Integrated Mindfulness Interven1on Elizabeth Berlasso, NSRCT, Psychotherapist Rob Dickson, Clinical Team Leader Tara Sampalli, PhD, Manager Minakshi Dhir, Research Associate Integrated Chronic Care Service, Primary Health Care There is more right with you than wrong with you - Jon Kabat-Zinn
Quality ini1a1ve Quality Ini1a1ve: Integrated Mindfulness Interven1on (IMI) at the Integrated Chronic Care Service What was being addressed? To improve applica1on of principles in everyday life Goal of the ini1a1ve: to develop and implement an integrated mindfulness interven1on Interven1on: Combined elements of stress management interven1on, a healthy rela1onship with food and func1onal health restora1on Interven1on group: Over 300 individuals (80% having more than three chronic condi1ons) have par1cipated in this interven1on to- date.
Integrated Chronic Care Service! Outpatient Service in Primary Health Care, Capital Health! Located in Fall River! Interdisciplinary care team! All patients are referred by physician or Nurse Practitioner 3
Why the integrated interven1on? we heard from our pa1ents Pa1ents indicated self- management strategies had to be meaningful and relevant. Individuals indicated feeling discouraged that their illness cannot be cured and fearful in their ability to live fully engaged in their lives Pa1ents struggled in drawing relevance from mindfulness prac1ce to their everyday coping and management of func5onal ac5vi5es.
Our Promise, Capital Health 1. Improving care for individuals with mul1ple chronic condi1ons through integrated and person- centered care 2. People living with chronic condi1ons: - Effec1ve self- management strategies - Receive appropriate early interven1ons - Achieve desired outcomes 3. For our health system: - BeTer use of exis1ng resources - A more sustainable system
The Journey
Process Changes " Phase I: Review of mindfulness interven1on offered at ICCS staff and pa1ents pa1ent feedback leads to exploring enhancements " Phase II: Mindful ea1ng and mindful movement interven1ons are introduced in ICCS as pilot projects. Outcomes are significant " Phase III: Informing and gezng the consent from the MassachuseTs Mindfulness Group of the proposed integrated program " Phase IV: An integrated and revised 8 week mindfulness interven1on program combining elements of stress, mindful ea1ng, mindful movement was developed " Phase V: Implementa1on and evalua1on " Phase VI: Thinking of the spread
Integrated Mindfulness Interven1on Developed by a psychotherapist, die11an and occupa1onal therapist Goals of the program: Timely recogni1on of symptoms, improve medica1on management, make necessary lifestyle adjustments and manage associated psychosocial stressors Ability to shi] from what was to what is as a way of beter coping and self- management abili1es being in the present, which is the essence of mindfulness By offering an interven1on that is group- based and available to the larger organiza1on for cost- effec1veness and sustainability
Elements of the integrated program Mindfulness- based stress reduc1on Mindful ea1ng Mindful movement
Elements of Mindfulness Inten1on AZtude ATen1on Right ac1on
MBSR Overview The health benefits of mindfulness can be boiled down to four elements, according to a Perspec1ves on Psychological Science study: body awareness, self- awareness, regula1on of emo1on and regula1on of aten1on. Prac1ce being curious Make peace with imperfec1on Hold emo1ons lightly Embrace Vulnerability Understand that all things come and go "How do you start?"
MBSR Research treatment of chronic condi1ons Anxiety Arthri1s Asthma Cancer Chronic Pain Depression Diabetes Fibromyalgia Hypertension GI MS Mul1ple Chemical Sensi1vity Psoriasis Benefits in allevia1ng symptoms Bringing a sense of balance and well being Improvement in func1onal health status Improvements in quality of life Improvement in concentra1on and focus Self efficacy Mindfulness research showing benefits in the treatment of many condi1ons
What is mindful ea1ng? Core principles Mindful ea1ng has been shown to be: Effec1ve tool in managing glycemic control in diabetes, managing hypertension, dyslipidemia, arthri1s and many others where weight loss maintenance is of utmost importance. Effec1ve in managing food sensi1vi1es
Mindful Ea1ng Research some examples Study showed improvement in mindfulness, anxiety, external- based ea1ng, chronic stress, reduc1on in abdominal fat, and cor1sol awakening response. (Daubenmmier et al. 2011) BMI reduc1ons were mediated primarily by reduc1ons in binge ea1ng through mindfulness interven1ons (Tapper et al. 2008) Study showed there was a decline in binge ea1ng episodes as well as anxiety and depressive symptoms. Smith et al. 2006
What is mindful movement? Mindful movement to address diminished sensa1on/body awareness, as well as poor movement quality. As we improve our ability to feel our muscles and our movements, the quality of movement is restored and muscle tension reduced Finding effec1ve ways of resezng or reeduca1ng the neuromuscular system.
