Using Mindfulness to Support Adults with Complex Needs: A Pilot Study


Authors

Dr. Mitchell Clark
Department of Psychology
Mount Royal University
Calgary, Alberta
Canada

Alysha Rae Liew, Calgary SCOPE Society

Ryan Geake, Calgary SCOPE Society

Ken Hatch, Calgary SCOPE Society and

Lesli Peddie, Calgary SCOPE Society

Corresponding Author

Correspondence concerning this article should be addressed to Dr. Mitchell Clark, Canada

Email: Dr. Mitchell Clark

Abstract

This pilot study investigated the use of mindfulness training as a support for adults with complex needs (ACN’s). ACN’s demonstrate a developmental/intellectual disability, in addition to mental illness and/or behavioural concerns, and may be seen as a danger to themselves, others or property. Staff members working with ACN’s were provided mindfulness training sessions twice a week for eight weeks. Two weeks after beginning this training, staff members began mindfulness training of the six participating ACN’s. The staff trainers used a set of 16 scripts developed as guides for training the ACN’s. Both staff and ACN’s completed self-report questionnaires before training (pre), once training was completed (post), and again three months after the training program was completed (follow-up). In addition to the self-report measures, specific prosocial (e.g., acts of kindness or cooperation) and challenging (e.g., acts of aggression or self-injury) behaviours were identified for each of the ACN participants and the frequency of these behaviors were tracked at pre, post and follow-up. While previous research has demonstrated the substantial potential of mindfulness as a valuable support for ACN’s, statistical analyses of the data collected during the study did not indicate any significant changes occurring between the pre, post and follow-up measures. The results did, however, provide the researchers with an opportunity to identify elements of the current study that may have undermined the anticipated positive outcomes. Recommendations include discontinuing the use of self-report measures for ACN’s and more consistent long-term tracking of both prosocial and challenging behaviours.

Introduction

Mindfulness is described by Jon Kabat-Zinn (1994, p.4), as simply "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally." The ability to pay attention and to be non-judgmental can be viewed as a characteristic or tendency that some people demonstrate with greater frequency and facility than others. Mindfulness can be regarded as a disposition or trait which an individual may demonstrate to a higher or lesser degree (Goodall, Trejnowska, & Darling, 2012; Redekop & Clark, 2016; Yu & Clark, 2015). Mindfulness can also be developed and enhanced through exercise and practice. For example, Josefsson, Larsman, Broberg, and Lundh (2011), compared 45 meditators to 47 non-meditators and found that length of meditation enhanced mindfulness which, in-turn, increased wellbeing. The relationship to enhanced wellbeing seen in those with increased mindfulness has led to its use in treating of a number of mental health disorders. In addition a number of mindfulness-based interventions have been developed (e.g., Mindfulness-based Stress Reduction, Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy, and Dialectical Behaviour Therapy) (Keng, Smoski, & Robins, 2011; Spijkerman, Pots, & Bohlmeijer, 2016).

Mindfulness and Mental Health

The effects of mindfulness practice on mental health have been the subject of a number of meta-analyses. For example, Keng et al. (2011), reviewed correlational research that examined the associations between self-report measures of trait-mindfulness or mindfulness-mediation practice and measures of psychological health. They also reviewed 56 randomized controlled trials that used the four mindfulness-based interventions noted above. Additionally, they evaluated a number of laboratory studies that examined the impact of mindfulness induction on mental processes related to emotion such as emotion regulation. Evaluating mindfulness across the three types of studies (correlational studies, clinical intervention studies, and laboratory-based), the authors concluded that mindfulness does support adaptive mental functioning. They suggest that training in mindfulness may produce positive effects including symptom reduction, enhanced subjective wellbeing and behavior regulation as well as reduced symptoms associated with a range of psychological disorders.

Additionally, Goldberg et al., (2018) conducted a meta-analysis of randomized controlled trials of adults with psychiatric diagnoses. One hundred and seventy one articles met the inclusion criteria out of a total of 5,582. For no treatment randomized control conditions and a range of specific treatment controls, mindfulness based interventions were found to be superior. When the control groups were provided an alternative evidence-based treatment, there was no difference. For studies using no treatment control comparisons, mindfulness-based interventions demonstrated greater disorder-specific outcomes for anxiety, depression, pain, schizophrenia, and eating disorders in comparison to control conditions.

A more recent publication describes the effects of meta-analysis of mindfulness-based interventions on the cognition and mental health of children and adolescents (Dunning et al., 2019). This analysis only included randomized controlled trials involving participants less than 18 years of age. The 33 studies were selected of 1,123 articles screened for inclusion. There were 3,666 children who participated in the 33 studies. Across all 33 selected studies, the mindfulness-based interventions produced significant improvements relative to controls in mindfulness and attention as well as depression, anxiety/stress, and negative behaviors.

