Clinical Handbook of Mindfulness (124 page)

—

Not allowing late arrivals to enter
: Once a group has already begun,

late arrivals should not be allowed to enter the group because they

may disturb participants during a meditation exercise. Furthermore,

it is important to set rules and discipline in order to transmit and

share a sense of priority and respect toward each other.

—

Using background music
: In order to allow inpatients to stay in

touch with their private experience in the here and now for a long

time, it is often useful to use soft background music that can gen-

tly accompany patients during the difficult process of the explo-

ration of challenging and disturbing internal experiencing. Normally

background music is not experienced as a source of distraction and

it helps allow patients to maintain concentration in the present

moment.

—

Gradual progress in implementing exercises
: As the difficulty of

exercises increases, inpatients with challenging patients must be

introduced to the exercises in a more gradual way than with outpa-

tients. This can be done by passing from exteroceptive (external sen-

sory awareness; e.g., mindfulness of sight and sounds) to interocep-

tive (inner mindfulness; e.g., body scan, sitting meditation) exercises,

Chapter 24 Mindfulness-Based Interventions in an Inpatient Setting

459

from shorter (5–10 min) to longer exercises (30–40 min) and from

informal (mindfulness of daily life) to formal meditation.

—

Selecting the exercises of the session depending on the makeup of

the group
: If there are many new, inexpert or disturbed patients in a

group, leaders should consciously choose exercises that are not too

activating.

—

Encouraging patients to use difficulties as opportunities
: During

group sessions, patients should be encouraged to use difficulties (e.g.,

stressful emotions and thoughts, self-discomfort or malaise, back-

ward noises, disturbing behaviors from participants, etc.) during ses-

sion
as opportunities
to promote and develop acceptance and non-

judgmental attitudes rather than as problems or obstacles.

—

Patients who fall asleep during the session should be woken up
:

Mindfulness means being present moment by moment. When people

fall asleep they simply are not aware in the present moment and they

loose an opportunity to learn this attitude.

Criteria for Exclusion from an Inpatient

Mindfulness-Based Group

Clinical experience suggests that mindfulness-based groups are not suitable

for severe inpatients that show certain stable or temporary clinical condi-

tions and features. Therefore, patients should be carefully selected for par-

ticipation in each group session. The conditions which would determine the

unsuitability of certain patients are:

—

patients in an acute depressive phase and too severely affected to

be able to establish a rapport with the instructor and the group
;

—

patients with active severe psychotic symptoms or with an extensive

delusional system
;

—

bipolar patients in an euphoric/manic state
;

—

patients with severe risk of dissociative crisis
;

—

patients with severe cognitive deficit/impairment and gross retar-

dation or agitation, and who present poor insight
;

—

poorly-motivated or hypercritical patients with an opposing atti-

tude, or who are unwilling or unable to collaborate with a group
;

—

patients under the effects of drugs or substances (alcohol, opioids,

cannabis, etc.)

When the above-mentioned conditions are no longer stable and patients

begin to improve during hospitalization, they can be admitted to the mind-

fulness group.

Useful Messages for Dealing with Difficulties in Groups

During mindfulness group sessions, the instructor can help participants deal

with any difficulties that might arise using specific messages that are consis-

tent with mindfulness attitudes and principles toward suffering. Some exam-

ples are given below.

460

Fabrizio Didonna

—

“Stay in touch with your experience” (emotion, thought, sensation,

feeling); “You can do it”; “Yes, you can”; “Allow it to be
. . .
”; “Don’t

avoid it
. . .
”; “Don’t fight it”; “Do not try to escape from it”; “Accept

it”; “Don’t judge it” (Acceptance, allowing the inner experience);

—

“Take a breath”; “Stay in touch with your breath”; “Breathe together

with me” (Breath as an anchor, decentering and defusion);

—

“It’s OK to feel like this, it is not wrong”; “Whatever it is, it’s OK”; “It

is just what it is right in this moment (non-judgement);

—

“Feel this emotion”; “Don’t escape from it”; “It doesn’t hurt” (going

toward and trough private experience);

—

“Thoughts are only thoughts, transient and impermanent mental

events”; “This thought is not ‘you’ or reality”; “Thoughts are not facts”

(relating in a different way to thoughts, disidentification);

The aim of all these statements and phrases is to help patients to over-

come, during the session, the point in which they would tend to activate

experiential avoidance or maladaptive reactions (e.g., self-harm, rumination,

etc.) as difficulties and problems related to the private experiences that arise.

Very often patients report that over time they were able to embody and inte-

riorize these messages and use them autonomously to deal with difficulties

in non-therapeutic situations.

