Resources mindfulness
Purpose
After attending a Mindfulness Teacher Development Training, a new teacher should run a course jointly with a more experienced teacher, who will act as mentor, and the new teacher as learner.
During this course, the learner keeps a reflective log. This can include anything that occurs to the learner e.g. reflections and learning points both from the course, and personal practice. Entries should be written after every session. It should include a “critical incident” during the course, where the learner experienced a difficulty, and how they responded to this. The cycle of reflection by Christopher Johns can be used for this (appendix 1). In addition, the log should include daily entries reflecting on personal practice for 1 month. The reflective log is not seen by the mentor.
At the end of the course, the reflective log is used as the basis for a reflective essay of around 500 words. Again, this should include reflections on the course and personal practice. This is seen by the mentor and can form the basis of a discussion where the mentor explores with the learner some the issues raised in the essay.
During the course, the mentor and learner agree on one formal practice, led by the learner, which is used as the basis for feedback. The best way for the mentor to evaluate this is to follow the practice from the “inside” i.e. how it feels when being led by learner.
The feedback can most effectively be done as an inquiry with the learner, led by the mentor at the end of the session or soon after it. It is best be done on a one-to-one basis rather than in a group. The tone of the feedback should be supportive, with some learning points woven into the inquiry. This can be done for more than one practice.
Other areas for the mentor to consider and provide feedback on during the course are:
The Mindfulness Practice Teaching Scale (Appendix 2) can be used for this purpose. The MBI-TAC is another useful resource, and includes guidance on levels of proficiency (http://mindfulnessteachersuk.org.uk/pdf/MBI-TAC-AUG2015.pdf). However, grading proficiency is not required in this evaluation and feedback.
This process can also be used for existing teachers. The procedure is similar to the above, except that the reflective log & essay can be done on any 8 week course led by learner, and the mentor evaluates practice using either video or sitting in. The mentor should observe the learner, so an audio recording is not suitable for this.
It can also be used for learners on a peer supervision basis for any course, as a form of CPD. In this case both learners could potentially take the role of mentor and learner for each other. It can also be done in other settings e.g. a follow-up session or staff practice group.
In the great majority of cases, evaluation and feedback will empower the learner to teach mindfulness courses in the future. For the process to be fully meaningful, it is important that the mentor is willing to raise significant concerns about the teaching of the learner. A useful question to ask is “would I be happy for this person to teach mindfulness to a relative of mine?”. In some instances, this may mean the learner suspending their mindfulness teaching in order have further personal development.
Appendices – next page
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Description What Happened |
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Feelings What were you thinking and feeling |
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Evaluation What felt good?
What felt difficult? |
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Analysis What sense can you make of the situation |
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Conclusion What else could you have done |
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Action plan If it arose again what would you do |
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Skills |
Skills Elements |
Are these skills demonstrated appropriately (tick one) |
The Good Points |
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1. Hardly at all |
2. Some of the time |
3. Half of the time |
4. Most of the time |
5. Nearly all of the time |
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Relational skills |
Acceptance, Warmth, Curiosity, Respect, Authenticity. |
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Embodiment of mindfulness |
Present, Calm, Alert, Responsive, Focussed. |
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Guiding mindfulness practices |
Precise language, Pacing and Key learning for particular practice/stage. |
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Constructive Comment |
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Conveying course themes through interactive inquiry and didactic teaching |
Layers of inquiry,
Experiential focus,
Links to key learning points |
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Introduction
In the past decade or so there has been an increase in interest in mindfulness-based approaches to health, and these are now being applied to a range of problems. The interest is in part fuelled by an increasing evidence base, the strongest of which is for recurrent depression [1]. Depression is a widespread condition and there is a challenge to provide cost-effective and empowering treatments while reducing dependency on antidepressant medication. This proposal presents a way of making mindfulness-based cognitive therapy (MBCT) widely available to people with depression in Scotland in a sustainable way. The proposal builds on the work already achieved by the NES-funded NHS Mindfulness Network.
MBCT meets a number of ambitions of The Scottish Government’s Mental Health Strategy 2017-2027 related to access to safe and effective treatment (p.23):
Treatment should be available across Scotland – the present proposal ensures an equitable distribution of MBCT for users nationwide.
Treatment that follows clinical guidelines – MBCT is recommended in the SIGN 114 Guideline and The Matrix
Treatment accessed in a timely way – 3 people can be treated for MBCT for the same staff resource as 1 person in individual therapy, offering the possibility of reduced waiting times.