Another recent meta-analysis reviewed the use of online mindfulness-based interventions on mental health (Spijkerman, Pots, & Bohlmeijer, 2016). Again, only randomized, controlled trials were selected for this review. The 17 studies that met the selection criteria included 2,360 participants (1,211 in the experimental groups and 1,149 in the control groups). Measures of depression, anxiety, stress, wellbeing, and mindfulness all showed significant improvements, although the effect size was small for all of these variables, with the exception of stress, for which there was a moderate effect size. In an analysis of the 17 studies that included an active control, the participants receiving the mindfulness-based intervention demonstrated a greater reduction in depression and anxiety/stress than the comparison group.

The research reviews above evaluating the use of mindfulness-based interventions support the efficacy of this practice across a range of age groups and of internet-delivered programs, as well as through face to face training with mindfulness instructors. The application of mindfulness training has also shown to be of value in support of persons with intellectual / developmental / disabilities (IDD) in a number of previous studies.

Mindfulness and Persons with Developmental/Intellectual Disabilities

In their meta-analysis, Hwang and Kearney (2013) found 12 studies that included 64 participants (49 males and 13 females) between 13 and 43 years. Twenty-two of the participants demonstrated an IDD and, of those, 17 demonstrated mental health issues as well. There were also six autistic individuals who demonstrated severe and chronic aggressive behavioural problems. In most cases the dependent variables of interest were aggressive behaviour and anxiety symptoms. One study with 34 participants focused on the impact of mindfulness on anxiety, social skills, and academic performance. Very small studies (one to three participants) were focused on deviant sexual arousal, smoking cessation, and weight loss. All 12 studies in the meta-analysis described positive outcomes from the use of mindfulness practices. The seven studies that focused on a reduction of aggressive behaviour reported a zero or near zero rate of occurrence following training. The study that examined the impact of mindfulness for 34 participants found reductions in anxiety, with increased social skills ratings and academic performance. Another meta-analysis completed by Chapman et al. (2013) included a majority of the articles reviewed in the Hwang and Kearney (2013) analysis. There were, however, two additional articles in the Chapman et al. (2013) review and both demonstrated results consistent with those in the Hwang and Kearney (2013) article.

A qualitative study conducted by Yildiran and Holt (2014) identified themes that emerged from interviews with six participants examining their experiences in a group mindfulness group program. The participants all demonstrated an IDD (aged 21 to 64). Additional diagnoses included paranoid personality disorder, autism, recurrent depressive disorder, and anxiety disorder. The identified themes were the ability to focus on one thing, improvement of a range of specific skills, helping people, and getting rid of bad habits while staying calm and happy. One less positive theme noted increased difficulty among older participants’ with learning new abilities.

A clinical program, Mindfulness-Based Cognitive Therapy (Segal, Williams & Teasdale, 2002; Williams, Teasdale, Segal, & Kabat-Zinn, 2007) was used with ACN’s by Idusohan-Moizer, Sawicka, Dendle, and Albany (2015). This ten-session process was effective in significantly reducing depression and anxiety scored on two clinical measures in 12 clients, as well as significantly increasing scores on a compassion scale.

Across the studies in which mindfulness-based interventions were used in programs for persons with IDD, there is general positive support for this approach in the reduction of challenging behaviors and mental health symptoms. Providing mindfulness training for those who act as caregivers (i.e., parents or support staff ) also appears to support enhanced outcomes for persons with IDD.

Mindfulness and Caregivers of Persons with Developmental/Intellectual Disabilities

Several studies have evaluated the outcomes of mindfulness training for caregivers (i.e., staff and parents) of individuals with IDD (Benn, Akiva, Arel, & Roeser, 2012; Singh et al., 2007). Benn et al. (2012) found that mindfulness training improved teaching and caregiving competence, and increased sense of personal well-being among parents and teachers of children receiving special education. Singh et al. (2007) looked at the behaviour of children with Autism following 12 weeks of mindfulness training and practice undertaken by their mothers. The children demonstrated reductions in aggression, noncompliance, and self-injury. The mothers reported increased satisfaction in their parenting abilities and interactions with their children.

Two other studies led by Singh (2009, 2016) provided mindfulness training to staff working in group homes supporting adults with intellectual/developmental disabilities. The first study (Singh et al., 2009) involved 23 staff working in four homes, each of which were residences for five individuals with IDD. Data were collected on incidents of physical or verbal aggression, verbal redirections, physical restraints, staff injuries and peer injuries. The rate of occurrence of all of these variables decreased during mindfulness training and use of restraints dropped to almost zero. The second study (Singh, Lancioni, Karazsia, & Myers, 2016) included a number of the same dependent variables as the initial study and, again, the mindfulness training program resulted in similar outcomes. Staff perceived stress also decreased substantially. Interestingly there was also a reported administrative cost savings of over $52,000 due to reduced turn over and days away, reducing the need for replacement staff during the study.

