This paper was written for the Mulberry Bush Foundation Degree module on: Professional Issues in therapeutic Provision for Children and Young People.
Full title: ‘Does mindfulness have a role to play in a psychotherapeutic community for children with complex needs’ ?
There has been rapid growth in the number of organisations attempting to integrate mindfulness into their professional culture. Mindfulness can be described as any activity which helps one to pay attention to what is happening right now. Jon Kabat Zinn (2013) defines it as ‘paying attention in the present, on purpose, in a particular way.’ Essentially it is the development of non-judgemental accepting awareness of moment by moment experience. North (2014) suggests that being mindful involves being in touch with your own mind and the constant stream of information and energy that flows in waves through your brain, as well as the brain of every other person around you. She believes that mindfulness should be at the heart of any kind of intended reflective practice. Mindfulness develops the ability to ‘witness’ one’s own emotions and body sensations. There is a plethora of mindfulness based educational and therapeutic programmes available; some of which can be used universally whilst others are more targeted at specific populations.
Having experienced the benefits of mindfulness personally, I now wish to investigate whether or not it has a place within a psychotherapeutic community for traumatised primary aged children. The practice of mindfulness is integral to Eastern philosophical traditions, most notably Buddhism from which much of the understanding and practice of mindfulness within Western psychotherapies has derived. When integrated into Western psychotherapies, mindful awareness is taught as a way of helping people tolerate psychological and physiological distress.
Much psychological distress arises from our early life experiences. In 1951, Bowlby recommended that infants and young children should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment. At the time this statement was revolutionary. There was great resistance to the idea that children needed affection to grow into healthy adults, assuming instead that as long as food and shelter were provided, the child would be fine. Since then we have seen that a child’s emotional environment is key not only to the development of physical and emotional health but also to academic and worldly success.
Rechtschaffen (2014) discusses the palpable agreement in current neuroscience, genetics, attachment psychology and developmental theory that the best thing for a developing child is love, attention and constancy. It is thought that the amount and quality of empathic attunement children receive wires their brains in either healthy or destructive ways. A well-functioning holding environment supports the child’s inner executive functioning. Our childhood environment sets up the ways our neural pathways fire together, creating the paths that we walk down in our lives. Highly stressful environments of neglect and abuse have been shown to create deficits in children’s working memory, attention and inhibitory control skills.
If a child’s early life is marked with dependability, he or she gains an inner sense of trust and can look to the world with optimism. If the conditions are not safe and nurturing, the child is imprinted with a sense of mistrust and the world becomes a dangerous place. Research into trauma, neglect and abuse has demonstrated severe effects on the brain. The Adverse Childhood Experience (ACE) study showed how difficult childhood experiences set a path for obesity, drug use, criminality and other destructive behaviours. These experiences increase the number of risk factors for serious chronic health and social problems (Felitti, 1998, pg.115)
The children I teach are placed at Mulberry Bush School because their physical and emotional needs were neglected in infancy. Children come to us with a range of diagnoses. Many of the children can be described as having an Attachment Disorder, Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD) or Oppositional Defiant Disorder (ODD) (www.mulberrybush.org.uk).
Commonly, the children we work with struggle to talk about their feelings and communicate through extremes in their behaviour. There are numerous learning difficulties including poor attention, low self-esteem, an inability to learn from experience and general low levels of achievement. Their emotional problems present barriers to successful learning.
One premise of mindful education is that all human beings are born with a capacity for compassion, integrity and wisdom. From this perspective, the ideal of education is to teach in such a way that fosters these qualities with an atmosphere of acceptance, forgiveness and encouragement. The hope is that when we learn to embody our own mindful attention, compassion and emotional regulation, the children in our care will receive the relational nourishment they need to become healthy, happy adults. Relationships play a significant role in therapeutic work. North (2014) proposes that paying attention to the emotional environment in which a young person exists, including our own state of mind, the communication between the team around the child and the state of the young person themselves is essential if we are to avoid disorganisation, rigidity or catastrophe .
Children need an environment in which their nervous systems can relax. When our nervous systems are on high alert then our working memories function poorly and our creative and our collaborative capacities are stymied. However, when a child feels safe, relaxed and attentive, learning comes naturally.
A wealth of peer reviewed research has been validating mindfulness. Neuroscientists, medical doctors and geneticists are showing that mindfulness cultivates attention, compassion, happiness, and relaxation and decreases impulsivity, anxiety and other difficult emotional states. Practicing mindfulness regularly has also been shown to support immune function and cognitive development. Mindfulness research over the past two decades has focused primarily on adult clinical populations; however in recent years these approaches have been adapted for use with children. I offer here a very brief synopsis of some of the science that is pertinent to this exploration of mindfulness in education.
