Jones, F.

Marx, R.

English

Canterbury Research and Theses Environment

Canterbury Christ Church University’s repository of research outputshttp://create.canterbury.ac.ukPlease cite this publication as follows: Marx, R and Jones, F. W. (2017) The path of mindfulness: an NHS case example. Healthcare Counselling & Psychotherapy Journal. pp. 18-21. ISSN 1475-0724. Link to official URL (if available):This version is made available in accordance with publishers’ policies. All material made available by CReaTE is protected by intellectual property law, including copyright law. Any use made of the contents should comply with the relevant law.Contact: create.library@canterbury.ac.uk  Strap: BEST PRACTICE Headline: THE PATH OF MINDFULNESS: AN NHS CASE EXAMPLE   Introduction: ROBERT MARX AND FERGAL JONES SHOWCASE THE WAY IN WHICH INNOVATIVE MINDFULNESS PROGRAMMES CAN ENHANCE MENTAL HEALTHCARE PROVISION WITHIN THE NHS  Pull quotes:  Mindfulness is seen as providing a way of developing a new relationship to our experience: an open, curious, warm embrace of the moment-by-moment unfolding of our lives, including both the pleasant and painful While the inclusion of MBCT in NICE guidelines means that it has been approved as an intervention to be offered by the NHS, implementation across the health service is patchy For most people deeply involved in mindfulness, this is not just a job, but rather it draws on deeply held personal values and experience  [COPY BEGINS] ‘Traveller, there is no path; the path is made by walking.’ (Antonio Machado)1  Mindfulness provision in UK healthcare In recent years there has been a rapid growth of interest in secular mindfulness-based interventions (MBIs). In this article we provide a brief history and overview of these interventions and their evidence base. We then present an example of how we have implemented and developed mindfulness provision within our NHS trust, in the hope that this might be of some help to others working towards the same end. Jon Kabat-Zinn, a leading teacher in this field, has described mindfulness as 'paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.’2 People have been practicing mindfulness for at least 2,500 years, often in a Buddhist context. In the 1970s, Jon Kabat-Zinn realised that these practices could be developed into a secular course designed to help alleviate the suffering of people experiencing chronic illness, pain and stress.2 He named this mindfulness-based stress reduction (MBSR). Then, in the 1990s, Zindel Segal, Mark Williams and John Teasdale drew on MBSR and cognitive therapy to develop mindfulness-based cognitive therapy (MBCT), a relapse prevention programme for people who had previously experienced recurrent episodes of depression.3 There are a number of other MBIs, which are frequently adaptations of MBSR or MBCT for particular client groups. Examples include the Breathworks programme for people experiencing   chronic pain, Mindfulness-Based Relapse Prevention for people with addiction problems, and Mindfulness-Based Childbirth and Parenting. Our main focus here is on MBCT and MBSR. In their usual format, both MBCT and MBSR are eight-week, group-based interventions. The heart of these courses is mindfulness practice: both ‘formal’ mindfulness meditations, such as the body-scan, mindfulness of the breath and mindful movement; and ‘informal’ practices, such as mindfulness in everyday life. During sessions, participants are invited to take part in such practices and to discuss their experiences of them, and for homework, participants are expected to practice mindfulness daily.  Not infrequently in the mainstream media, mindfulness can, somewhat unhelpfully, be presented as a way of clearing our minds or creating a special state of mind. The emphasis in MBCT and MBSR is different. Mindfulness is seen as providing a way of developing a new relationship to our experience: an open, curious, warm embrace of the moment-by-moment unfolding of our lives, including both the pleasant and painful. This way of relating has been shown to help alleviate stress, prevent depressive relapse and increase wellbeing, through helping us to disengage from worry and rumination, and through the development of greater self-compassion.  Consistent with this thinking, there is good evidence from randomised controlled trials that MBCT reduces the chances of depression returning for people who have experienced recurrent depression but are currently in remission.4 This had led to its inclusion in the NICE guidelines for depression, from 2004 onwards, for this purpose.5 The effectiveness of MBSR at improving wellbeing is also supported by research trials.6 Moreover, recently there has been interest from MPs and peers in the UK parliament in the benefits that mindfulness can bring to healthcare and society, culminating in the publication of the Mindful Nation UK report.7  However, while the inclusion of MBCT in NICE guidelines means that it has been approved as an intervention to be offered by the NHS, implementation across the health service is patchy,8 with there being relatively good provision of MBCT in some areas and little or no provision in others.  