A meta-analysis of eight studies examining the impact of mindfulness-based interventions on caregiver stress and distress were drawn from an initial group of 65 papers (O’Donnchadha, 2018). Of the eight papers that met the minimum criteria, four included a control group. All together there were 385 professional caregiver participants including direct service staff, managers, and others (e.g., social workers, nurses, psychologists). The mindfulness-based interventions were associated with existing therapeutic programs such as Acceptance and Commitment Therapy or Mindfulness-based Positive Behavior Support. Seven of the studies measured participants on their perceived level of stress and four of the studies reported significant improvements in the stress levels noted in the self-reports while two studies saw an increase in stress. In three of the studies, participants were measured on their level of distress. In two of these studies self-reported distress showed a significant decline while in the third study there was an increase in distress.

The value of mindfulness-based interventions for caregivers is demonstrated in the research described above. The positive results from direct mindfulness-training of persons with IDD and from mindfulness training of caregivers raises the question of whether a combination of these two approaches might support even more significant benefits. There have been limited efforts to combine mindfulness training for both caregivers and persons with IDD in a single study.

Combined Delivery of Mindfulness-based Interventions for Carers and Persons with IDD

There have been some efforts to provide mindfulness training to both carers and persons with IDD. Chapman and Mitchell (2013) collected 76 survey responses from the 114 attendees with IDD and 28 questionnaires from among the 57 paid carers, family members and supporters who participated in one of 12 workshops. The workshops included an introduction to mindfulness, a mindful body scan, and a mindful breathing exercise. Survey and interview responses indicated it was a useful and positive practice for most of the participants. Generally, the participants indicated they found the workshops useful as a way to relax and that the body scans could help them with their breathing and ability to focus on the present moment. There were six qualitative interviews conducted with individuals who had been randomly selected from among the workshop participants with IDD. This study was unable to provide any indication of the impact that these workshops might have had for the caregivers or the persons with IDD.

A more recent study did provide a description of mood and social behavior change among a group of six adolescents with IDD who had emotional regulation difficulties, along with eight of their parent caregivers (Heifetz & Dyson, 2017). The participants with IDD completed at least six of the eight sessions of a mindfulness-based intervention program which was titled “Calming Thoughts and Calming Minds.” The parents attended three sessions just for caregivers as well as attending the first and last of the sessions of the “Calming Thoughts, Calming Minds” program with their adolescent child. A series of measures were used across the pre, post (following seven weeks) and follow-up (after booster session 2 weeks after program completion and 1 month follow-up). Due to the low numbers, trends were identified in the descriptive data. Parents’ data suggested a trend toward more mindful parenting and the adolescent participants reported being happier and more relaxed at the end of each session and there appeared to be a trend toward improvement in their social behaviors.

While there was positive responses to this group program by both parents and their adolescent children, difficulties were reported regarding consistent practice of mindfulness at home. To support better practice at home the authors suggest an incentive system may be helpful with adolescent participants.

Aim and Objectives of the Current Pilot Study

The aim of this study was to evaluate the impact of mindfulness training on subjective well-being, as well as, on pro-social and challenging behaviours of ACN’s. Mindfulness training of both the staff supporting these individuals and the ACN’s themselves, have resulted in improvements to challenging behaviours demonstrated by ACN’s. While these results have been demonstrated in studies that provide training for either staff (or parents), or individuals with complex needs, this proposed study is structured to evaluate the impact of mindfulness training for both staff (direct support staff and supervisory/administrative staff) and ACN’s on subjective well-being, and pro-social and challenging behaviours of ACN’s.

Method

Participants

Participants came from two groups:

1. ACN’s supported by the Calgary SCOPE Society – 6 ACN’s participated (5 male, 1 female). Ages ranged from 25-63 with a mean age of 38.67.

2. Staff supporting those ACN’s selected as participants – 15 staff participated (8 male, 7 female). Ages ranged from 24-64 with a mean age of 41.07.

Materials

A number of surveys/questionnaires were used with the ACN group selected for the study.