People working in the caring professions have an unusually high degree of stress, burnout and ill health. ‘Compassion fatigue’ refers to the way we can overextend our caregiving without getting adequate support. It is easy in a therapeutic community to feel overwhelmed by the projections from traumatised children. Unless we take care of ourselves we get exhausted and become incapable working to full capacity. Mindfulness has been shown to address physical health problems directly and is effective in reducing pain, high blood pressure and improving the symptoms of physical conditions (Jacobs, 2011). Mindfulness research has shown an increased ability to feel in control, to make meaningful relationships, manage difficult feelings, and be calm, resilient, compassionate and empathic. As a psychological intervention it is also proving effective in addressing substance abuse, stress, anxiety, sleep problems and recurrent depression (Baer, 2014)
Research by Kemeny (2012) showed a decrease in stress, anxiety and depression and an increase in compassion and other positive states of mind in teachers who underwent an eight-week mindfulness training course. The findings suggested that the teachers who had gone through the training had a greater capacity to experience the inevitable stressors of teaching whilst maintaining an emotional balance, even during provocative situations. Teacher mindfulness has the potential to interrupt or de-escalate an emotionally charged situation.
There has recently been a flurry of research on the effects of mindfulness on classrooms. The current evidence base is limited due to issues of sample size, design, and methods of measurement. Methodologies are still evolving and lack sufficient precision which limit the validity of the findings. The heterogeneity of the populations studied makes it difficult to build a consistent picture of efficacy. Despite this a number of studies demonstrate that mindfulness interventions for children and adolescents are feasible in most populations.
Neuroscience can help us understand the benefits and usefulness of mindfulness training in the lives of children. Even very young children can understand the concepts relating to the way in which the human brain has evolved. The instinctual reptilian part of our brain motivates us through hunger, desire, protection and fear; its presence has supported our survival for millennia and remains a powerful force. The middle pre-frontal cortex is the seat of the higher aspects of our self. It houses the energy for key behaviours around empathy, intuition, insight, emotional and bodily regulation. The neocortex is the reasoning, more rational part of our brain. Siegel (2011) has written extensively on how mindfulness helps children use their whole brain in a more integrated way. Horizontally integrated so that their left brain logic can work with their right brain emotion but also vertically integrated, so that the physically higher parts of their brain, which allow them to consider their actions, work well with lower parts, which are more concerned with instinct, gut reactions, and survival. This is related to the basic neuroscience concept that ‘nerve cells that fire together, wire together. Recent findings in neural plasticity show that our brains can generate stronger and healthier neural connections based on our mental habits. Mindfulness trains our brains to respond in ways we choose rather than always in a default manner. For those children I teach, who have learned to use violence as a reaction to feeling scared, mindfulness can help him or her become more aware of this habitual behaviour and the feelings underneath it with the hope that eventually the reactions will become rewired to more positive responses.
Long term neuroscience research is demonstrating that mindfulness can positively transform the architecture of the brain, improving sustained attention, visuo-spatial memory, working memory and concentration. Davidson (2003) suggested that the practice of mindfulness, by increasing the blood flow to the cerebral cortex, can thicken those areas associated with executive functioning, attention and emotional integration whilst at the same time reduce the gray matter density in those areas of the amygdala linked to stress and anxiety.
Semple et al (2010) conducted a six week pilot study to examine the acceptability of teaching mindfulness to children and concluded that mindfulness could be taught to children as young as 7 years old. In particular there were promising effects in the alleviation of attention problems and anxiety symptoms. They went on to assess the impact of a 12 week MBCT programme in children who were struggling academically. The authors proposed that anxiety influences attention, which in turn impacts on academic achievement. Significant improvements were found on both. Broderick and Metz (2009) similarly conducted a study which reported a decrease in negative affect and an increase in feeling calm and self-accepting.
Joyce et al (2010) reported pre and post group differences in children aged 10 – 13 years on measures of behaviour problems and depression. The ten week programme was delivered by teachers and led to a reduction in self-reported behavioural problems, most notably in those who showed clinically significant scores at pre-intervention. Schonert (2010) showed a significant increase on self-report scores of optimism, resilience and a trend towards positive emotions after a ten lesson programme delivered by teachers to 9-12 year olds. Teacher reports also showed an improvement in social and emotional competence and a decrease in aggression and oppositional behaviour.