The roll-out of MBCT within the NHS also brings with it the challenge of maintaining its quality and safety as it is made more widely available. Mindfulness is not a risk-free enterprise. For example, people with trauma histories can be very easily triggered into flashbacks and other dissociative experiences by some mindfulness exercises. There are now national Good Practice Guidelines (GPG) on minimum standards needed to teach, supervise and train others in MBCT, MBSR and other eight-week programmes.9 Teachers who meet the GPG can now apply to be registered on the UK Listing of Mindfulness Teachers.9   We now present an account of how we have implemented MBIs within our NHS Trust. We hope that this may be of some use to others who are making a similar journey.  A case example of mindfulness implementation in an NHS Trust (Sussex Partnership NHS Foundation Trust)    Although lone individuals had been offering MBCT groups in Sussex to staff and patients since 2004, with some staff offering mindfulness meditation since long before then, we had all been working rather in isolation, fired up by a passion about the benefits of the approach from both personal and professional experience. Sussex Mindfulness Centre (SMC)10 was formed in 2012, when we brought together those of us involved in mindfulness research, teaching and training in Sussex Partnership NHS Foundation Trust. Together, we realised that we could all enhance each other’s work.  Researchers could have easier access to clinical populations by working more closely with clinical colleagues; mindfulness clinicians had a pool of expertise they could draw on to evaluate the effectiveness of the work they were doing; and trainers could supply trained teachers able to provide the mindfulness interventions.   Furthermore, we found that this collaboration allowed us to develop and research innovative adaptations of MBCT and MBSR with populations who would not normally receive a mindfulness intervention and see if the approach could be of benefit to more people. With research colleagues at Sussex University and Canterbury Christ Church University, the SMC research lead, Dr Clara Strauss, has been prodigious in leading numerous funded trials. For example, we have developed and piloted a four-week mindfulness group with shorter, more grounding practices for people with serious and complex mental health problems, including bipolar disorder and personality disorders; we have researched the use of mindfulness within a programme for people who hear voices; we have provided a number of adapted MBCT groups to people with dementia and their carers; we are currently offering a mindful sea-swimming course; we have adapted MBCT to include kindness and compassion-oriented practices to see if this could be helpful to staff in the Trust. In this way, we are able to not only use the evidence base but also to contribute to it. SMC has produced over 30 peer-review research publications in the last three to four years. In addition to the more innovative research, we are able to evaluate all MBCT groups we run in all services for both patients and staff using a centrally collated pack of quantitative and qualitative questionnaires. Since 2011, we have been offering a year-long foundation training to enable staff to deliver the eight-week MBCT/MBSR programmes. More recently, we have also been offering a second training in adapted mindfulness-based interventions directed at people who want to offer shorter mindfulness interventions than the eight-week courses. These might include mindfulness drop-ins on psychiatric wards, mindfulness within individual therapy, mindfulness with populations where adaptations are needed, such as with people with learning disabilities or children, and mindfulness in prisons. The trainings have drawn in a mixture of Sussex Partnership staff and people from other NHS Trusts, community organisations and private individuals. We use an apprenticeship model of training11 that has a heavy emphasis on personal mindfulness practice, and on learning through teaching in front of, or alongside, more experienced teachers.   We now have 40 trained mindfulness teachers working for Sussex Partnership working in adult mental health, at primary and secondary levels, in child and young people’s services, in older people’s   services, and more recently in forensic and learning disability services. To our knowledge, this represents the largest grouping of trained mindfulness teachers anywhere in the NHS. One of the delights of this is that it can sometimes feel that this group and its associates forms a small but distinctive and appreciative culture where people often feel at home. We have been keen to develop this sense of community to include the wider mindfulness community locally and this happens at such events as our annual conference, our day and week-long retreats and a new regional bi-monthly meeting of mindfulness teachers.      