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Journal of Intellectual Disability Research
93
doi: 10.1111/jir.12082
volume 59 part 2 pp 93–104 february 2015
Mindfulness-based cognitive therapy for adults with
intellectual disabilities: an evaluation of the effectiveness
of mindfulness in reducing symptoms of depression
and anxiety
H. Idusohan-Moizer,1 A. Sawicka,2 J. Dendle3 & M. Albany4
1 South West Devon Learning Disability Team, Cornwood, Devon, UK
2 Teignbridge Community Learning Disability Team, Teignbridge, Devon, UK
3 Clinical Psychology, University of Exeter, Exeter, Devon, UK
4 Clinical psychology, University of Plymouth, Plymouth, Devon, UK
Abstract
Background Mindfulness-based interventions have
been shown to be effective in the treatment of a
range of health and psychological disorders in
adults and young people without intellectual disabilities (ID). Clinical studies are emerging reporting
on the efficacy of mindfulness-based interventions
as a stand-alone treatment for common clinical disorders in adults with ID.
Method This paper aims to evaluate the efficacy of
an innovative structured mindfulness-based cognitive therapy (MBCT) group programme adapted for
adults with ID with a diagnosis of either recurrent
depression, anxiety or both clinical conditions and a
history of deliberate self-harm behaviour. Two
Correspondence: Dr Helen Idusohan-Moizer, South West Devon
Learning Disability Team, Delamore Park, Unit 4, The Barns,
Cornwood, Ivybridge PL21 9QP, UK (e-mail: helen.idusohan@
devon.gov.uk).
groups ran consecutively consisting of a total of
fifteen participants and seven carers. All participants
were recorded as having either a borderline, mild, or
moderate ID. The group programme ran over a
period of 9 weeks with a follow-up session at 6
weeks post group intervention. Outcome measures
included the Hospital Anxiety and Depression Scale
and two sub-scales from the Self-Compassion Scale
administered at baseline, post therapy and at 6-week
follow-up.
Results The evaluation showed that participants
reported an improvement in their experience of
depression, anxiety, self-compassion and compassion for others. The most significant impact was in
the reduced levels of anxiety reported. Improvements across all outcomes were maintained at
6-week follow-up.
Conclusion The results of the evaluation suggest
that people with intellectual disabilities benefit from
a structured MBCT group intervention and the
results are maintained at 6-week follow-up.
© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
volume 59 part 2 february 2015
Journal of Intellectual Disability Research
94
H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
Keywords anxiety, depression, intellectual
disabilities, mindfulness-based interventions,
self-compassion
Introduction
The prevalence of mental health problems in
adults with intellectual difficulties
It is generally accepted that the prevalence of
mental illness in adults with intellectual disabilities
(ID) is higher than in the general UK population
without ID (Cooper & Bailey 2001). Smiley (2005)
reported that the prevalence rate of mental illness in
people with ID is somewhere between 30 and 50%,
and in a population-based study, Cooper et al.
(2007) revealed a 40.9% point prevalence rate of
mental ill health in adults with ID. Mental illness
was associated with factors such as having more life
events, being female, and having a lower cognitive
ability. Deb et al. (2001) found the rate of mental
illness to be similar to the general population
without ID. However, this study found rates of
schizophrenia and phobic disorders in people with
mild to moderate disabilities to be higher than in
the general population without an ID. Increasing
age and physical disabilities were also found to be
associated with developing a mental illness. Methodological issues are noted in most of these epidemiological studies and so an accurate picture of the
prevalence rate of mental illness in this population
is difficult to reliably report.
People with ID contend with a lifetime of social
exclusion, discrimination, internal and external
stigma and unrelenting adversity alongside inadequate social and emotional support. These life
experiences predispose people with ID to depression and anxiety related disorders. The prevalence
of depression and anxiety specifically in people with
ID in the UK has yet to be precisely determined
because of the process of diagnosis being fraught
with difficulties not often encountered with people
without ID. For instance, the reliability of diagnosis
based on instruments not suitable for determining
psychopathology in this population, and errors in
the appropriateness and application of diagnostic
criteria, such as International Statistical Classification of Diseases and related health problems and
Diagnostic and Statistical Manual of Mental Disor-
ders Fourth Edition validated on individuals with
average IQ functioning (Cooray & Bakala 2005).
Comorbidity is another difficulty encountered as is
the major problem of diagnostic overshadowing –
the tendency to overlook or undermine the symptoms of mental illness and attribute the client’s
presentation to having an ID. Prasher (1999) suggests that the point of prevalence rate for a major
depressive illness in adults with ID is in the order of
2–7%, which is not dissimilar to that for the general
population which Prasher (1999) puts at 3–5%.