  • Demographics Questionnaire;
  • Personal Well-being Index–Intellectual Disability (PWI-ID) (Cummins & Lau, 2005);
  • Five Factor Mindfulness Questionnaire (FFMQ) (Baer et al., 2006) (adapted into Plain Language (P-L) for this study);
  • PERMA scale (a measure of the construct of “flourishing”) (adapted in to P-L for previous study) (LaRosee, 2015);
  • Weekly incident reports and contact notes produced by staff describing behaviours demonstrated by the ACN participants;
  • Coding forms for collecting the occurrences of aggression, self-injury or other disruptive or impulse control behaviour demonstrated by ACN participants. In addition, coding forms were used to collect staff observations of pro-social behaviours such as cooperation, expressions of empathy, and kindness; and
  • Scripts that were to be used by the staff to give structure to the mindfulness training sessions they provided to the ACN participant(s). The scripts followed the same structure throughout the sessions and included

1. An opening meditation - a guided meditation that focused the ACN participant on their breathing while encouraging them to gently bring their minds back to their breath when it wandered (approximately 5 minutes).

2. Review of past sessions and homework to encourage the use of mindful pauses and practice of previous experiential exercise(s) from previous weeks between formal training sessions.

3. Experiential use of new practice such as mindful walking or the use of a body scan to gradually relax different parts of the body as they mentally scan their body.

4. A short mindful pause exercise to have the ACN participant practice being mindful of their activities that they can use at various times of the day.

5. A closing thought: a positive statement repeated by the ACN participant.

Several surveys/questionnaires were used with the staff participating in the study.

  • Demographics Questionnaire;
  • Personal Well-being Index–Adult (PWI-A) (International Wellbeing Group, 2013);
  • FFMQ (Baer et al., 2006); and
  • PERMA scale (a measure of the construct of “flourishing”) (Butler & Kern, 2015).

Procedure

The study included the development of a series of training sessions to enhance dispositional mindfulness among staff supporting ACN’s living in the Calgary region. Staff were trained to assist those they support in the development of greater mindfulness in their lives. The project included a mindfulness training program for staff and the evaluation of outcomes, both among staff as well as the ACN participants they supported. Measures of mindfulness, subjective well-being, and flourishing were administered to staff as well as ACN’s. In addition, challenging behaviours (e.g., aggression, self-injury, or other disruptive or impulse control related behaviours) and pro-social behaviours, (e.g., cooperation, helping, or expressions of empathy) were measured before and after training as well as on three- month follow-up for ACN’s.

This study involved the development and implementation of a series of staff training sessions based on a review of program descriptions from the literature on mindfulness, in addition to consultant advice. As well as exercises and content aimed at developing dispositional mindfulness, staff received content directed at supporting the development of mindfulness in the ACN’s they support. Relevant literature on programs that have been operated for persons with IDD, as well as consultant advice, were used to develop the train-the-trainer material (i.e., training scripts to be used by the staff during their sessions with ACN’s). Assessments (listed above) were administered prior to the training programs, immediately following the training programs, and again three months later.

There were different sets of procedures used with the ACN participants and with the staff participants. While there were procedural differences, both groups were asked to complete the same pattern of activities. All participants were assessed on a series of measures before the mindfulness training program began. They attended mindfulness training, twice a week for eight weeks. At the end of the eight weeks they were again assessed on the same measures they completed previously. Finally, they were assessed using the same measures three months after the last assessment.

Staff participants were scheduled into two weekly mindfulness training sessions out of four possible sessions available at the service provider office facility. The training sessions continued for eight weeks. While they were attending the training sessions, staff participants had their work responsibilities covered off (for both travel and mindfulness class time) by temporary staff. In addition, staff were encouraged to practice independently each week as often as they felt able. The training sessions include an hour of “mindfulness training” and a half-hour of practicing and reviewing the activities the staff were using to train the ACN participants. The scripts that were used for the training sessions with the ACN’s were discussed and practiced during the last half-hour of the staff training sessions.

The ACN participants were invited to participate in two training sessions per week (described above). These weekly sessions were led by one of the staff who was a participants in the mindfulness training program for staff. Each of these training sessions were conducted using the script for that session. In addition, the ACN participants were encouraged to practice mindfulness exercises described in the scripts every day. The staff also offered to complete the exercise they were practicing that week on additional occasions during the week if the ACN participant wished. At the end of the week the ACN participant received a $10 gift card if they had completed the two training sessions.

Results

All data were compiled and analyzed using SPSS v. 25. There were two ACN’s who demonstrated consistently high response sets on the PWI-ID. Cummins and Lau (2005), indicate that individuals who consistently respond high or low should be removed from analysis. However, these individuals were included in the analysis because they did not demonstrate a consistent response set on the other measures. There were a few missing cases for the PERMA and FFMQ measures and the mean for that group and question, was substituted for any missing responses.