Summary

Acceptance and mindfulness-based treatment programs can be effectively

adopted in clinical inpatient settings, especially in specialized units for spe-

cific disorders, and they are interventions that can optimize the resources of

the staff. These kinds of approaches offer a cost-efficient way to generically

teach useful skills for disengaging patients from the dysfunctional cognitive

processing modes that characterize severe and acute disorders. Furthermore,

this form of treatment seems to obtain a good compliance and appears to be

well tolerated even by patients with high levels of discomfort or disturbance.

Unlike outpatient treatment, in an inpatient setting the environment and

the ward milieu, can play an important role in the implementation and effects

of mindfulness-based interventions. Inpatient settings may offer patients the

opportunity to follow an intensive program with more frequent mindfulness

sessions and meditation practice on a daily basis.

Nevertheless, providing mindfulness training for severe and acute disor-

ders in an inpatient setting is not an easy task and requires practitioners and

professionals understand the many obstacles and challenges that character-

ize inpatient units, and which are basically inexistent in outpatient treatment.

These difficulties mean that specific formats and organization must be used

when implementing mindfulness-based interventions in an inpatient setting,

that is, the structure of the interventions must be adapted to the hospital-

ized population and environment. Furthermore, several specific and general

coping strategies that are useful for dealing with patients’ difficulties during

mindfulness groups must be used. However, as was explained above, mind-

fulness intervention is not suitable for all inpatients and the selection of who

is fit or unfit can be made using some criteria of exclusion from mindfulness

groups which come from the author’s clinical experience.

Chapter 24 Mindfulness-Based Interventions in an Inpatient Setting

461

In order to implement an effective mindfulness-based program in inpa-

tient treatment, it is important to point out that all therapeutic staff need to

be trained in mindfulness and it is important to try and keep the approach

of different members of staff as consistent as possible. Supervision is also

required on a regular basis.

In all the treatment interventions and for the entire duration of the

patients’ stay, the emphasis must be on the principles of a
cceptance
and the

here and now
. It is also important that both patients and instructors regu-

larly practice mindfulness training in order for it to be effective in inpatient

treatment.

Although clinical experience suggests that in general there are no particu-

lar contraindications in providing mindfulness-based treatment for severe and

challenging problems, specific methods, strategies, exercises and meditation

styles, e.g., the way in which mindfulness practice is proposed, should be

used for various forms of severe pathology and psychological problems (psy-

chosis, BPD, dissociative disorders, etc.). The success and/or failure of these

should be analyzed in order to understand which strategies work best for

which patients in which conditions. Implementing mindfulness-based group

work with challenging inpatients often requires gradual progress regarding

the difficulty of the exercises proposed. This can be done by passing from

exteroceptive to interoceptive exercises, from shorter to longer exercises,

and from informal to formal meditation (Didonna, 2008).

As far as actual outcomes are concerned, to date there are few randomized

and controlled studies
(Bach & Hayes, 2002; Katz et al., 2000)
that have evaluated the effectiveness of acceptance and mindfulness-based interventions

in inpatient treatment. This is because the application of this approach is in

a relatively early stage and also because it is notoriously difficult to demon-

strate the effectiveness of one therapeutic intervention (such as mindfulness

training) within an inpatient setting, separating it from the rest of the numer-

ous specific and non-specific therapeutic variables which characterize a hos-

pitalized treatment program. For example, it is quite difficult to differentiate

the effect of the ward milieu from the specific effect of the therapy and

differentiate the impact of each intervention on the outcome. Nevertheless,

there are several encouraging qualitative studies
(Barley et al., 1993;
Bohus et al.,
2000; Gaudiano & Herbert, 2006; Katz et al., 2002; York
,
2007)
whose results suggest that patients value mindfulness-based intervention and find it

beneficial at discharge and that mindfulness can be a key component in a

therapeutic inpatient program.

Further investigation is clearly required to establish whether or not the

benefits are maintained at follow-up and to understand how clinical improve-

ment at discharge can be associated with changes in mindfulness skills.

Mindfulness-based interventions are not an array of therapeutic tech-

niques, but they do attempt to offer patients a new cognitive style, a “way

of being” and a general approach to life and suffering. For this reason, mind-

fulness can be effectively used even for individuals with high levels of suf-

fering, such as hospitalized patients, if we are able to transmit to them not

only the meditation techniques, but above all the core and basic principles of

the mindfulness-based perspective (acceptance, compassion, here and now,

non-judgement, etc.), which are aimed at understanding the causes of and

reducing individual suffering.

462

Fabrizio Didonna

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