Depression in people with ID can present at all ages
but is reported to be more common in women than
in men. It is well documented that the incidence of
anxiety in people with ID is very high and is often
underreported and under diagnosed (Cooray &
Bakala 2005). Challenging patterns of behaviour
seen in people with ID is often the means by which
they cope with anxiety, stress and frustration. Moss
et al. (2000) identified anxiety disorders as more
prevalent in individuals with self-injurious behaviour
than those without. Raghaven (1997) revealed a
similar, if not higher prevalence of generalised
anxiety disorder in people with ID than in the
general population without ID.
Treatment approaches for depression and anxiety
in people with intellectual disabilities
The effectiveness of psychotherapeutic interventions
and what constitutes as an intervention for people
with ID has long been an issue for debate. Taylor
et al. (2008) reported increasing evidence for the
effectiveness of cognitive behaviour therapy (CBT)
approaches in treating a range of psychiatric disorders in this population. Willner (2005) in a review
on psychotherapies for people with ID reported that
cognitive behavioural therapies using a simplified
Beckian approach to treat anxiety and depression
resulted in large and significant decreases in
outcome scores which were maintained at 6-month
follow-up. There was also evidence for
psychodynamic and psychoanalytic approaches;
however, outcome data were limited by being
descriptive or anecdotal in most cases. Prout &
Browning (2011) in their review of the effectiveness
of therapies for this population conclude that both
individual and group psychotherapeutic interventions such as CBT, imagery rehearsal therapy and
© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
volume 59 part 2 february 2015
Journal of Intellectual Disability Research
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H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
anger management offer some degree of benefit as
long as reasonable adaptations/adjustments are
made to make the therapy accessible. The issue of
‘reasonable adjustment’ remains unclear as in our
opinion, modifying an intervention to a large degree
questions the evidence base for the intervention, an
argument highlighted by Leyin (2011). It must also
be noted that approaches such as CBT may not be
suitable for all people with ID, particularly those
with little or no language and have severe disabilities and high support needs (Sturmey 2004). The
limited range of evidence-based psychotherapies
available to people with ID presenting with depression and anxiety compared to the general population without ID suggests that an increase in
treatment options is needed. Exploring the possibilities of increasing therapy choice that is resource
and cost effective and ‘fits’ the presentation rather
than vice versa is one of the reasons for developing
this innovative programme.
Mindfulness and mindfulness-based cognitive
therapy for people with intellectual disabilities
Mindfulness is the practice of paying attention in a
particular way, on purpose, in the present moment,
and non-judgmentally (Kabat-Zinn 1990).
Mindfulness-based cognitive therapy (MBCT)
combines a form of Eastern meditation with
elements of cognitive therapy (Segal et al. 2002).
It has been developed with the aim of reducing
relapse in persons with recurrent depression and
anxiety, and those vulnerable to episodes of depression and anxiety. Based on the work of Jon Kabat
Zinn, MBCT includes simple breathing meditations
and yoga stretches to aid individuals in becoming
more aware of the present moment, including
getting in touch with moment to moment changes
in the mind and body. MBCT also includes psycho
education on depression and anxiety and a number
of exercises from cognitive therapy that demonstrate
the association between thinking patterns/styles,
feelings and behaviour, and ways individuals can
look after themselves when they feel overwhelmed
by low mood or anxious thoughts. Individuals with
ID presenting with depression and anxiety will often
have had the recurrent experience of trauma, loss,
uncertainty, rejection and exclusion, resulting in
hopelessness, internal stigma and in many cases
self-loathing and poor self-esteem. Many would
either have been denied therapy in the past or not
benefitted from therapy because of insufficient
adaptations. Mindfulness-based therapies can offer
people with ID a way of making room for new ways
of seeing old problems and by so doing change the
relationship they have with the every day cares of
life. MBCT can help people with ID to recognise
and observe more clearly patterns of the mind and
to create distance from thoughts that would otherwise affect their mood in an unhelpful way. Mindfulness relies more on reducing experiential
avoidance by enabling individuals to become aware
of and normalise emotions and bodily sensations
without engaging in any futile effort to challenge
and rid themselves of these experiences. This
process relies less on verbal exchange between
therapist and client which some people with ID find
difficult. There is little emphasis in MBCT as in
conventional CBT on changing/challenging
thoughts associated with beliefs. The focus is on
systematic training to be more aware, moment by
moment of physical sensations and of thoughts and
feelings as mental transient events in any given
moment; letting go of these thoughts and sensations
without getting caught up by them. Such abstract
notions are simplified and made more concrete for
people with ID by using metaphors and analogies
such as ‘the tug of war’ (Hayes et al. 1999). MBCT
relies more on promoting radical acceptance of
one’s self which in itself is the catalyst for change.
