Beyond Mindfulness

Mindfulness article: Meiklejohn, J., Phillips, C., Freedman, M. L., Griffin, M. L., Biegel, G., Roach, A., ... & Isberg, R. (2012). Integrating mindfulness training into K-12 education: Fostering the resilience of teachers and students. Mindfulness, 3(4), 291-307.

What is mindfulness? Mindfulness, as defined by John Kabat-Zinn, is “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.”

What does mindfulness practice consist of? Mindfulness meditation involves focusing one’s attention on a specific “anchor” such as one’s breath. When noticing that one’s mind begins to wander from the anchor, the person tries to return his/her attention to the anchor. Mindfulness practice can be formal (e.g., meditating) or informal (e.g., using mindful awareness while performing a daily task such as showering).

Can mindfulness help adults? There is a strong body of evidence that mindfulness benefits adults in numerous ways, including “reducing stress, anxiety, and depression; enhancing neuroendocrine and immune system function; improving adherence to medical treatments; diminishing need for medication; altering perception of pain; increasing motivation to make lifestyle changes; and fostering social connection and enriched interpersonal relations.” One randomized controlled trial (RCT) found that many of these results happened after participants completed an MBSR class that lasted just 8 weeks.

Can mindfulness help K-12 teachers? There are a number of programs geared towards teaching mindfulness to educators -- e.g., Mindfulness-Based Wellness Education (MBWE), Cultivating Awareness and Resilience in Education (CARE), and Stress Management and Relaxation Techniques (SMART) in Education. According to subjective measures, these programs are successful, as participants consistently report such positive effects as decreased occupational stress and increased work motivation. More research is needed to show if these programs also positively affect such objective factors as classroom climate, teacher efficacy, and student learning.

Can mindfulness help K-12 students? Only a small number of RCTs have been conducted on the efficacy of mindfulness in elementary schools. Students who participated in one 12-session mindfulness training showed improvements in an objective measure of selective attention and improvements in teacher-rated measures of attention, social skills, and test anxiety. Students who participated in another mindfulness program showed improvements in a self-reported measure of optimism and improvements in a teacher-rated measure of behavior. Another RCT showed no overall improvement for students in the mindfulness group, but students in the group with weaker initial executive functioning skills showed improvements in these skills.

Although more research is needed to verify the benefits of mindfulness for students, initial research suggests it can have the following benefits: “fostering pro-social behavior via strengthening self-regulation and impulse control; alleviating the effects of stress that obstruct learning; and providing a skill set that promotes brain hygiene, and physical and emotional well-being across the life span.” Up-to-date research can been found on the What Works Clearinghouse website.

Is there evidence supporting the effectiveness of specific school-based mindfulness programs? The authors mention two mindfulness programs that are used in some DPS schools: Learning to BREATHE and MindUP. The authors reference one pilot study demonstrating the effectiveness of Learning to BREATHE: Broderick and Metz (2009). Learning to BREATHE: A pilot trial of a mindfulness curriculum for adolescents. Advances in School Mental Health Promotion, 2, 35-46. The authors reference one study showing the effectiveness of MindUP: Schonert-Reichl and Lawlor (2010), The effects of a mindfulness-based education program on pre- and early adolescents’ well-being and social and emotional competence. Mindfulness, 1, 137–151.

Are there any validated measures of mindfulness for children? The authors list three measures which have been shown to have acceptable internal consistency and “multiple forms of validity”: the Child Acceptance and Mindfulness Measure (CAMM), the Mindful Thinking and Action Scale for Adolescents (MTASA), and the MIndful Attention Awareness Scale-Adolescent (MAAS-A).

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DBT article: Perepletchikova, F., Axelrod, S. R., Kaufman, J., Rounsaville, B. J., Douglas‐Palumberi, H., & Miller, A. L. (2011). Adapting Dialectical Behaviour Therapy for children: Towards a new research agenda for paediatric suicidal and non‐suicidal self‐injurious behaviours. Child and Adolescent Mental Health, 16(2), 116-121.