Mindful movement Bodily awareness comes more easily to some people than it does others. Moreover, depending on the degree of awareness in a par1cular body region, a person may ini1ally struggle to feel much of anything at all. htp://www.mindful.org/mindful- voices/editors%e2%80%99 - blog/mindful- movement Slow mindful movement means doing something really different taking aten1on to the sensa1ons of a state between fran1c ac1vity and stopping, and leaning into the discomfort of that. It feels very alive, very annoying, and very worthwhile.
Mindful movement research There are specific physical benefits associated with each of these mindful movement prac1ces. Research shows yoga, for example, has health benefits including: " Increased strength and flexibility " BeTer balance and coordina1on " Improved reac1on 1mes " BeTer lung func1on " Heightened cardiovascular condi1oning " Weight loss.
Mindful movement research Psychological benefits of prac1ce include: " Relaxa1on " Greater equanimity " BeTer concentra1on " Improved mood
Mindful movement research Scien1fic studies have found yoga as a useful adjunct to the care of such condi1ons as: " Asthma " Arthri1s " Carpal tunnel syndrome " Mul1ple Sclerosis " Heart disease
IMI modules overview Broad goals from specific sessions: with OT and die11an What are the aspects that are addressed? Link to daily ac1vi1es/auto pilot Integra1on of principles of self- awareness, self- reflec1on and meaningfulness It became evident from the various forms of feedback that mindfulness training could not sit as a separate component of wellness, but rather it needed to contribute to a direct, more effec1ve and informed experience of day- to- day func1oning. Bodies are meant to move and be ac5ve, minds are meant to rest for op1mal health
Process measures IMI outcome measures Wait 1mes for dietary, psychotherapy and occupa1onal therapy treatment, IMI program comple1on rates Pre to post interven1on Mindfulness ATen1on and Awareness Scale (MAAS) Symptoms Check- List Inventory (SCL- 90R) Canadian Occupa1onal Performance Measure (COPM) Pa1ent interviews post interven1on
IMI Outcomes Measures Pre- post Interven1on (SD) P value SCL- 90R 32.2 (20.5) <0.0001 MAAS 0.25 (0.05) 0.001 Score of 6 indicates high level of mindfulness COPM (n=50) Recent addi1on to IMI 53. (1.1) Performance 4.3 (2.1) Sa1sfac1on <0.0001 <0.0001 Pain and fa1gue scores Improve by 20% (pain) Improve by 35% (fa1gue) Other subjec1ve improvements BeTer sleep, beter ea1ng habits, return- to- work, able to do household work, more ac1ve overall (social) = improved QoL; reduced use of medica1ons
What do our pa1ents say? Being mindfully present has helped me cope with whatever life brings at work, at home and in my everyday ac5vi5es and live well with my mul5ple problems I am able to self- manage and have a be@er quality of life with my family and friends. I know when to stop and catch myself from over doing
Resources htps://www.youtube.com/watch?v=_if4a- ghg_i The Tucker Founda1on and Dartmouth Hitchcock Medical Center present Jon Kabat- Zinn "The Healing Power of Mindfulness Hayes, S. C. & Pankey, J. (in press). Psychological acceptance. In W. T. O Donohue, J. E. Fisher, & S. C. Hayes (Eds.), Empirically supported techniques of cogni1ve behavior therapy: A step by step guide for clinicians. New York: Wiley. htp://www.mindful.org/subscribe- interrupters htp://www.youtube.com/watch?v=cukxfrwtcgm htp://marc.ucla.edu/
Resources Daubenmmier J, Kristeller J, Hecht FM, et al. (2011). Mindfulness Interven1on for Stress Ea1ng to Reduce Cor1sol and Abdominal Fat among Overwieght and Obese Women: An Exploratory Randomized Controlled Study. Journal of Obesity, 2011. Daubenmier Mindfulness Stress Ea1ng Tapper, K., Shaw, C., Ilsley, J., et al. (2008). Exploratory randomised controlled trial of a mindfulness based weight loss interven1on for women, Appe5te, doi:10.1016/j.appet.2008.11.012. Tapper Mindfulness Wt loss for women 08 Smith, BW, Shelley BM, Leahigh L, et. al. (2006). A preliminary Study of the Effects of a Modified Mindfulness Interven1on on Binge Ea1ng. Journal of Evidence- Based Complimentary & Alterna1ve Medicine, 11(3), p. 133-143.