MBCT is mostly skill based offering the individual
with ID a range of strategies which will enable them
to be more receptive, flexible and have greater
control over their behavioural and emotional
response to events in their lives. In other words,
enabling them to become more ‘response-able’ in
challenging situations.
Cultivating a compassionate mind as a component
of mindfulness-based cognitive therapy for people
with learning disabilities
In adapting current interventions for people with
ID, the role of shame, self-criticism and selfloathing is often overlooked and not targeted as
key factors in the maintenance of depression and
anxiety. Gilbert (1998) described ‘shame’ as
thoughts and feelings about how one is perceived
© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
volume 59 part 2 february 2015
Journal of Intellectual Disability Research
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H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
negatively by others (external shame) and therefore
one feels rejected and vulnerable to attacks from
others. Perceiving oneself as vulnerable and
rejected can result in the development of maladaptive coping strategies as a means of dealing with
such perceptions, which can often be observed in
people with ID. In internal shame, the focus of
attention is on self-awareness of how one exists
and functions in the world compared to others.
The self is evaluated as inadequate, flawed, bad
and devalued. External and internal shame often
fuse together (Lewis 2003) triggering an episode in
which the individual perceives the world as turning
against them and is unsafe. Under such circumstances individuals tend to find self-worth, selfsoothing and self-acceptance difficult and/or
frightening (Gilbert & Procter 2006). Teaching
people with ID how to cultivate a compassionate
mind enables them to accept and develop a more
healthy relationship with aspects of themselves and
their environment without trying unproductively to
rid themselves of the pain often associated with
these aspects of their existence that is experienced
as out of their control. Developing self-compassion
encourages people with ID to engage in the
process of ‘letting go’ of self-blame, painful memories and experiences and in so doing eases suffering. Self-compassion consists of three fundamental
interrelated components. These include: (1) selfkindness-being kind and understanding towards
oneself rather than being harsh, judgemental and
self-critical in times of perceived failure; (2) seeing
one’s experiences as part of common humanity
rather than as separating and isolating; and (3)
mindfulness-holding one’s painful thoughts and
feelings in balanced awareness rather than overidentifying with them (Neff 2003a,b, p. 224).
Teaching people with ID to become more aware
of these interrelated components is necessary in
order to develop self-compassion. The ability to
develop and show one’s self-compassion, patience
and tolerance is important in all the therapies that
come under the umbrella of mindfulness and is
thought to be an important mediator of psychological well-being (Neff et al. 2007). It may well be
an important factor in any mindfulness-based
intervention for anxiety and depression (Birnie
et al. 2010; Keng et al. 2012) hence its inclusion in
the MBCT group therapy programme.
Why is mindfulness-based cognitive therapy a
feasible treatment intervention for persons with
intellectual disabilities?
In championing the agenda of normalisation and
valuing people with ID, one must ask the question
why should people with ID be denied access to a
range of potentially effective treatments offered to
people without ID? Doing all that we can to
improve access to the same range of psychological
treatment programmes available in mainstream
mental health services goes some way to ensuring
an equitable service for people with ID. MBCT is
now a widely accepted evidenced based intervention
for the treatment of clinical disorders such as
depression (Kuyken et al. 2008; Godfrin & van
Heeringen 2010; Hofmann et al. 2010). Meta analytic studies have reported that MBCT is most
effective in treating recurrent depression but has
showed minimal effectiveness in those who had less
than three episodes of recurrent major depression
(Piet & Hougaard 2011). MBCT is also shown to
be effective in the treatment of anxiety-related disorders (Kim et al. 2010; Chiesa & Serretti 2011) and
has a positive effect on the regulation of emotion
(Stein et al. 2008; Keng et al. 2012).
The emerging research into the effectiveness of
specific mindfulness techniques as a clinical intervention for adults with ID is promising. The efficacy of these stand-alone interventions have been
evidenced in the treatment of aggression in individuals with mild and moderate ID in a community
setting (Singh et al. 2003, 2008, 2011a), in treating
sex offenders (Singh et al. 2011b) and as a wardbased programme for treating aggression in women
in a medium secure setting (Chilvers et al. 2011).
Mindfulness as a core process in Dialectical Behaviour Therapy (DBT) has also been shown to be an
effective intervention in the treatment of forensic
clients with ID (Sakdalan et al. 2010). Robertson
(2011) has used mindfulness-based interventions for
people with ID for many decades, combining
aspects of CBT, Acceptance and Commitment
Therapy (ACT) and mind-body relaxation in the
management of anxiety, depression, aggression and
self-injury. The purpose of developing the MBCT
programme for people with ID is based on existing
research and literature reviews suggesting that
mindfulness-based interventions and practice can
© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
volume 59 part 2 february 2015
Journal of Intellectual Disability Research
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H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
lead to improvements in behaviour, psychological
well-being, lifestyle and quality of care and support
people with ID receive (Hwang & Kearney 2013).