Services that promote and support recovery-based approaches – depression is often a recurring condition, and MBCT’s primary effectiveness is in reducing the likelihood of future episodes.
These points are followed up below.
People with physical health conditions are more likely to become depressed than those without a condition [2]. Mindfulness-based interventions, including MBCT, have been evidenced to improve symptoms of mood disorder and psychological wellbeing in physical health conditions [3]. Mindfulness thereby is consistent with the Route Map to the 2020 vision for Health and Social Care [4], which aims to support self-management so that people are better able to maintain their health and to manage periods of ill-health, and: deliver improved outcomes for people living with multiple morbidities, including mental health conditions (p.9).
The WHO has identified depression as the leading cause of disability worldwide. For many sufferers, depression is a recurring condition. The more previous episodes a person has had, the more likely they are to have a future episode. In Scotland, 1 in 5 people will experience an episode of depression; 50% of these will experience at least one more episode, 80% of these will go on to experience additional episodes. This means that around 64,000 over the age of 16 will experience 3 or more episodes of depression. 161,000 people had GP consultations due to depression in 2011/12 [5].
MBCT is a group-based therapy which takes place over 8 weekly sessions. The emphasis is on teaching meditation-based practices, including movement, which the participant is asked to use at home on a daily basis. There is discussion focused on participants’ experiences of the practice, where learning points are drawn out. Teaching MBCT requires a high level of skill and knowledge of the patient group. Group numbers vary, depending on participants’ vulnerability. The costing here is based on 15 participants with 2 therapists.
For recurrent depression, MBCT can significantly reduce the likelihood of a further depressive episode over the following year. It is most effective for those with more severe depression and more previous episodes, where other active treatments have had limited benefit [1]. This is a robust finding, and MBCT is a recommended treatment in both the SIGN Guideline for the Non-Pharmaceutical Treatment of Depression [6] and the NES Matrix Guide to Delivering Evidence-based Psychological Therapies [7]. There is also some evidence that the effectiveness of MBCT is comparable to antidepressant medication [8]. In addition, studies have shown that MBCT can be effective in helping health staff cope with stress. Participants often continue to use the practices over a 4-year follow-up period [9]. Because MBCT is delivered in a group format, it is cost effective: 3 people can be treated with MBCT with the same amount of resource as 1 person in individual therapy [Appendix 4].
MBCT was funded on a pilot basis in 2005 by the Doing Well by People with Depression project. Support was then taken up by NES Psychological Therapies, who have provided a small amount of funding for MBCT (under £10,000) each year. Using this, a Scottish NHS Mindfulness Project has been developed, with some national co-ordination and identified mindfulness leads in each of the 11 mainland health boards. A mindfulness teacher development pathway has been implemented, increasingly devolved to health boards but with a degree of national co-ordination and support. Because of the government support through NES, Scotland is the only country in the world with a national strategy for mindfulness in healthcare. Sustainability of implementation is enhanced by the requirement that therapists have a regular personal practice of mindfulness. This gives them a strong commitment to the approach as they see the benefits it has in their own lives.
As a result of this, regular mindfulness courses are run in nearly all the health board areas. There are 75 active mindfulness therapists across the Scottish NHS delivering mindfulness to 1130 clients per year. Local audit data have shown significant benefit to patients from these courses.
These figures demonstrate that mindfulness can be implemented nationally in a cost effective way. However, they fall well short of the need identified above. The NES funding has been valuable, but it has been small and only agreed to on a year-by-year basis, making longer term planning difficult. National co-ordination is low level, in addition the health board leads have to perform this role within their existing job without specific time allocated for it. Implementation has been variable, with some health boards being less supportive than others. The current therapist training pathway, including a 4-day workshop, has proved adequate in initiating implementation. However, the Scottish mindfulness training pathway is now falling short of internationally recognised mindfulness therapist guidelines [10].
The current proposal would:
The features of the proposed curriculum are (see also appendix 2):
On completion of the course, the trainee will run a course jointly with a mentor. The mentor will observe the trainee and provide feedback using established competency frameworks e.g. MBI-TAC [11]. If the trainee meets minimum standards, they will then be certified to teach MBCT. There will be a continuing development programme for qualified therapists.
