Mindfulness and Occupation

This blog post is inspired by the forthcoming #occhat on Mindfulness and Occupation (Tuesday 28th August, 8-9pm BST, follow #occhat on Twitter) as well as numerous discussions on Twitter, particularly in #BPDchat, #OTalk and #occhat, on the nature of the relationship between Mindfulness and Occupation. The first part is designed to suggest some related reading and a list of questions to prompt reflection on the topic before the #occhat, the second part in my personal reflection on Mindfulness and Occupation.

Related reading (this list, books in particular, is by no means exhaustive) :

Books

Kabat-Zinn, J (2004) Full Catastrophe Living, How to Cope with Stress, Pain and Illness using Mindfulness Meditation. London: Piatkus

Linehan, M (1993) Skills Training Manual for Treating Borderline Personality Disorder. New York; The Guilford Press.

Journal Articles (with great thanks to @clissa89 who supplied many of these)

Davis, D; Hayes, J (2011) What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy 48 (2), 198–208

Elliot, M (2011) Being mindful about mindfulness: an invitation to extend occupational engagement into the growing mindfulness discourse. Journal of Occupational Science 18(4), 366-376.

Gockel, A (2010) The Promise of Mindfulness for Clinical
Practice Education. Smith College Studies in Social Work 80, 248–268

Grossman, P (2011) Defining mindfulness by how poorly I think I pay attention during everyday awareness and other intractable problems for psychology’s (re)invention of mindfulness: comment on Brown et al.(2011). Psychological Assessment 23(4), 1034–1040

Gura, S (2010) Mindfulness in Occupational Therapy Education. Occupational Therapy in Health Care 24(3), 266-271

Hill, C; Updegraff, J (2012) Mindfulness and its relationship to emotional regulation. Emotion 12(1), 81-90

Reid, D (2008) Exploring the relationship between occupational presence, occupational engagement, and peoples well-being Journal of Occupational Science 15(1), 43-47.

Reid, D (2009) Capturing presence moments: The art of mindful practice in
occupational therapy. Canadian Journal of Occupational Therapy 76(3), 180-188

Reid, D (2011) Mindfulness and flow in occupational engagement: Presence in doing. Canadian Journal of Occupational Therapy, 78 (1), 50-56

Stew G (2011) Mindfulness training for occupational therapy students. British Journal of Occupational Therapy, 74(6), 269-276.

Wright, J; Sadlo, G; Stew, G (2006) Challenge-skills and mindfulness: an exploration of the conundrum of flow. OTJR: Occupation, Participation and Health, 26(1) 25-32

Mindfulness Defined

Mindfulness refers to a person having total awareness of their environment, and requires a person to full participate in and experience life (Kabat-Zinn, 2004). Mindfulness meditation is based on this and involves a determined effort to engage in mindfulness. Such exercises can help develop an automatic mindful awareness of self and environment.

Mindfulness is now a common feature in psychological therapies. Jon Kabat-Zinn created Mindfulness Based Stress Reduction (MBSR), from which Mindfulness Based Cognitive Therapy (MBCT) was derived for people with recurrent depression (MBCT, nd). Dialectical Behavioural Therapy (DBT) is a therapy derived from Cognitive Behavioural Therapy (CBT). It is modified, primarily to suit a client group diagnosed with Borderline Personality Disorder (although has subsequently been applied to other diagnoses), in a number of ways. One of the key points is that DBT focuses on acceptance and validation in the present moment, additionally DBT uses mindfulness as a core skill set, and those engaged in group DBT skills training will repeat the mindfulness module at the end of each other module (Linehan, 1993). For further reflection on the fit of Occupational Therapy with DBT you may be interested to read https://pd2ot.wordpress.com/2012/06/22/dialectical-behavioural-occupational-therapy/ , it also explores the role of occupation to the specific mindfulness skills used in DBT.

Points for Reflection

When I read through the articles listed above I noted a few key points or questions for my own reflection. They might be a useful prompt for pre #occhat reflection.

Focussing on Occupational Therapy Intervention, which incorporates Mindfulness Practice.

Potential Benefit to the Professional

1. A professional who is able to apply a mindful approach to their interventions will be able to ensure they are fully present in the session, aware of the imposition of distracting thoughts and also able to contain and acknowledge their own emotional reactions to, or prompted by, the client.

Potential Benefit to the Client

2. As well as the benefits to the client of having an OT who is fully ‘in the moment’, mindfulness could increase their awareness and understanding of the issues they are facing and communicate this to the OT.

3. A client who can utilise mindfulness practice may maximise the benefit of an OT session. For example, a person who has recently had a traumatic or life-changing illness/injury would be able to recognise that their thoughts were drifting to distress over lost skills and be able to validate the related emotion while bringing their attention back to the task. Similarly, if an occupation resonated with a traumatic experience for a person, implementing mindfulness may mean they are able to have a different, more helpful, experience.