Mindfulness has been a recurring plank of the trust’s staff wellbeing policy. We have had about 370 staff complete eight-week adapted MBCT groups and these have been shown to reduce staff stress, and increase self-compassion and wellbeing.12 Trials are also underway to recruit more than 2,000 staff across the region to participate in a trial evaluating the effectiveness of the online mindfulness app, Headspace. In a separate study, the intention is for 90 trust staff to be offered mindfulness self-help books to see if this could help.    In the last few years, we have become more outward facing, allowing us to be informed by, and contribute to, national developments in mindfulness. One of our trainers is currently the chair of the UK Network of Mindfulness-based Teacher Training organisations. Our service users, teachers and trainers all contributed to the evidence provided to the All Party Parliamentary Group on Mindfulness with Drs Clara Strauss, Bridgette O’Neill and Kate Cavanagh writing the health section of the Mindful Nation UK report which resulted from the meetings. We also work with other organisations, such as the Office for National Statistics and our neighbouring NHS trust, providing mindfulness groups for their staff.   A large scale study, ASPIRE, which looks into the implementation of mindfulness in the NHS, is soon to be published by Professor Willem Kuyken and colleagues at the University of Oxford. Their work shows that we are by no means alone in developing mindfulness in our NHS trust and there are great examples of heroic championing of mindfulness in the NHS in such places as South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust, Nottinghamshire Healthcare NHS Foundation Trust, Tees, Esk and Wear Valleys NHS Foundation Trust, and in the NHS in Scotland. Our own experience is that there have been three elements that have been key to implementation so far. Firstly, it has been essential to have both ‘top down’ support – in our case from a number of people at director level – combined with individual clinicians who are willing to champion the approach and go the extra mile to make it happen. For most people deeply involved in mindfulness, this is not just a job, but rather it draws on deeply held personal values and experience. We have been extremely lucky to have had support for mindfulness at all levels of the organisation and the combination of strategic endorsement and on-the-ground passion has worked well.   Secondly, the research has been absolutely crucial to successful implementation. It was the inclusion of MBCT in the NICE guidelines in 2004, and the plethora of research that has come since, that opened the doors in the UK for mindfulness to transition from being a fringe activity to the current place of MBCT as a mainstream treatment for recurrent depression. At a local level, it has been our   own evaluation and research into everything we do that allows us to innovate safely, and establishes the legitimacy of what we are doing and what we seek to develop.    The third key element of the implementation of mindfulness for us has been collaboration. There are so many people without whom we would not have even reached the starting line. We owe a tremendous debt of gratitude to our colleagues in other mindfulness centres nationally, such as Bangor and Oxford, who have been our mentors, supervisors and trainers; to our local community of deeply experienced mindfulness practitioners and trainers who have shown amazing commitment to the NHS;  to our academic colleagues in neighbouring universities who have offered invaluable expertise; to our ex-service user ‘advocate’ group that has shown great courage in speaking out in many different forums about their experiences with mental health and mindfulness; and internally with our colleagues in many different departments and services who have taught mindfulness or paved the way for others to do so.   We face the same problems that occur nationally with equitable provision across geographical areas and services, and in maintaining the safety and integrity of the approach. We want to harness people’s enthusiasm to teach MBIs while giving a clear message that they should only be delivered by those who have been properly trained. In such lean times, the financing of our work is also challenging. We have had tremendous support from our Education and Training Director and our Research Director. However, most of what we do is financed by self-generated income. Research work is financed by research grants from external bodies, and training costs are met by external fee-paying individuals and organisations. It can feel like running a business within an organisation and this calls on us to be both entrepreneurial and cautious. In these very stretched times, this dependence of income generation can make everything we have built up feel fragile and precarious. It creates interesting tensions between our ethos and motivation to provide mindfulness services in order to benefit clients, and not for profit; whilst having to generate income to survive.     