Perepletchikova et al. describe DBT as a therapeutic modality which “targets affective and behavioural dysregulation by teaching coping skills and using problem solving within a validating environment.” They further note that “DBT is a principle-based intervention not defined by specific format, techniques or a set of skills but, rather, by the balance of acceptance and change within a dialectical framework.”

DBT has been shown to be effective at treating adults and adolescents displaying suicidal and non-suicidal self-injurious behavior. It has not previously been used to treat non-adolescent children displaying self-injurious behavior, but there’s a clear need to do so, as over the past 20 years, the rate of pre-adolescent children committing suicide has doubled. Perepletchikova et al. designed an intervention, DBT for Children, that kept the basic principles of DBT but made it child-friendly and, for example, incorporated colorful handouts, experiential exercises, a board game (for behavioral chain and solution analysis), and role-play activities.

Perepletchikova et al. conducted a pilot to test the efficacy of DBT for Children. They took 11 children aged 8-11; 55 percent of the children had clinically significant levels of depression, 45 percent had clinically significant levels of anxiety, and 45 percent reported having suicidal thoughts. The intervention involved a biweekly class that lasted for six weeks. Post-intervention results showed decreases in depression and suicidal ideation, a decreased in problem behavior, and an increase in coping skills.

Perepletchikova et al. plan to add a caregiver training to the intervention. This added component is so important because acceptance is a crucial component of DBT, and one of the most effective ways to help children feel accepted is to encourage an accepting home environment. It is also important to teach the program’s coping skills to caregivers, as this will allow them to help their children practice the skills at home.

I’m interested in these results, as I’d like to learn more about DBT and how I can apply some of its principles to my own practice. I have several questions about DBT. First, what criteria should be used before including someone in a DBT program? DBT was designed for individuals exhibiting self-injurious behavior, but I know it has also been shown to help individual with less extreme behavior. Second, would the above intervention be appropriate in a school setting? Would parts of it need to be adapted before being used in schools? Third, I know that many counselors/therapists have incorporated parts of DBT into the own practices, using these principles to enhance other curricula as well as their own individual and group counseling sessions. I’d love to see more examples of this. I don’t foresee myself implementing a full DBT program, as least not anytime soon, and so I’d love to see how others have used individual parts of DBT.

Below are the DBT for Children skills training modules, which I’m reproducing for my own future reference.

Mindfulness

Introduction	Mindfulness is paying attention on purpose, in the moment and without judgments.
States of Mind	“Emotion Mind,” “Reasonable Mind,” and “Wise Mind.”
What Skills	Observing and describing behaviors and emotions, and participating in activities with awareness.
How Skills	Focusing on one thing in a moment, entering into the experience non-judgmentally and doing what works.

Distress Tolerance

STOP Skills	Avoiding impulsive reactions using the acronym STOP: Stop and do not move a muscle, Take a step back, Observe what is going on, Proceed mindfully.
DISTRACT	Controlling emotional and behavioral responses in distress using the acronym DISTRACT: Do something else, Imagine pleasant events, Stop thinking about it, Think about something else, Remind yourself of positive experiences, Ask others for help, Count your breath, and Take a break.
Self-Soothing	Tolerating distress by using five senses.
Pros and Cons	Considering pros and cons of responding to distress.
Letting It Go	Techniques for accepting events that cannot be changed.
Willfulness and Willingness	Being willing to accept reality as it is as opposed to being willful in refusing to tolerate distress.

Emotion Regulation

The Wave	Emotion Wave is seen as going through 6 stages: event, thought, feeling, action urge, action and after effect.
Surfing Your Emotion	Regulating emotional arousal by just attending to an emotion without trying to change its intensity
Opposite Action	Changing affective reaction by acting opposite to the emotion.
PLEASE Skills	Reducing emotional vulnerability with PLEASE skills: attend to PhysicaL health, Eat healthy, Avoid drugs/alcohol, Sleep well, and Exercise
LAUGH Skills	Increasing positive emotions with LAUGH skills: Let go of worries, Apply yourself, Use coping skills, set Goals, and Have fun.