PWI (Adult and Intellectual Disability versions)

The PWI data were analyzed using pre-established methods (Cummins & Lau, 2005; International Wellbeing Group, 2013). The mean converted scores for staff and ACN’s can be seen in Figure 1 and 2, respectively. The total PWI score comprises all domains items combined with the exception of happiness with life as a whole. As can be seen in Figures 1 and 2, both staff and ACN’s scored above normative ranges across all domains.

After the pre-established methods, the data were analyzed using a Friedman test (non-parametric alternative to one-way ANOVA with repeated measures). Results from the Friedman tests can be seen in Tables 1 and 2. While there were no significant differences, a visual examination of the staff ratings on the PWI (Figure 1) demonstrated that staff increased on all domains immediately following the mindfulness training. In addition, the ratings provided by staff after 3 months continued to be higher than the pre-program ratings for seven of the domains (standard of living, health, life achievement, personal relationships, personal safety, future security and total PWI score). Community connectedness was virtually the same and, in spite of most areas showing an increase from the pre-assessment to the three-month follow-up, the happiness with life as a whole decreased. A visual examination of the ACN results (Figure 2) do not suggest any particular pattern in the results. It is interesting to note that across all domains for almost all of the assessment times (pre, post and follow-up) the ratings were higher than the staff ratings, suggesting that they were more satisfied in all areas of their life than the staff.

Figure 1. Mean converted PWI scores for staff (n = 15). Normative range for Western societies is 70-80 (Cummins & Lau, 2005).



Figure 2. Mean converted PWI scores for ACN’s (n = 6). Normative range for Western society is 70-80 (Cummins & Lau, 2005).



Table 1 Friedman Test Results for Staff on the PWI measure

PWI Domain

N

Chi-Square

df

Significance

Happiness with life as a whole

15

0.591

2

.744

Standard of living

15

1.167

2

.558

Health

15

1.895

2

.388

Life achievement

15

1.644

2

.439

Personal relationships

15

3.050

2

.218

Personal safety

15

2.457

2

.293

Community-connectedness

15

2.311

2

.315

Future security

15

0.750

2

.646

Total PWI score

15

1.368

2

.504


Table 2 Friedman Test Results for ACN's on the PWI measure

PWI Domain

N

Chi-Square

df

Significance

Happiness with life as a whole

6

4.000

2

.135

Standard of living

6

0.000

2

1.000

Health

6

3.000

2

.223

Life achievement

6

0.500

2

.779

Personal relationships

6

1.500

2

.472

Personal safety

6

1.500

2

.472

Community-connectedness

6

2.667

2

.264

Future security

6

0.500

2

.779

Total PWI score

6

0.111

2

.946


PERMA (Adapted Plain Language and Original versions)

The PERMA data were analyzed using pre-established methods (Butler & Kern, 2014). The mean converted scores for staff and ACN’s can be seen in Figure 3 and 4, respectively. As can be seen in Figure 3, the staff scored high in positive emotion, engagement, relationships, meaning, accomplishment, and health across all time periods. They also scored low or slightly below average in the domains of loneliness and negative affect across all time periods. Figure 4 shows that ACN’s scored slightly above average or high in positive emotion, engagement, relationships, meaning, accomplishment, and health across all time periods. They also scored between low and average in the domains of negative affect and loneliness across all time periods. ACN’s demonstrated overall decreases in negative affect and loneliness, however, the results were not significant.

After the pre-established methods, the data were analyzed using a Friedman test. Results from the Friedman tests can be seen in Tables 3 and 4. There were no statistically significant differences on any domain across testing times for the staff participants. There was a significant difference in negative affect for the ACN group, X²(2) = 9.364, p = .009) across time periods. Post hoc comparisons with Wilcoxon Signed Ranks using the Bonferroni correction of p = 0.017 resulted in no significance (before with after p = .408; before with 3 months after p = .039; after with 3 months after p = .027).

Figure 3. Mean converted PERMA scores for staff (n = 15). Scores of 0 or 1 are very low in that domain; 2 or 3 are low; 4 is slightly below average; 5 is average; 6 is slightly above average; 7 or 8 are high; and 9 or 10 are very high (Butler & Kern, 2014).



Figure 4. Mean converted PERMA scores for ACN’s (n = 6). Scores of 0 or 1 are very low in that domain; 2 or 3 are low; 4 is slightly below average; 5 is average; 6 is slightly above average; 7 or 8 are high; and 9 or 10 are very high (Butler & Kern, 2014).