There are concerns about the reliability of these kinds of findings because of the use of self-report and teacher assessment measures. This led me to search for studies which utilised more independent ratings. Napoli (2005) found that an experience of a 24 week mindfulness programme led to a reduction in test anxiety and improvements in both teacher rated and objective measures of attention, social skills and symptoms of ADHD. This study is further supported by Mrazek’s findings that mindfulness training improves reading comprehension scores by an average of 16% and working memory capacity (2013).
Concerns around the burgeoning number of small studies demonstrating significant, but not overwhelmingly strong correlations led Zoogman et al (2014) to publish a meta-analysis of mindfulness interventions with young people. They found no evidence of iatrogenic harm. Mindfulness treatments were found to be superior over control comparison conditions especially in factors such as concentration, depression and behaviour. Raes (2013) showed clinically significant reduced levels of depression at a six month follow up in a group of Dutch children from five schools compared to the control group. In this study it was found to have both a curative and a preventative effect.
Mendelson (2010) employed a mindfulness based intervention to improve self-regulatory capacities in primary aged children from disadvantaged backgrounds. The intervention included yoga based physical activity, breathing techniques and guided mindfulness practice designed to help children manage arousal and stress levels. Significant results were identified on measures of involuntary responses to stress and there was a noted increase in trust towards adults and peers.
Oord et al (2011) reported on a randomised trial evaluating the effectiveness of an 8 week mindfulness course for children displaying ADHD with a parallel course for parents. Statistically significant changes were found in both child and parent symptoms of ADHD even at an 8 week follow up.
Rechtschaffen (2014) believes that children who grow up with environmental trauma can particularly benefit from the emotional regulation tools, stress relief, and impulse control techniques offered by mindfulness as ‘it can be a secure base of stability and an inner lifeline in a ‘tumultuous young life’ (pg.107). Trauma distances us from the present moment, disassociates us from our bodies and turns us away from difficult sensations. The body’s alarm systems turn on and then never quite switch off so that we never truly feel relaxed. Always on guard; the primitive brain is constantly scanning for threat even if the current situation is safe. Bessel van der Kolk says ‘the goal of post-traumatic stress disorder treatment is to help people live in the present, without feeling or behaving according to irrelevant demands to the past’ (1994, pg. 118)
Mindfulness is thought to help trauma victims return to the present moment and eventually to homeostasis. It can help them feel their body in the chair, see and hear the colours, shapes and sounds in the room. With mindfulness the aim is to cultivate a refuge of safety and happiness where they might one day be able to feel their anger, explore it and find productive ways of channelling it. Levine (1997) suggests that ‘traumatic symptoms stem from a frozen residue of energy that has not been resolved and discharged. This residue remains trapped in the nervous system where it can wreak havoc on our bodies and spirits’.
Mindfulness can provoke difficult responses in children that can have adverse effects without adequate containment. If the release is not adequately held, there can be re-traumatisation rather than healing. Treleaven (2013) highlights the dangers of mindfulness becoming a dissociative practice rather than a healing one. He argues that without adequate understanding of trauma a mindfulness teacher could unwittingly push a student into a sensory awareness that is overly distressing.
On balance, having reviewed much of the literature and despite the methodological limitations, Harnett (2012) proposes a cause for optimism when considering whether to include mindfulness as part of a practitioner’s repertoire for treating children and families. It should be taught to children but also to the adults who care for them, whether that is parents, carers, teachers or childcare practitioners. What is needed now is a clearer understanding of what treatment should consist of and the dose of treatment that is necessary to effect change. There needs to be a greater understanding of the active ingredients of the mindfulness programmes if they are to be used optimally which is yet to be investigated systematically.
The aim of the current study was to investigate whether mindfulness based activities had any noticeable effect on a small group of adults and/or children in one class in a psychotherapeutic community for traumatised children. Based on the embryonic nature of research, I decided on a non-directional hypothesis. The experimental hypothesis stated that ‘a three week mindfulness intervention of six lessons has an effect on the mindfulness scores of 7 children in a psychotherapeutic school for traumatised children’. The null hypothesis stated that ‘a three week mindfulness intervention of six lessons has no effect on the mindfulness scores of 7 children in a psychotherapeutic school for traumatised children, and any difference found is due to chance’. For the purpose of this study my independent variable was a three week mindfulness intervention of six lessons. The dependent variable was measured using quantitative mindfulness scores on a Child and Adolescent Mindfulness Measure (CAMM) prior to and at the end of a six lesson mindfulness intervention. (http://www.ruthbaer.com/academics/CAMM.pdf) I utilised a repeated measures research design as the same participants completed the same questionnaire on two separate occasions.