Interpersonal Effectiveness

Worry Thoughts & Cheerleading	Goals of interpersonal effectiveness, what gets in the way of being effective and cheerleading statements.
Gaols	Two kinds of interpersonal goals, “getting what you want” and “getting along.”
DEAR Skills	How to “get what you want” using DEAR skills: Describe the situation, Express feelings and thoughts, Ask for what you want, Reward or motivate the person.
FRIEND Skills	How to “get along” by using the FRIEND skill: be Fair, Respect the other person, act Interested, Easy manner, Negotiate, and be Direct.

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Acceptance and Commitment Therapy (ACT) article: Coyne, L. W., McHugh, L., & Martinez, E. R. (2011). Acceptance and commitment therapy (ACT): Advances and applications with children, adolescents, and families. Child and Adolescent Psychiatric Clinics, 20(2), 379-399.
Coyne et al. write that Acceptance and Commitment Therapy (ACT) is part of the cognitive-behavioral tradition. Cognitive-behavioral therapy (CBT) pointed out that previous therapies had discounted the important role that cognitions play in psychopathology and claimed that cognitive changes precede behavioral changes.

Coyne et al. acknowledge that much evidence has shown CBT’s effectiveness at treating a host of psychiatric disorders, but they argue that CBT has a major shortcoming. I don’t understand their argument -- “treatment component targeting cognition explain little variance in outcomes over and above those targeting behavior” -- and so I’m going to spend the remainder of this assignment trying to summarize ACT.

ACT’s primary goal is for individuals to achieve psychological flexibility. One can be said to be psychologically inflexible if the following two elements are present: cognitive fusion and experiential avoidance. Cognitive fusion occurs when we take our own thoughts and words as literal truths. For instance, I might have the thought “I’m a loser,” and I might conclude that this is not just a thought but an actual truth about reality. When I have such thoughts, I might go on to avoid experiences that make that thought more likely to occur. ACT contends that healing occurs when, instead of avoiding our problems, we confront them, experience them directly.

ACT attempts to achieve its goal of psychological flexibility by strengthening six psychological processes.

1. Cognitive defusion. This is the process in which we learn that our thoughts are “merely verbal events rather than actual events.” Whereas CBT attempts to change our thoughts, ACT attempts to change our relationship with our thoughts. In other words, the goal here is to accept the thought, to learn to live with it. In so doing, the hope is that the thought will cease having so much power over us. 
2. Acceptance. Instead of avoiding an unpleasant situation, the goal here is to allow ourselves to experience the situation. For instance, ACT would ask someone experiencing pain to turn their thoughts, not away from the pain, but towards it in a nonjudgmental, accepting manner. 
3. Present moment awareness. The goal here is to continually accept one’s circumstances, to have ongoing awareness of one’s circumstances. 
4. Self as context. The idea here is that we’re not the sum of our thoughts. We experience our thoughts, which come and go, but we are not our thoughts. 
5. Values. Values are important to ACT, as these are the guiding principles that motivate our behavior. 
6. Committed action. This is where the rubber meets the road, where one uses the necessary techniques to achieve one’s values. 

The authors write that some are hesitant to use ACT with children because it seems so esoteric. I can definitely understand why people feel this way, as I found the authors’ explanation of ACT to be somewhat confusing. Nonetheless, they insist that ACT is actually a great therapeutic modality for children, as it relies more heavily on experiential (as opposed to didactic) tools. There is a growing body of evidence of ACT’s efficacy among adults. Although there are some indications that ACT can also benefit children, the research here is still small, and larger RCTs still need to be conducted.