Table 3 Friedman Test Results for Staff on the PERMA measure

PERMA Domain

N

Chi-Square

df

Significance

Positive Emotion

15

0.327

2

.849

Engagement

15

1.444

2

.486

Relationships

15

1.018

2

.601

Meaning

15

4.353

2

.113

Accomplishment

15

0.113

2

.945

Overall

15

0.655

2

.721

Negative Affect

15

1.107

2

.575

Health

15

1.038

2

.595

Loneliness

15

0.000

2

1.000


Table 4 Friedman Test Results for ACN's on the PERMA measure

PERMA Domain

N

Chi-Square

df

Significance

Positive Emotion

6

3.273

2

1.95

Engagement

6

0.300

2

.861

Relationships

6

0.933

2

.627

Meaning

6

2.818

2

.244

Accomplishment

6

1.7333

2

.420

Overall

6

0.609

2

.738

Negative Affect

6

9.364

2

.009*

Health

6

3.364

2

.186

Loneliness

6

1.900

2

.387

Note. *p < .05

FFMQ (Adapted Plain Language and Original versions):

The FFMQ data were analyzed using pre-established methods (Baer et al., 2006). The mean converted scores for staff and ACN’s can be seen in Figure 5 and 6, respectively. As can be seen in Figure 5, staff experienced an overall growth in the nonjudge facet (not statistically significant). The ACN’s had growth in the facets of describe, nonjudge, and non-react as can be seen in Figure 6 (not statistically significant).

After the pre-established methods, the data were analyzed using a Friedman test. Results from the Friedman tests can be seen in Tables 5 and 6. There were no statistically significant differences on any facet across testing times for either group of participants.

Figure 5. Mean converted FFMQ scores for staff (n = 15). For facets of observe, describe, act with awareness and nonjudge scores range between 8-40, with higher scores reflecting higher levels of mindfulness (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). The facet of nonreact ranges from 7-35 with higher scores reflecting higher levels of mindfulness (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006).



Figure 6. Mean converted FFMQ scores for ACN’s (n = 6). For facets of observe, describe, act with awareness and nonjudge scores range between 8-40, with higher scores reflecting higher levels of mindfulness (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). The facet of nonreact ranges from 7-35 with higher scores reflecting higher levels of mindfulness (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006).



Table 5 Friedman Test Results for Staff on the FFMQ measure

FFMQ Facet

N

Chi-Square

df

Significance

Observe

15

1.298

2

.523

Describe

15

0.792

2

.673

Act with Awareness

15

0.246

2

.884

Nonjudge

15

2.528

2

.282

Nonreact

15

0.982

2

.612



Table 6 Friedman Test Results for ACN's on the FFMQ measure

FFMQ Facet

N

Chi-Square

df

Significance

Observe

6

0.609

2

.738

Describe

6

4.000

2

.135

Act with Awareness

6

0.364

2

.834

Nonjudge

6

1.091

2

.580

Nonreact

6

2.696

2

.260



Behaviour Tracking:

Specific ACN behaviours were tracked using daily contact notes and incident reports to see if the mindfulness program had any effect on the behaviours. Please see Figures 7, 8, 9, 10 and 11 for more details. Each client had 3 specific behaviours of concern and 3 specific pro-social behaviours selected for tracking (all labelled as prosocial behaviour 1, 2, 3 or behaviour of concern 1, 2, 3 in the graphs to maintain confidentiality). The graphs do not account for missing data or non-recorded information. There are only 5 graphs despite there being 6 ACN’s because the tracking was not completed for one of the ACN’s after training and 3 months after training. Dates for before training were April 21-June 2, after training was July 28-September 8, and 3 months after was October 28-December 9.

Figure 7. Behavioural data tracking for ACN participant #1. Before training included 43 days of tracking, after training included 43 days of tracking and 3 months after training included 43 days of tracking.



Figure 8. Behavioural data tracking for ACN participant #2. Before training included 43 days of tracking, after training included 43 days of tracking and 3 months after training included 43 days of tracking.



Figure 9. Behavioural data tracking for ACN participant #3. Before training included 43 days of tracking, after training included 43 days of tracking and 3 months after training included 43 days of tracking. Behaviour of concern 1 is not visible as it follows the same trend as total incidents.



Figure 10. Behavioural data tracking for ACN participant #4. Before training included 43 days of tracking, after training included 43 days of tracking and 3 months after training included 43 days of tracking. Behaviours of concern 1, 2, and 3 are not visible on the graph as they follow the same trend as total incidents (0 all the way across).



Figure 11. Behavioural data tracking for ACN participant #5. Before training included 43 days of tracking, after training included 28 days of tracking and 3 months after training included 41 days of tracking.