Limitations of incorporating Mindfulness into OT interventions.

4. Mindfulness may not suit every individual and, as with any OT intervention, a client-centred approach needs to be adopted. That said, I considered some client groups that may struggle to engage as a whole. A person experiencing psychosis may find it incredibly challenging to be aware of their thoughts. Reid’s (2009) article discussed the relationship between the Middle Pre-frontal Lobe and appreciation of emotions and feelings, which is inherent to mindfulness. Consequently a person with brain injury to that region would be struggle to engage with mindfulness.

5. Mindfulness is not an easy skill to learn, and it requires frequent practise to become an automatic process and a client must be motivated and choose to engage with this approach.

6. For some clients mindfulness can verge on being a traumatic experience. I have known people who find the experience of not-dissociating from resonant occupations to be painful and prompt extreme self-defeating behaviour. Risk may need to be assessed along with multi-disciplinary team working to have a consistent and contained approach.

7. Training – the OT needs to develop their own skills through appropriate training. As there is little evidence available as to the value of incorporating mindfulness into OT intervention, there is likely to be little funding for such training.

Could the application of Occupational Therapy Theory facilitate greater benefit from Mindfulness Exercises?

8. Will a client find it easier to engage in a mindfulness exercise based on an occupation that holds meaning for them?

9. Conversely, could the meaning of an occupation make the task of engaging in mindfulness too much of a challenge?

10. Could increased levels of mindfulness skill be encouraged by ‘graded’ mindfulness practice, from benign exercises to those which might evoke stronger emotional reactions?

Final Point for Reflection

11. I found myself imagining facilitating an OT intervention and wondered how a mindful approach would compare with implementing Schön’s (1983) ‘Reflection In Action’. I think my initial reaction was to feel that the concepts aligned well, until I considered that thinking about the present moment and what was occurring in it (as in reflection in action) was the antithesis of being fully involved in the moment. So, where does that leave the compatibility of the mindful approach with reflective Occupational Therapy?

Service User Perspective (Mine)

There is a sign in a venue I dance in that states, ‘Please be mindful of the stairs.’ I always chuckle internally and imagine myself sitting down in front of them to observe or describe them, in a true ‘DBT Mindfulness Style’. In many ways, we all are familiar with the concept of ‘paying attention’ or being mindful, just as the creator of this sign wanted people to not have accidents on the stairs due to inattention. As those who have read the rest of my blog posts will be aware I was, initially, a reluctant recipient of both OT and DBT. My lack of engagement also extended to the Core Mindfulness incorporated into DBT. In reading the above articles and reflecting on the points I raised I also considered how I felt about the role of Mindfulness in OT interventions.

As my OT was also my DBT therapist, mindfulness was utilised to manage difficult situations. For example, in supported cooking sessions the OT would encourage me to bring back any thoughts that were disappearing off into ‘judgement land’ and to focus on the task. I also remember struggling with feeling overwhelmed with tasks such as hanging my washing out when I returned to my flat as a day patient. The OT suggested that I mindfully hang out socks, instead of judging myself for racing through the task and ‘performing badly’. It sounds simple, but this approach helped greatly.

I feel quite clear that mindfulness facilitates recovery-focused meaningful occupation. As for the reverse? As part of my individual DBT interventions we started every session with a mindfulness exercise. I believe I found these to be, simply, exercises. It didn’t seem to matter whether I liked the task or not, or if I would choose to do it outside of the session, my ability to engage was more determined by other factors such as mood or events in the Therapeutic Community (TC). I do remember that I found some of the group exercises difficult if they carried specific resonance. For example a game called ‘warp speed count’ had associations with childhood and I found the task of remaining mindful to be too large. However, I can also see a progression, or grading, in both what I could engage with and also what I could contribute to mindfulness. Eventually I was able to fully participate, mindfully, in ‘Warp Speed Count’, so much so that I felt able to lead a mindfulness training session for professionals, using the game as my example. The gradation to this point involved coping with more challenging mindfulness exercises in sessions and taking the lead in individual mindfulness sessions before leading group mindfulness.

References

Kabat-Zinn, J (2004) Full Catastrophe Living, How to Cope with Stress, Pain and Illness using Mindfulness Meditation. London: Piatkus

Linehan, M (1993) Skills Training Manual for Treating Borderline Personality Disorder. New York; The Guilford Press.

MBCT (nd) Mindfulness Based Cognitive Therapy [online]. Available at: http://mbct.co.uk/ [accessed 12 August 2012]

Schön, D (1983) The Reflective Practitioner: how professionals think in action. London: Temple Smith

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