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Class Notes:

DBT

1. Traditional Modes in DBT: Individual Therapy for 1 hour, Skills Training 3 hours, Phone Coaching 24/7, Consultation Group for 90 minutes. 
2. What we can do in schools: Skills Training, Consultation, Become Grounded in Theory. 
3. Skills Module: Mindfulness, Distress Tolerance, Emotional Regulation, Interpersonal Effectiveness. 
4. The Perhaps Game. 
5. Central Dialectics: Students are doing the best they can and they need to do better; acceptance/validation and challenge/change; balancing emotion and reason; your goals and the goals of the student; research and practice; desires and responsibilities; freedom and responsibility. 
6. Dialectical Dilemmas: comes to school and avoids class; being class clown and getting good grades; defending my rights and making friends; identity (no hood) and follow rules. 
7. Wise Mind: Venn Diagram between Rational Mind and Emotional Mind – e.g., Hermione (Rational), Ron (Emotional), Harry (Wise) 
8. Diary Card: Target behavior example >> going to gym. Need 3 weeks. 

DBT (part 2):

1. Rock exercise. Everyone gets a wrong, spends 2 minutes getting to know rock, then teacher collects rocks. Students go to table to pick out “their” rock. 
2. DBT Skills in Schools – Mazza 
3. Mindfulness Skills: 
1. What Skills: Observe, Describe, Participate 
2. How Skills: Non-judgmentally, One-Mindedly, Effectively 
4. Mindfulness for students w/ intellectual disabilities (Julie Brown) 
1. Breathe 
2. Check my surroundings 
3. Body check 
4. Label and rate my emotions 
5. Notice my thoughts 
6. Notice my urges 
5. Distress tolerance: use when you can’t solve a problem (source: Eichs DBT book). 
1. ACCEPTS 
2. IMPROVE 
3. Half-smile (put a smile on your face, your body associates smiling w/ being happy >> this elevates your mood) 
4. Creative outlet 
5. Pros and Cons (Linehan: 4 squares) 
6. PLAN (picture yourself controlling a big feeling, list the tools…) 
7. Radical acceptance 
6. Self-soothe kit: 
1. Journal and pens 
2. Bubbles 
3. Positive notes to yourself 
4. Lotion 
5. Books 
6. Stuffed animal 
7. Photos of people you care about 
8. Coloring book 
9. Fidget toys 
10. Bubble wrap 
11. Glitter bottle 
12. Pet tornado 
13. Wall pushes, break-dancing breaks (play Run DMC) 
14. Go Noodle app
15. Ball to give kids physical movement 
16. Etc. 
7. TIPP your physiology 
1. Temperature – e.g., go outside when it’s cold, throw cold water on face 
2. Intense exercise – cardio 
3. Progressive relaxation – 
4. Paced Breathing – breathe in for 7 seconds, out for 11 seconds (7-11 Breathing) 
8. Emotion Regulation Skills 
1. Vulnerability example = kryptonite. Kid example: being hungry makes me angry. 
2. PLEASED 
9. Breathing: Use hoberman sphere to demonstrate in and out. 
10. The Wave Skill Instructions 
11. Build Mastery 
12. Build Positive Experiences 
13. Opposite to Emotions 
1. Emotions love themselves, like to keep themselves going. 
2. Do the opposite of what you feel like doing. 
14. Interpersonal Effectiveness 
1. GIVE 
2. DEAR MAN 

Session #3, Biofeedback, ACT

1. Biofeedback: technique you can use to learn to control your body’s functions; you’re connected to electrical sensors that give you feedback. E.g., heartbeat, thermal response (e.g., bio-dot, mood ring, stress thermometer), galvanic response (sweat glands/conductivity of skin) (e.g., NeuLog, Thought Stream), brainwave response (Muse Headband) (Muse helps with mindfulness). 
2. Jackie Bott’s email: AT Request Form. Student needs 504 or IEP. Need informed parent consent. 
3. The ACT Approach: A Comprehensive Guide by Gordon and Borushok 
4. Russ Harris, The Happiness Trap