I used the CAMM because research conducted by its designers (Greco et al, 2005) suggested that it is a developmentally appropriate measure of mindfulness with internal consistency and good test-retest reliability. It was designed for young people over the age of 9 which is ideal as the population making up my sample are aged between 10 and 12. It is a 10 item self-report questionnaire which has been designed to asses present moment awareness and non-judgemental, non-avoidant responses to thoughts and feelings. CAMM scores are positively correlated with quality of life, academic competence and social skills and negatively correlated with somatic complaints, psychological inflexibility, thought suppression and behaviour problems. Total scores on the CAMM are computed by summing the responses to the 10 items, yielding a possible range from 0 to 40 with 0 being the most mindful and 40 the least.
In addition to this quantitative data I collected qualitative data in the form of a reflective journal during the mindfulness intervention. In this journal I was able to make a note of any situations or responses that felt relevant to the hypothesis.
The participants in my study were selected using an opportunity sample. They were the 7 (n=7) children that are members of Thames class at the Mulberry Bush School. 86% of the sample were male. 71% of the sample were from a British white ethnic background with the remaining sample coming from a mixed race ethnicity. I am aware that any findings gained from such small opportunity sample lack generalizability but for the current purposes I felt that any alternative would prove difficult and that some primary research was better than none.
To ensure that physical and psychological harm was minimised I gave due attention to the ethics of carrying out research on this sample. As the participants were all under 16, fully informed consent was gained from those in loco parentis. I also explained the study to the children before we began which, in hindsight might have been a mistake given the possible demand characteristics that may be present in the findings from knowing the research aims. If participants know that they are being studied they are likely to modify their answers because of social desirability bias and this may have reduced the validity of my findings. Giving the same test at the beginning and at the end can also lead to order effects since their recall of the original test may not have diminished in just three weeks. This is an inevitable failing of any self-report measure which must be taken into account when analysing the results. I also assured the participants that any results found would remain confidential and that any write up would be anonymised. They were reassured that they could withdraw from the investigation at any time they wished. Mindfulness is not something you make anyone do against their wishes.
Some initial mindfulness lessons did not go well at all. Inviting traumatised children to delve beneath their tough exteriors into more vulnerable realms was an unsettling process. Children made rude noises, ran out of the room, taunted each other and directed their ire at me. There have been times when I have thought it would be best if I did not persevere with mindfulness in such a setting and I have questioned my motives for introducing it. I reflected upon whether it was my desire for peace that underpinned my intention rather than a genuine need in them to learn mindfulness.
During one lesson I noticed a child fidgeting with a piece of paper. The noise was affecting the other children and I could feel my own anxiety developing. As I watched he knocked his pencil case to the floor. The other children looked up and I was just about to tell everyone to try a return to the mindfulness exercise. I was trying to control the shaky atmosphere in the classroom and contain my own anxiety. However I realised that his behaviour was communicating a palpable tension in the room so I asked him whether he needed anything. He admitted to having troubles sitting still and requested that we carry out a yoga exercise. He needed to move so I asked everyone to move. We did it a few times and then we returned to mindful breathing afterwards. The child knew in that moment far better than I did what the group needed. It helped me realise that every experience has information if we listen closely enough. When I was curious about my own anxiety and remembered to listen to his experience, I was able to digress from the fixed plan and open up to what was needed in that moment.
I have noticed an increased cultivation of compassion towards others as my practice has developed. Where once I may have seen a child being resistant or obstinate I now have a deeper commitment to looking more deeply at the child who is possibly acting out of fear or pain. I have been more able to see the communication about their basic needs. The greatest teaching impact comes through relationships so the hope is that my emotionally accessible presence can support their ability to learn.
Mindfulness practice has allowed me to read my own inner stress barometer which has helped me set boundaries so that I do not over extend myself as much as I used to do. By mostly modelling emotional regulation whilst at the same time remaining fairly transparent and self-accepting, I hope I have been able to give the children the space to feel secure enough to be creative.
The following bar chart shows more clearly the effects of the current mindfulness intervention. Before the mindfulness intervention the mean score was 21 and this reduced to 14.86 at the end of the three weeks. There has been a 29% mean reduction of 6.14 points on the CAMM which suggests that overall the group of children has become more mindful over time. However, a major limitation of my study is that it has assessed only the short term impact of the intervention. It is limited in its ability to determine how enduring the treatment effects may be both in the presence or absence of ongoing meditative practice so the results should be treated with caution.