In order to run the training effectively, the following resources are proposed:
The total cost of the project is calculated at slightly under £155,000 per year – see Appendix 1. There is the additional cost for health boards of releasing staff for training and supervision. There are precedents for this staff release e.g. in CBT and DBT, and modality-specific supervision is recognised through the NES specialist supervision training system.
With this resource, we would expect to train and support 20 new therapists across Scotland in the first year and – subject to review – in subsequent years. The distribution of these will reflect population and deprivation levels. If each new therapist runs two courses per year, it is anticipated that the number of patients treated with mindfulness will increase incrementally by 300 patients per year (allowing for a therapist attrition rate of 10%). This means that, over the first 3 years of the project, over 5,000 extra patients will have received mindfulness therapy. If only 3% of these patients would have gone on to receive inpatient treatment, the cost of the whole proposed project will be recouped by prevented hospital costs (see appendix 3).
We have been in discussion with the NHS-based South of Scotland CBT Course, and there is the potential for collaboration with them.
Outcomes will be audited using standard measures of depression and mindfulness. These will be combined nationally to form an evaluation database.
Authors
Neil Rothwell, Clinical Psychologist, Joint NES Mindfulness Lead
Lucy Gamble, Clinical Psychologist, NHS Greater Glasgow & Clyde
Margaret McLean, Counselling Psychologist, NHS Grampian
Vee Freir, Clinical Psychologist, Joint NES Mindfulness Lead
Fiona Clague, Clinical Psychologist, formerly NHS Tayside.
Karen Fenna, Art Psychotherapist, formerly Joint NES Mindfulness Lead
For the Scottish NHS Mindfulness Network.
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0.6 |
Co-ordinator |
42006 |
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0.4 |
Administrator |
10070 |
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1.2 |
wte local leads |
84012 |
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Travel |
1000 |
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Materials |
500 |
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Room hire |
6000 |
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Accreditation |
3000 |
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Training for mentors |
4000 |
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Equipment |
3000 |
including laptop and phones |
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Total |
153587 |
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A supervisor will be allocated to each trainee at the start of the course. The course will take place over one year minimum and can be extended for part-time staff.
1. Day of Silent Practice. Tasks and intentions for the course. Introduction to the use of a reflective journal.
2-5. Core teacher development, similar to what is already offered. There will be 4 days allocated for this, instead of the current 3 (excluding the silent day), allowing a greater degree of spaciousness. Topics will include the core practices, inquiry and feedback.
The trainee will help run an 8-week course, with a mentor, around this point.
6. Principles and rationale of MBCT. Similarities and differences to MBSR. Cognitive aspects of MBCT. Origins of mindfulness. Introduction to the possibility of adapting it for different client groups e.g. child, learning disability.
7. Inquiry skills.
8. Asessment and outcome measurement, including use of the Evaluation/Feedback Procedure and MBI-TAC. Influencing the wider system. Strategies for getting courses started, Admin issues, barriers and facilitators etc (Use of implementation resources). Idea is to get people aware of the practical issues and challenges and to engage with necessary managers/colleagues in their own workplaces to address these issues before the end of the course
9. Group skills and risk management. encouraging peer support within groups, Overview of issues in adapting MBCT/MBSR to different populations, what adaptations exist and evidence base (student presentations?),
10. Specific meditations: loving-kindness, mountain, lake. Poetry. Ending groups, follow ups and maintenance of practice, Reflecting on learning and next steps
Trainees should participate on a suitable training of 5 days or more. If a trainee has problems attending one of these, it can be discussed with the supervisor.
At the end of the course, the trainee will assist an experienced teacher to run a course. The teacher will act as mentor and will use the Evaluation and Feedback Process and/or the MBI-TAC to provide feedback to the trainee.
References
[1] Kuyken W, Warren FC, Taylor RS, et al. Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials. JAMA Psychiatry. 2016 Jun 1;73(6):565-74.
[2] Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet Oncology 2007;370(9590):851-58.
[3] Carlson EL. Mindfulness-based interventions for physical conditions: a narrative review evaluating levels of evidence. ISRN Psychiatry 2012;DOI: 10.5402/2012/651583.
[4] A Route map to the 2020 vision for health and social care. Scottish Government, May 2013, p.9.
[6] Scottish Intercollegiate Guidelines Network, Non-Pharmaceutical Management of Depression in Adults. Guideline 114, 2010.