Conclusion Mindfulness has seen a meteoric rise in awareness over the last ten years, with a huge proliferation of research leading to a presence in the media, in parliament and in the NHS. However, this has translated into rather patchy provision across the UK, and has generated tensions between a desire to increase access to mindfulness-based approaches and the need to maintain standards for teaching and training to ensure integrity, quality and safety. Sussex Mindfulness Centre has been very fortunate in being able to bring together mindfulness research, practice and training to offer a range of evidence-based and innovative mindfulness interventions. It is built on good quality research and training, on a wide network of collaborations with skilled and highly motivated colleagues within the organisation and around it, on a significant dose of good luck that the people needed at all levels could come together at the same time, and on a clear intention to benefit those that this approach can reach.       Acknowledgments We would like to acknowledge the huge contributions of Clara Strauss, Karunavira, Taravajra, Bridgette O’Neill, Cate Kavanagh, Adrian Whittington, Mark Hayward, and many others, to the work of the Sussex Mindfulness Centre.    Biography Dr Robert Marx is co-lead for the Sussex Mindfulness Centre with responsibility for mindfulness training and governance. He is a consultant clinical psychologist and cognitive-analytic psychotherapist working for Sussex Partnership NHS Foundation Trust where he is involved in training, delivering and supervising mindfulness-based and cognitive-analytic therapy work.    Dr Fergal Jones is a Reader in Clinical Psychology at Canterbury Christ Church University, and works in Health in Mind, an IAPT service run by Sussex Partnership NHS Foundation Trust and Turning Point, where he provides supervision to mindfulness teachers and cognitive behavioural psychotherapists. With others, he is currently researching self-help MBIs.   REFERENCES 1 Machado A. Proverbios y cantares XXIX [Proverbs and songs 29], Campos de Castilla; 1912. Translation: Craige BJ. Selected Poems of Antonio Machado. Louisiana: Louisiana State University Press; 1979.  2 Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York: Bantam Dell; 1990. 3 Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse (2nd ed). New York: Guilford; 2013. 4 Kuyken W, Warren FC, Taylor RS, Whalley B, Crane C 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; 73, 565–574. 5 National Institute for Health and Care Excellence (NICE). Depression in adults: recognition and management. [Online.] NICE. 2016. https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#continuation-and-relapse-prevention (accessed 2 February 2017).  6 Khoury B, Sharma M, Rush SE, Fournier C. Mindfulness-based stress reduction for healthy individuals: a meta-analysis. Journal of Psychosomatic Research 2015; 78, 519–28.    7 Mindfulness All-Party Parliamentary Group. Mindful nation UK. London: The Mindfulness Initiative; 2015. 8 Crane RS, Kuyken W. (2013). The implementation of mindfulness-based cognitive therapy: learning from the UK health service experience. Mindfulness 2013; 4, 246–254. 9 UK Network of Mindfulness-based Teacher Training Organisations. Good practice guidelines for teaching mindfulness-based courses. [Online.] UK Network of Mindfulness-based Teacher Training Organisations; 2015. http://mindfulnessteachersuk.org.uk/index.html#guidelines (accessed 22 January 2017). 10 Sussex Mindfulness Centre (SMC). Mindfulness governance. [Online.] Sussex Mindfulness Centre; 2017. http://www.sussexpartnership.nhs.uk/mindfulness (accessed 25 January 2017). 11 Marx R, Strauss C, Williamson C. Mindfulness apprenticeship: a new model of NHS-based MBCT teacher-training. Mindfulness 2015; 6(2): 253–263.  12 Marx R, Strauss C, Williamson C, Karunavira, Taravajra. The eye of the storm: a feasibility study of an adapted Mindfulness-based Cognitive Therapy (MBCT) group intervention to manage NHS staff stress. The Cognitive Behaviour Therapist 2014; 7: 1–17.  READER RESPONSE The authors would welcome feedback on this article. To contact them, please email robert.marx@sussexpartnership.nhs.uk or fergal.jones@canterbury.ac.uk    

The path of mindfulness: an NHS case example

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The path of mindfulness: an NHS case example

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