To analyse my results further I used the Wilcoxon signed-ranks test (see appendix one). I chose this test because my study utilised a repeated measures design and a non-directional experimental hypothesis. The W-value was found to be 0. The critical value of W for a sample size of 7 (N = 7) at a probability level of p≤ 0.05 is 2. Therefore, my results are significant at p≤ 0.05. This means that I can be 95% confident that I can accept my experimental hypothesis and reject the null hypothesis. A three week mindfulness intervention of six lessons has an effect on the mindfulness scores of 7 children in a psychotherapeutic school for traumatised children.
This project has enabled me to take a more heightened reflective stance on my practitioner role at the Mulberry Bush School. I have realised that I need to take more time to listen to my colleague’s stories to help create an optimum emotional environment in my team. The development of greater mindfulness skills has enhanced my capacity to listen with full attention to the cues of the children in my class. I have found myself adopting a more non-judgemental acceptance and compassion for myself and the children in my care and this has in turn led to improved emotional regulation.
Some organisations focus exclusively on the cultivation of mindfulness in the staff group in an attempt to help practitioners with self-care. The premise here is that if the adults have a sense of well-being, then this will naturally translate into an environment of wellness for the children in their care. This process has demonstrated to me how much more effective my responses are to children who are struggling in class when I am being mindful. When I am tired, preoccupied by other matters and my mind is more ‘full’ I have tended to react rather than respond and this has often escalated situations unnecessarily.
Bringing our own awareness to the difficult feelings inside gives us the knowledge we need to learn and develop resilience. Children are attuned to teachers and can rely on us to help them with regulation. When a child feels understood they can begin to see their own self-worth. In this view it is our own attention and happiness that helps children to cultivate a healthy way of being.
The development of good enough relationships with traumatised children requires emotional maturity. Knowing that most of our own actions are driven by unconscious motives is essential. Any activity which increases awareness of our own projections and those that are passed on to us can be seen to be beneficial. Anais Nin (1961) suggested that ‘we do not see things as they are; we see them as we are’. Our own inner angst paints the world with a dark hue. We project onto the outside when we are uncomfortable with our experience on the inside. Sigmund Freud, the father of psychoanalysis, said that ‘unexpressed emotions never die. They are buried alive and will come forth later in uglier ways’. If I am not mindful of my own inner world and the painful and unpleasant experiences, then I will see these experiences mirrored in world around us. We project out what we find too painful to accept inside. Rechtschaffen (2014) believes that this is where mindfulness practice comes in. If I find myself in a situation where children are unable to settle I can learn to feel the emotions in my body as sensations. It offers the skill of witnessing one’s own frenzied thoughts without getting swept up in them. This can be seen as ‘pulling back one’s own projections’ and can ultimately create an inner responsibility for our own emotions. This cultivates a discernment to see the world as it really is rather than how we have imagined it to be and to see which parts of the group dynamics are projections and which parts are true experiences.
Some organisations offer direct services provided by experienced mindfulness practitioners. This might be an area that the Mulberry Bush Organisation chooses to explore as part of their developing MBOX provision. My view is that mindfulness lessons can be supportive for the emotional, mental, and physical development of all children, no matter how complex their needs. In this approach any lessons that teach children to breathe, become aware of their thought patterns, and relax into their bodies is inherently helpful even if coming from a practitioner without the most thorough training.
Harnett (2012) suggests that mindfulness should be considered as one strategy for obtaining positive outcomes when working with children and their families rather than an endeavour it its own right. Mindfulness based interventions can sit within and complement other intervention strategies such as individual time, art therapy, music therapy and Autogenic Training. Systemic change is more effective than stand-alone provision.
For the greatest effect, the whole organisation and the families we serve could be taught how be more mindful. My recommendation for the Mulberry Bush School would be for an integrated approach which begins with training the whole staff group in mindfulness. At least one member of staff should be encouraged to train extensively to mentor the movement within the organisation whilst maintaining their own commitment to personal mindfulness practice. Children should be taught a mindfulness curriculum such as the one designed by the Mindful Schools Project (paws.b) during each year of their placement at the school.
It would be helpful for children (and adults) to have access to a space in the school designed for mindfulness. This should be a safe, nourishing, dedicated space which children can refer themselves to when they are feeling unregulated. The school council could be consulted in the design of this space to ensure that children feel that their well-being is being considered.
Whether these recommendations are implemented or not is less important to me than the knowledge that I have gained about myself during this project. I have been able to reflect upon the importance I attach to mindfulness in my own life. It has confirmed my need to maintain and deepen my own practice. It has highlighted the importance for me to attend a regular mindfulness meditation group and occasional silent retreat in addition to my continued home practice. I have also realised how much I would like to carry out further academic training in this area.
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