[7] NHS Education for Scotland, The Matrix: A Guide to Delivering Evidence-Based Psychological Therapies in Scotland, 2015.
[8] Kuyken W, Hayes R, Barrett B, et al., Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015; 386(9988): 63-73.
[9] Kabat-Zinn, J.; Lipworth, L.; Burncy, R.; Sellers, W., Four-Year Follow-Up of a Meditation-Based Program for the Self-Regulation of Chronic Pain: Treatment Outcomes and Compliance.
The Clinical Journal of Pain: 1986; 2 (3).
[10] https://www.mindfulnessteachersuk.org.uk/pdf/UK%20MB%20teacher%20GPG%202015%20final%202.pdf
[11] http://oxfordmindfulness.org/wp-content/uploads/2017/05/Download-here-9.pdf
The Scottish NHS Mindfulness Network supports and co-ordinates the delivery of Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) for patients and staff throughout mainland Scottish NHS Health Boards. It is supported by NHS Education For Scotland. It has a developed pathway for therapist training and supervision. Mindfulness courses are delivered to patients (with depression, anxiety, chronic pain, other mental and physical health conditions) and to staff (for managing stress and fostering wellbeing). The Scottish NHS Mindfulness Network is a member of the British Association for Mindfulness-Based Approaches (BAMBA). BAMBA upholds standards across the UK through their Good Practice Guidelines and listing of mindfulness therapists. The Scottish NHS Mindfulness Network consist of 2 National Co-ordinators, and up to 2 Mindfulness Leads for each of the 11 mainland Health Boards.
https://learn.nes.nhs.scot/40297/scottish-nhs-mindfulness-network
The provision of Mindfulness-Based interventions varies across Health Boards. The areas with strongest provision, have good managerial support, an active mindfulness lead with allocated time within the job role, localised training of mindfulness therapists including a forward plan to enhance sustainability of teams who are delivering mindfulness in localities across the Health Board. Some Health Boards have limited or no provision. Factors which have contributed to this include loss of managerial support or changing priorities; loss of a mindfulness lead, or a lead who has limited support / time in their job plan; the retirement of key mindfulness therapists / influencers; lack of investment in the sustainability of a service including the training of suitable staff.
If a Health Board no longer has a mindfulness service operating, it can be a challenge to get it re-started again. This guide is intended to support areas to offer mindfulness-based interventions who will need to re-build capacity. It can be used alongside the decision-making process outlined in the Matrix using the hexagram tool.
Go to www.matrix.nhs.scot and search for Mindfulness.
The hexagon tool has been introduced to assist services in deciding if a particular therapy intervention is suitable and fitting for a health board area. It comprises six domains. The domains of evidence, supports and usability are summarised for each intervention and rated in terms of strength (from 1-5). The other three domains of fit, capacity and need offer guided questions to enable a team to facilitate discussion to support implementation decision making.
Mindfulness-based interventions (MBSR / MBCT) have strong ratings for EVIDENCE, USABILITY and SUPPORTS (using the strength of the network). The hexagon tool can support the decision-making process in terms of NEED and FIT.
Could mindfulness-based therapies meet a clinical / wellbeing need in your service? Are they a good fit? Would you like to develop or restart a mindfulness-based service for patients / staff wellbeing? Do you have staff keen to receive training?
This paper will focus particularly upon the domains of CAPACITY and SUPPORT. The aim is to assist health board and service areas to get mindfulness-based delivery off the ground again in situations where it has become particularly limited or where it has ceased to operate. It will look at the conditions and supports which are necessary to maintain a service to sustain capacity. It will look at capacity building in terms of the selection and training of staff and the support available through the Scottish NHS Mindfulness Network, following their recommended training pathway for Mindfulness Therapists.
Building Capacity: The Training Pathway in Mindfulness-based therapy
Using the SUPPORT of the network
https://learn.nes.scot/40297/scottish-nhs-mindfulness-network; Network co-ordinators: Neil Rothwell (neilrothwell33@gmail.com), Charlotte Procter (charlotteprocter2000@gmail.com)
APPENDIX
The following lists a few of the recommended courses and practice opportunities which can be accessed outside of the NHS. This list is not exclusive and there may be other opportunities in your locality. The network coordinators or mindfulness leads will be able to advise on their suitability.
