Clinical Handbook of Mindfulness (122 page)

depressed patients, who show some behaviors during mindfulness groups

that are totally different from the ones they have in all other conditions and

environments.

Chapter 24 Mindfulness-Based Interventions in an Inpatient Setting

451

Heterogeneity during the sessions can also allow patients to feel a

sense of “normality” of the experience of suffering (human condition

implies/includes suffering) regardless age, diagnosis, symptoms, and so on.

This is especially true because during mindfulness group sessions, the

instructor never talks about the specificity of the disorders, but always

explains that each person has different ways of manifesting suffering all of

which have a common origin (attachment, aversion, delusions and distor-

tions, automatic pilot, judgement, etc.) and that each individual’s own form

of suffering is probably only quantitatively different, and not necessarily qual-

itatively different, from that of people with different disorders and of people

without clinical problems.

The Importance of Regular Practice

Developing mindfulness skills is not easy and requires the regular practice

of meditation. When working with severe disorders, it is important to bear

in mind that these patients are generally not used to doing meditation and

often they don’t even know what meditation is. It is important to explain to

patients that mindfulness can be considered a therapeutic skill, connected

in various ways to their problems, and that as is the case all new abilities,

regular practice is required in order to learn the new skill. A useful analogy

for patients is that of athletes: when a person wants to learn a new sport,

they have to train regularly, with the help of a coach or trainer in order to

face the challenges that the competition (life) will present them with.

One of the basic strategies for dealing with the chronic difficulties inpa-

tients have with doing meditation is to provide them with guided regular

practice of mindfulness on a daily basis. This is particularly important with

challenging patients because they find it hard to feel motivated and willing to

practice alone. This is important because empirical observation and clinical

experience show that the more patients do formal and informal meditation,

the more stable and beneficial the effects of the meditation practice. One way

to help inpatients learn to practice meditation regularly (if possible even after

discharge) is to provide them with a half hour of guided mindfulness practice

early in the morning and another half hour late in the afternoon. This allows

patients to understand that mindfulness is not just a simple technique, but

rather that it could become a regular way of being which can affect/condition

their emotional states and give them a sense of calm and balance all day long.

This kind of daily practice should be guided, if possible, by a healthcare

professional (psychologist, psychiatrist, nurse, social worker), but in the

absence of professional resources even by an intern or practitioner who can

use a recorded mindfulness exercise (audio tape, audio CD) and just coordi-

nate and check the state of patients during the practice. Daily practice can

be a powerful and helpful complement to the weekly mindfulness sessions

with the instructor.

Problem Formulation in Inpatient Treatment

Other chapters in this book (see Chapters 5 and 11) have already highlighted

the importance in clinical application of mindfulness of sharing a clear con-

ceptualization of the patient’s problem as well as a clear understanding of

452

Fabrizio Didonna

the clinical mechanisms of change of mindfulness that can help modify the

activating and maintaining factors that are highlighted in the problem for-

mulation. This becomes even more important during inpatient treatment in

which patients are receiving several different kinds of therapeutic interven-

tion and may have difficulties understanding the meaning and rationale of

each one and their coherence and integration. Problem formulation is also a

helpful tool for developing and enhancing motivation for mindfulness prac-

tice inside and outside group sessions.

Problem formulation can be shared during individual sessions before start-

ing the mindfulness training and also by using special sheets and verbal

descriptions or explanations during group sessions.

An example of mindfulness-based problem formulation is that done with

patients suffering from BPD, which is one of the most frequent diseases

found in inpatient treatment, often in comorbidity with other problems.

In order to allow borderline patients to understand the power, poten-

tial and relevance of mindfulness intervention, it is helpful to share a

cognitive-behavioral conceptualization of the borderline crises with patients

(Figure 24.1). After the occurrence of an impulsive crisis characterized by

different maladaptive behaviors (such as self-injury, substance abuse, suici-

dal attempts), in time patients experience a stage of remission from the

symptoms, which is here called “
temporary calmness
.” Then, at a certain

moment some specific events (such as invalidating experiences or messages,

abandonment or exclusion behaviors on the part of others, traumatic mem-

ories, etc.) can arise and consequently the patients activate and perceive

several inner changes at emotive (guilt, anger, disgust, feeling of emptiness

shame), cognitive (flashes, rumination) or physical bodily sensations con-

nected to past abuse, hyper-arousal levels. These perceived changes are eval-

IMPULSE DYSCONTROL/ MALADAPTIVE BEHAVIOURS

(self-harm, substance abuse, suicidal attempts, etc.)

Activating

REMISSION (‘temporary calmness’)

Factors (e.g.

invalidating experiences)

Perception of private experience/inner changes

EMOTIONAL

COGNITIVE

SOMATIC

(e.g. anger, shame, disgust,

(traumatic memories, flashes,

(sensations in ‘critical’ body

guilt, feeling of emptiness)

worries, rumination)

parts, hyper-arousal, etc.)

State of Mindfulness-‘Being Mode’

Meta-evaluation – Self-Invalidation

Misinterpretation of changes as

‘uncontrollable’, ‘unacceptable’, ‘wrong’ , ‘too painful’, or ‘self-related’

Emotional Dysregulation

‘Doing Mode’: Acting to shut out or escape

Dissociative states

from emotions, sensations, thoughts

Figure. 24.1.
The hypothesized role of mindfulness-based interventions with

respect to the process of crisis activation in borderline personality disorder.