Correlations:

Correlations were conducted between the PWI/PERMA measures and the FFMQ measures for all three-time periods. The PERMA domain of accomplishment was significantly positively correlated with FFMQ facet of nonreact across all three-time periods (before – r = .558, p = .009; after - r = .561, p = .008; 3 months after - r = .596, p = .004). The PERMA domain of relationships was also significantly positively correlated with FFMQ facet of nonreact across all three-time periods (before – r = .476, p = .029; after - r = .439, p = .047; 3 months after - r = .542, p = .011). Finally, the PERMA domain of negative affect was significantly negatively correlated with FFMQ facet of acting with awareness across all three-time periods (before – r = -.646, p = .002; after - r = -.525, p = .014; 3 months after - r = -.534, p = .013).

Conclusions

Unfortunately, no significant results were found, however, an understanding of how to improve the implementation of mindfulness was gained. Additionally, a greater understanding of the difficulties in measuring change as a result of increased mindfulness was also attained. Despite a lack of significant results, 33% of the ACN participants are still currently using mindful practices in their day-to-day and find the exercises helpful. With support, ongoing strategies to promote continued use of these exercises could be implemented.

Some limitations of the current study include a small sample size in both groups. Additionally, there were some conceptual flaws in the design and implementation of the mindfulness training. The train-the-trainer model that was used to train staff could have benefited from further development and longer implementation before applying it to the ACN`s. This finding was supported by the instructors of the mindfulness program. There was confusion due to the differences between the training for staff and for ACN’s. In addition, there were some difficulties ensuring consistent compliance with the training procedure for the ACN’s in the delivery of the prepared mindfulness scripts. This was particularly problematic as the study relied on staff for both behavioural data tracking as well as levels of engagement. Finally, the use of self-report measures was questionable as ratings and responses were viewed as frequently impacted by emergent events and life situations.

Future research could explore a new delivery model that would allow greater control and consistency. An example would be one person conducting the training with both staff and ACN`s on an individualized basis. They could go to ACN homes and provide consistent training to both the ACN and staff present as well as adapt the training to the learning needs and preferences of the ACN. This would provide more confidence in the outcome of a follow-up study. Another suggested change is the collection of qualitative data. Quantitative self-report measures are valuable; however, qualitative interviews and descriptive comments could have provided a more detailed and richer source of understanding. Therefore, qualitative measures would be useful for future implementations of this potential valuable process for persons with complex needs.

Implications for Policy, Practice or Educational Priorities

The use of mindfulness with ACN`s has demonstrated value in previous research. Unfortunately, our findings did not support that. However, a number of confounding factors may have affected the findings. A future study that addresses some of these limitations would be helpful in supporting better strategies for implementing mindful practices and enhancing ACN and staff well-being. Further efforts toward creating a mindful organization may act as a useful model for service providers throughout the Province and more widely.

Acknowledgements

The authors are grateful to the ACN’s who participated in this study as well as their families. We also wish to express our appreciation to the staff who participated in the mindfulness training sessions and those who also acted as trainers for the ACN’s who were included in the study.

The authors are also grateful to Alberta Health Services for funding of this project through the Increasing Capacity of Human Services and Alberta Health Services to Address Adults with Complex Needs program and in particular Ms. Cathy Aspen, AHS Research Coordinator, for her encouragement and support.

Finally, we wish to note our appreciation to Dr. Nicole Libin and Ms. Kara Budden for their work as mindfulness trainers as well as for their suggestions and advice throughout this study, and to Dr. Allan Donsky for his contributions to the design of this project.

References

Baer, R.A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment 13(1), 27-45. doi: 10.1177/1073191105283504

Benn, R., Akiva, T., Arel, S., & Roeser, R.W. (2012). Mindfulness training effects for parents and educators of children with special needs. Developmental psychology, 48 (5), 1476.

Butler, J., & Kern, M.L. (2015). The PERMA-Profiler: A brief multidimensional measure of flourishing. Retrieved from http://www.peggykern.org/questionnaire.

Chapman, M.J., Hare D.J., Caton, S., Donalds, D., McInnis, E., & Mitchell, D. (2013). The use of mindfulness with people with intellectual disabilities: A systematic review and narrative analysis. Mindfulness, 4, 179–189 doi: 10.1007/s12671-013-0197-7.

Chapman, M.J. & Mitchell, D. (2013). Mindfully valuing people now: An evaluation of introduction to mindfulness workshops for people with intellectual disabilities. Mindfulness, 4, 168–178. doi: 10.1007/s12671-012-0183-5.

Cummins, R.A. & Lau, A.L.D. (2005). Personal well-being index – Intellectual disability (3rd edition). Melbourne: Australian Centre on Quality of Life, Deakin University.