The Mindfulness Project offers regular online 8-week mindfulness courses (MBSR / MBCT) delivered by experienced teachers (include a day of practice). Cost £295 per person trained.
https://www.londonmindfulness.com
The Highland Mindfulness Groups is a registered charity and has supported the delivery of courses to the NHS in Grampian and the Highlands. It offers 8-week MBSR courses delivered on Zoom. Courses are free to local people and cost £125 to other participants. They also offer monthly meditation days and residential retreats.
https://highlandmindfulness.co.uk
Mindfulness Sussex delivers 8-week courses on Zoom (MBSR / MBCT-L). The £260 fee includes an orientation session, the 8 weekly sessions, a 6 hour retreat of intensive practice, audio downloads and a course handbook. The teacher, Ed Halliwell is registered on BAMBA.
https://mindfulnesssussex.co.uk
Clear and Mindful (Claire Hartwell) delivers 8-week MBSR courses online (otherwise based in Argyll). The cost is £195 for the 8 weekly sessions plus an additional £50 for a half day practice session.
https://clearandmindful.co.uk
Mindfully Being are able to offer a bespoke training for a group of participants in a health board or service area. Courses have been offered within NHS Lothian at a cost of £3000 for an 8 week course.
Other mindfulness trainers may be available to offer bespoke courses and this may be more cost-effective than sending participants onto individual courses.
Contact Charlotte Procter, Neil Rothwell or any mindfulness lead in the Scottish NHS Mindfulness Network.
Palouse Mindfulness developed by Dave Potter, MBSR teacher from University of Massachusetts Medical School. A free pre-recorded online self-paced MBSR course with guided meditations, teaching materials, resources including TED talks from world renowned teachers. Optional live Zoom meditations and discussion meetings / Facebook group to accompany you on the course.
https://palousemindfulness.com
Breathworks Community of Practice: Space to Breathe – live meditations every Tuesday evening at 7 pm with Vidyamala on Zoom (past recordings available on YouTube).
https://www.breathworks-mindfulness.org.uk/live-tuesday-meditations-with-vidyamala
Mindfully Being: “Mindful Tuesdays” - online free meditation with Dr. Avinash every Tuesday from 7.30 – 8 am on Zoom.
Oxford Mindfulness Foundation offer two free daily online mindfulness sessions (Monday to Friday), 1.00 – 1.30 pm and 7.00 – 7.30 pm. They offer free monthly guest talks / CPD workshops on the application of mindfulness.
https://www.oxfordmindfulness.org
The Mindfulness Association offer daily live practice sessions on Zoom at 10.20 – 11.00 am and 7.00 – 8.00 pm.
https://mindfulnessassociation.net
The Mindfulness Network, a UK based mindfulness-teacher training organisation offer free online practice sessions (mindfulness and compassion based) under the Community of Friends on Fridays 8.15 to 8.45 am.
https://home.mindfulness-network.org
One day, weekend or week long workshops are opportunities for more intensive practice to deepen your experience of mindfulness. It is recommended that a mindfulness therapist engages in some deeper mindfulness practice on an annual basis. BAMBA recommends a minimum of 5 days each year. These could be taken individually if that best suits your personal / family circumstances. Many workshops / day practice events are available online. Attending a live event with an experienced teacher would be particularly beneficial.
Many of the organisation mentioned in this guide will offer retreat / practice opportunities. Other suggestions include Gaia House (https://gaiahouse.co.uk); Holy Isle (https://www.holyisle.org); The Mindfulness Association (https:www.mindfulnessassociation.net); Mindfully Being (https://mindfullybeing.co.uk); Living Mindfulness (https://www.livingmindfulness.net).
Mindfulness Scotland offers a one-year Mindfulness Teacher Training Course in MBSR / MBCT, delivered in a hybrid format with face to face teaching at the Maggie’s Centre, in Glasgow. It is accredited by BAMBA and appropriate for Health and Social Care professionals. It includes 7 training days, one of which is a specialist workshop, and an online weekend retreat. Hosted online peer support groups meet between teaching days for skills development and participants can attend regular online practice sessions. Cost £1, 750.
www.mindfulnessscotland.org.uk
Mindfulness UK offers an online teacher training course in MBSR (12 months minimum), which includes teaching days in a virtual classroom (35 hours), a specialist workshop, five days of silent retreat, supervision of two led courses leading to registration as a teacher on the BAMBA website. A portfolio is submitted which logs personal practice and reflections on the learning journey. Cost £1, 465 for initial course; £495 supervision for two taught courses.