Chapter 24 Mindfulness-Based Interventions in an Inpatient Setting

453

uated (meta-cognition) in terms of “
uncontrollable, intolerable, unaccept-

able
,
very painful
or
self-related
(which means that patients identify them-

selves with those contents)” experiences and they may also self-invalidate

their own inner states. This misinterpretation and/or self-invalidation acti-

vate
emotional dysregulation
(Linehan, 1993),
a psychological state characterized by chaotic and uncontrollable feelings and confusion. This state

normally leads patients
to react
(and not to ‘respond’) by activating a “doing

mode” in which they (differently from depressed patients who are generally

unable to act) tend to act in order to shut out or escape from the intolera-

ble emotions, sensations, or thoughts. The only way that borderline patients

know how to act in order to deal with this experience is by escaping from the

subjectively terrifying and unacceptable reality through dissociative states or

by activating maladaptive behaviors, thus leading them into a new
borderline

crises
, and the vicious circle is maintained.

The Author hypothesizes that mindfulness-based interventions can

help these patients on a first level by helping them prevent or stop each

meta-evaluation that they tend to activate regarding the distressful private

experience (emotions, thoughts, sensations) that arises. On a second level,

indirectly, mindfulness states help patients to prevent or neutralize the con-

sequent emotional dysregulation also because they are trained to not react

immediately to a negative experience when one occurs but rather to
observe,

describe and stay in touch with it, accepting it as it arises without judging
.

Doing so they can learn to avoid starting the vicious circle that leads to fur-

ther impulsive crises or avoidant behaviors (e.g., dissociation). They can do

this using decentering, defusion and disidentification as cognitive styles and

modes and using acceptance as well, learned through mindfulness training.

Clinical observation during group sessions shows that mindfulness-based

interventions, in particular in inpatient treatment, can help patients with

impulse dyscontrol problems (e.g., BPD) to learn a different
mental style and

metacognitive attitude
toward problematic and emotional states, sensations

and cognitions which are incompatible with the impulsive and maladaptive

behaviors (self-harm, binge eating, substance abuse, etc.) that patients use

to deal with these states. Other important effects have been highlighted

by
Linehan (1993; Linehan, Armstrong, Suarez, Allmonn, & Heard
,
1991),

who included in her cognitive-behavioral model for borderline patients –

dialectical-behavior therapy – an important component of mindfulness-based

intervention (see also Chapter 13 of this volume). This kind of training can

increase attention control, improve awareness of self and others, reduce

emotional reactivity, provide a foundation for self-validation, and reduce feel-

ings of emptiness and self and cognitive dysregulation.

The use of metaphors in the context of mindfulness groups (such as

thoughts like clouds in the sky
or
seeing emotions or cognitions like a

waterfall
) could also be helpful in helping patients stay in touch, decenter

and overcome the distressful private experience.

It has been observed that in order to help borderline patients, especially

those with severe problems, to learn mindfulness skills, it is useful to pro-

vide specific inpatient mindfulness-based groups in which individuals can

find a setting that better allows them to overcome, step-by-step, the unavoid-

able difficulties that they would normally find in practicing formal meditation

exercises in outpatient settings.

454

Fabrizio Didonna

Clinical Goals in a Mindfulness-Based Inpatient Program

Within inpatient psychiatric units where there are patients suffering from

mood disorders, anxiety disorders and problems related to impulsivity (e.g.,

BPD, bulimia nervosa) the goals of mindfulness training are:

—

to help individuals diagnosed with
major depression
(during par-

tial remission or a moderate/not acute symptomatic phase) to learn

the skills that will help them to deal effectively with dysphoria and

changes in their mental states and to stop and prevent rumination and

possible subsequent relapse;

—

to train patients who have problems
controlling impulses
(e.g., BPD)

adopt a different
mental style and metacognitive attitude
toward

problematic emotional states, sensations and cognitions, incompati-

ble with impulsive and maladaptive behavior (self-harm, binge eating,

substance abuse, etc.) or experiential avoidance (flight, dissociation,

etc.) that patients use to deal with these states;

—

to help patients with
anxiety disorders
(panic, generalized anxiety

disorder, obsessive-compulsive disorder) to develop a new and more

functional mental attitude (observation, acceptance and decentering)

toward their own physical symptoms and, in general, toward their

inner experience.

In general, all inpatients, regardless of the diagnosis, are trained to observe

and intentionally become aware at all times of their thoughts, body sensa-

tions and emotions, being and remaining in the present time, developing a

different way of relating to their private experience. More specifically, they

are trained to acquire and develop the capacity to
recognize
and
consciously

accept
without judging (not “turning away” and not “attachment”) undesired

emotions and thoughts as an alternative to activating their customary, auto-

matic, pre-programmed modes, which tend to perpetuate their psychiatric

problems. Furthermore, patients learn how to acquire the capacity to choose

the most effective response to any unpleasant thought, sensation and situa-

tion that they may encounter (i.e., responding vs. reacting, shifting from a