Dunning, D. L., Griffiths, K., Kuyken, W., Crane, C., Foulkes, L., Parker, J. and Dalgleish, T. (2019). Research Review: The effects of mindfulness-based interventions on cognition and mental health in children and adolescents – a meta-analysis of randomized controlled trials. Journal of Child Psychology and Psychiatry 60:3 (2019), pp 244–258. doi:10.1111/jcpp.12980

Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., T. L. Simpson (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, Volume 59, 2018, pp. 52-60

Goodall, K., Trejnowska, A., & Darling S. (2012). The relationship between dispositional mindfulness, attachment security and emotion regulation. Personality and Individual Differences, 52(5), 622–626. doi:10.1016/j.paid.2011.12.008.

Hwang, Y., & Kearney, P. (2013). A systematic review of mindfulness intervention for individuals with developmental disabilities: Long-term practice and long lasting effects. Research in developmental disabilities, 34(1), 314.

Idusohan-Moizer, H., Sawicka, A., Dendle, J., & Albany, M. (2015). Mindfulness-based cognitive therapy for adults with intellectual disabilities: An evaluation of the effectiveness of mindfulness in reducing symptoms of depression and anxiety. Journal of intellectual disability research, 59(2), 93.

International Wellbeing Group. (2013). Personal well-being index- adult (5th edition). Melbourne: Australian Centre on Quality of Life, Deakin University.

Josefsson, T., Larsman, P., Broberg, A., & Lundh, L. -G. (2011). Self-reported mindfulness mediates the relation between meditation experience and psychological wellbeing. Mindfulness, 2, 49–58.

Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. Hyperion: New York.

Keng, S.L., Smoski, M.J., & Robins, C.J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6).

LaRosee, A.R. (2015). Does the structure of flourishing vary between individuals with disabilities/student populations? (Unpublished honours thesis). Department of Psychology, Mount Royal University, Calgary, Canada.

O’Donnchadha, S., 2018. Stress in caregivers of individuals with intellectual or developmental disabilities: A systematic review of mindfulness‐based interventions. Journal of Applied Research in Intellectual Disabilities, March 2018, Vol.31(2), pp.181-192.

Redekop, M., & Clark, M. (2016). From life’s difficulties to posttraumatic growth: How do we get there? Psychology, 7, 1451-1466.

Segal, Z.V., Williams, M. G. & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. NY: Guilford, New York.

Singh, N.N., Lancioni, G.E., Winton, A.S.W., Singh, J., Curtis, W.J., Wahler, R.G., & McAleavey, K.M. (2007). Mindful parenting decreases aggression and increases social behaviour in children with developmental disabilities. Behaviour modification, 31(6), 749.

Singh, N.N., Lancioni, G. E., Winton, A.S.W., Singh, A.N., Adkins, A.D., Singh, J. (2009). Mindful staff can reduce the use of physical restraints when providing care to individuals with intellectual disabilities. Journal of applied research in intellectual disabilities, 22(2), 194–202. doi: 10.1111/j.1468-3148.2008.00488.x.

Singh, N.N., Lancioni G.E., Karazsia, B.T., & Myers, R.E. (2016). Caregiver training in mindfulness-based positive behaviour supports (MBPBS): Effects on caregivers and adults with intellectual and developmental disabilities. Front. Psychol. 7(98). doi: 10.3389/fpsyg.2016.00098.

Spijkerman, M.P.J. Pots, W.T.M. & Bohlmeijer, E.T. (2016). Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clinical Psychology Review, Volume 45, 2016, pp. 102-114.

Williams, M., Teasdale, J., Segal, Z., & Kabat-Zinn, J. (2007). The Mindful way through depression: Freeing yourself from chronic unhappiness. New York: Guilford Press.

Yildiran, H., & Holt, R.R. (2014). Thematic analysis of the effectiveness of an inpatient mindfulness group for adults with intellectual disabilities. British Journal of Learning Disabilities, 43(1), 49–54.

Yu, M., & Clark, M. (2015). Investigating mindfulness, borderline personality traits, and well-being in a nonclinical population. Psychology, 6, 1232-1248. http://dx.doi.org/10.4236/psych.2015.610121.

Author Biographical Notes

Mitchell Clark, Ph.D., R.Psyc.
Associate Professor
Department of Psychology
Mount Royal University

Dr. Clark has conducted research overseas focused on stress and disability among refugees, and on the quality of life of families that include persons with disabilities. He has also conducted international research on the wellbeing of children and maintains an interest in international rehabilitation services and issues. Other interests include mindfulness, applied behavior analysis, computer-supported learning, etiology of disabilities, and clinical psychology. He is a member of the College of Alberta Psychologists and the International Association for the Scientific Study of Intellectual Disability.

 

International Journal of Disability, Community & Rehabilitation
Volume 18, No. 1
www.ijdcr.ca
ISSN 1703-3381