a Mindfulness-Based Program

in Inpatient Treatment (M-BPIT)

Setting

An example of the application of a meditation approach for hospitalized

patients can be found in the mindfulness-based therapy program in inpa-

tient treatment (M-BPIT) provided by the Department of Psychiatry of the

Villa Margherita
clinic in Vicenza (Italy), where an adapted version of

mindfulness-based cognitive therapy (MBCT)
(Segal, Williams & Teasdale,

2002)
forms the most important part of an integrated treatment program

Chapter 24 Mindfulness-Based Interventions in an Inpatient Setting

455

primarily based on the cognitive-behavioral approach. More specifically, this

department offers mindfulness training for the inpatients of its Unit for Mood

and Anxiety Disorders and for the Unit for BPD.

In this program the duration of hospitalization is four weeks; the frequency

of the mindfulness training is two weekly sessions (2 h/session) plus two

daily practice sessions of a half-hour each (
morning and evening mindful-

ness sessions
). The number of participants varies significantly and ranges

from six to eighteen because it depends on the physical and psychological

condition of the patients each day.

Material provided during the sessions includes handout sheets containing

the rationale behind the session and usefulness of the group, explanations

and instructions on how to carry out the exercises, problem formulation,

quotes, stories and an audio tape or CD ROM with guided mindfulness exer-

cises for daily practice. For BPD patients, mindfulness training is integrated

with a skills training group
(Linehan, 1993),
body/expressive group therapy and individual cognitive-behavioral therapy (CBT). For patients suffering

from anxiety or mood disorders (in particular major depression and severe

obsessive-compulsive disorder), mindfulness training is integrated with cog-

nitive group-therapy sessions, body/expressive group therapy and individ-

ual CBT.

The mindfulness groups are always led by two professionals, an instructor

and an assistant.

Adapted Form of MBCT

Within the inpatient unit program, the treatment team has found it useful

to provide and implement an adapted form of MBCT,
(Segal et al., 2002)

which differs from the original approach in the duration of some of the

exercises, the introduction to new meditation exercises, the format of the

sessions and the frequency of the meetings (twice a week). As is the case

in all mindfulness-based training, participants are trained to practice both

formal
(mindfulness meditation) and
informal
(the application of mindful-

ness attitudes and skills in everyday life) exercises (see also Chapter 1 of

this volume). The
formal meditation exercises
include “mindful walking,”

“mindful eating” (the raisin exercise), “sitting meditation” (mindfulness of

breathbody/sounds/thoughts; see also Appendix A of this volume), “mindful-

ness of the body” (body scan, see also Appendix A of this volume), “mindful

movements, stretching/yoga,” “the secure place” (guided imagery exercise),

practice of the morning
(mindful breathing), and
practice of the evening

(mountain meditation, lake meditation, sea meditation, etc.), exercises out-

doors, and relational mindfulness (in couples). The
informal meditation

exercises
include mindfulness during everyday activities, mindfulness when

experiencing pleasant/unpleasant events, mindful breathing (breathing as an

“anchor”), the
three-minute breathing space
and the “thoughts-are-not-facts”

exercises
(Segal et al., 2002),
free mindful walking, mindfulness of sight and sound (see Appendix A), and eating meditation during meals.

Typical Format of an Inpatient Mindfulness-Based Group Session

The duration of a mindfulness group session is one and a half hours, in a large

room in which patients are provided with cushions, mats and chairs. They

456

Fabrizio Didonna

are free to choose whether they prefer to sit on a chair or a mat, but most of

them choose the mats.

In each session the following steps are normally used.

—

After patients have settled down in the room and on their mats

or chairs and after the roll call (only the patients considered to

be ready for treatment by the team of professionals are admitted

to the session), the instructor starts to explain and illustrate the

aims of the group, the general meaning and rationale of mindfulness

for the patients’ problems (problem formulation, acceptance, non-

judgemental attitude, exposure), and the consistence and integration

of the group with the other therapies in the treatment program.

—

Explanation of the first mindfulness exercise, normally chosen

depending on the group composition of the given session, evaluat-

ing the possible problems of the patients present.

—

Formal mindfulness exercise (20–40 min).

—

Practice review and sharing comments on the exercise.

—

Understanding the meaning and rationale of the exercise for the

patients’ problems using comments, suggestions, questions, difficul-

ties and benefits that arose during the exercise.

—

Break (10 min).

—

Final meditation (10–15 min).

—

Sharing comments on the exercise.

—

Homework and handing out of material for participants (sheets,

descriptions of exercises, quotations, CD for practice).

Exercises and themes of the group would be run in continuing cycles.

Obstacles and Difficulties in Inpatient Groups

As has already been stated, during inpatient mindfulness groups we have

to deal with several problems that are usually not as frequent in outpatient

groups.

—

Emotional activation
: Several mindfulness exercises, in particular

the ones in which patients are asked to stay deeply in touch with

their body and physical sensations, can activate intense emotions,

especially anxiety. Patients can often feel a sense of lack of control

during a long sitting or meditation exercise done lying down because

of the relaxation feelings and because they don’t want to be in touch

with an often hated body (usually in sexually abused and trauma-

tized patients) that they have avoided or harmed or punished in the

past. For these reasons some patients may activate intense feelings of

shame, guilt, disgust and anxiety and might be frequently and eas-

ily distracted, and may ask for a break or even suddenly abandon

the group.

—

Dissociative crisis
: Dissociation can be considered a more extreme

form of avoidance from undesired and painful feelings. This symptom

is normally found in patients suffering from posttraumatic stress disor-

der (see also Chapter 16 of this book) or BPD. It can be an important

and disabling problem during a group, but not as frequent as might

Chapter 24 Mindfulness-Based Interventions in an Inpatient Setting

457

be imagined. In the author’s clinical experience, there have only been

four or five severe dissociative crises during mindfulness group ses-

sions in several years of trainings with hundreds of inpatients with

traumatic experiences and BPD.

—

Patients that fall asleep
: Patients may fall asleep as a result of medi-

cation, excessive relaxation or even as a form of avoidance.

—

Disturbing background noises
: Inpatient settings and mental health

services are usually not designed to be “meditation centers.” There-

fore, noises that are normal in these contexts but intrusive for the ses-

sion may disturb patients during the meditation exercises. Patients are

always invited to consider noises as particular sounds and imperma-

nent events that become the object of awareness in the here and now

and to turn them into opportunities to develop a non-judgemental

acceptance toward difficulties.

—

Late comers
: It is not uncommon for inpatients to arrive late to group

sessions. This can disturb the mindfulness exercises, which require

silence. This happens because of the difficulties many patients have

following rules either because of their psychological problems or

because they have inadequate priorities during their stay in the inpa-

tient setting.

—

Physical problems or malaise
: Some patients, especially older ones

(see also Chapter 23 of this book), may associate to psychological dis-

ease with physical problems; this can create several difficulties when

trying to practice some specific mindfulness exercises (e.g., sitting

meditation or mindful walking).

Coping Strategies to Deal with Difficulties

In order to deal with the problems and obstacles that severe inpatients can

have during the group, the following strategies, which have been developed

through clinical experience, may prove to be helpful.

—

Ensuring daily practice
: One of the most important strategies to

effectively deal with challenging problems during an inpatient mind-

fulness group is ensure that patients are practicing mindfulness in

a consistent and regular way on a daily basis with the guidance of

instructors who have extensive experience and competence regard-

ing the problems the inpatients suffer from.

—

Providing two therapists for each session
: It is very important that

mindfulness groups for severe inpatients are guided and conducted

by two leaders: a leader (instructor) and an observer (assistant). This

is important so that should a patient have any difficulty, the observer,

or co-leader, can intervene in order to try and help the patient to

overcome the problem or resist until the end of the exercise, while

the leader can continue to provide the instructions of the exercise for

the rest of the group.

—

Providing individual help
: Difficult patients need to be provided

with individual help between group sessions to optimize and allow

their participation in the group. In order to prevent counter-

productive experiential avoidance, it is important to help patients

458

Fabrizio Didonna

who are ready to be in the group but who either are hesitant to partic-

ipate for the first time or have had difficult or frightening experiences

in a session and are hesitant to return to the group.

—

Avoiding, if possible, large groups
with severe patients (max 8–10

participants). Large groups increase the risk of significant and difficult

problems that have to managed during the sessions. This is especially

a problem if the leaders do not have extensive experience in leading

mindfulness groups for psychiatric problems.

—

Selection of patients
: Not all patients admitted to the ward may be

ready to participate in the mindfulness group because of various clin-

ical and personality features (see next section).

—

Giving/providing more instructions during exercises than what is

done in outpatient groups
: Inpatients normally need to be frequently

guided during the process of meditation because they tend to get dis-

tracted more easily than outpatients, their minds easily tend to wan-

der off or ruminate, and they easily loose the contact with the here

and now.

—

Keeping the more difficult patients close to the group leader
: In

order to provide patients that may easily have problems (e.g., anxiety,

dissociation, pain) during a session prompt help, it might be useful

to ask them to sit or lay down close to the leaders. This often gives

patients a sense of protection and safety that allows them to get and

stay in touch with difficult inner states.

—

Providing support and encouraging patients in difficulty
. If neces-

sary or appropriate, the leaders can hold the hands of patients who

are nervous, anxious or at risk of dissociation.

—

Accompanying patients having difficulty coping back to their ward
:

If necessary, patients who find it very difficult to cope with their prob-

lems should be accompanied back to their ward in order to prevent

intense crises (e.g., dissociation, panic, etc.) that could compromise

the continuity of the entire session.