The treatment programme also offers an alternative
to one on one therapy as well as in our opinion
being more cost and resource effective.
Method
Participants
The participants were recruited from three community learning disability teams in the South and
South-West areas of Devon in the UK. The aims of
the treatment programme were discussed at the
three team’s multidisciplinary meeting and team
members were encouraged to refer male and female
clients on their caseload that met the inclusion criteria. The facilitators also offered to meet with
potential clients that referrers’ were unsure about
their suitability for the group. The inclusion criteria
was male and female clients aged 18+ (no upper age
limit applied) with borderline, mild or moderate ID
who had experienced one or more episodes of
depression or generalised anxiety, or both clinical
conditions with or without a history of deliberate
self-harm behaviour. Those diagnosed with bipolar
affective disorder were also invited to take part in
the group providing they were not in the manic
stages of illness. Those with a diagnosis of psychosis, severe or profound ID were excluded from the
programme. No ethical approval was sought or
needed as this was an evaluation of a treatment
programme.
The treatment programme consisted of two
groups which ran consecutively across two sites.
Group 1 consisted of six service users; five female,
one male and three carers. The carers consisted of
two family members and one paid support worker.
All but one participant had received one on one
therapy in the past. Five participants had either a
borderline or mild learning disability and one had a
moderate disability. Group 2 consisted of nine
service users, three women, six men and four
carers. The carers were one family member and
three paid support workers. The majority of the
service users were on the waiting list for one on one
therapy. Two participants in this group had a moderate disability. All the service users in both groups
had a documented history of recurrent depression
and/or anxiety, alongside other secondary mental
health problems and deliberate self-harm behaviour.
Fifteen service users and seven cares in total consented to participating in the group across the two
sites. Ten participants across both sites completed
the programme; one participant with a moderate ID
attended six sessions, another also with a moderate
disability completed five sessions, one person with a
mild disability attended three sessions and two with
a mild disability dropped out after the first session.
The participants who attended sporadically and did
not complete the programme were the ones who
were accompanied to the group. Out of the seven
carers who attended the groups only two who were
family members participated in all ten sessions.
Table 1 is a summary of the demographics of the
participants.
Table 1 General demographics
Demographics
Female (n = 8)
Male (n = 7)
Age (mean)
Range
ID category:
Borderline
Mild
Moderate
Ethnicity:
White British
Employment:
Employed
Student
Volunteer
Unemployed
Marital status:
Married
Single
Cohabiting
Divorced
Diagnosis:
Anxiety
Depression
Anxiety & depression
Bipolar affective disorder
Previous therapy:
Individual therapy
Group therapy
Nil therapy
31.5
21–41
30
21–44
4
4
0
0
4
3
8
7
3
2
2
1
3
1
0
3
0
6
2
0
2
5
0
0
4
0
2
2
5
0
2
0
6
0
2
2
1
4
ID, intellectual disabilities.
© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
volume 59 part 2 february 2015
Journal of Intellectual Disability Research
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H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
Programme description
The MBCT group programme for depression and
anxiety for adults with ID is loosely based on Segal
et al.’s (2002) manualised MBCT programme for
depression. Aspects of the Segal programme kept
intact and included were as follows: (1) mindfulness
of the breath; (2) basic yoga stretches; (3) the raisin
exercise; and (4) diary of pleasant and unpleasant
events. In addition, the programme draws on metaphors and analogies from ACT (Hayes et al. 1999),
incorporates modified exercises on developing selfcompassion (Neff 2003a,b) and meditation on the
soles of the feet (Singh et al. 2003). The programme was delivered using Powerpoint slides of
pictures illustrating the important key points in
every session and handouts were provided with clear
home assignment instructions and summaries of
each session. Table 2 summarises the content of
each session.
Table 2 Summary content of the MBCT programme
Session 1
Session 2
Session 3
Session 4
Session 5
Aims of the mindfulness-based cognitive
therapy programme
The programme aimed to improve mental wellbeing and reduce the experience of depression and
anxiety by achieving the following:
• Improve emotional literacy by labelling and
exploring the experience of a range of emotions and
the interrelatedness of emotions to physiological,
behavioural and cognitive processes.
• Improve awareness of the present ‘the here and
now’ to reduce rumination on the past and anxious
thoughts about the future.
• Teach self-regulation skills such as mindfulness of
the breath (Kabat-Zinn 1990) and meditation on the
soles of the feet (Singh et al. 2003) for the regulation
of emotions such as anger.
• Improve self-compassion and self-acceptance.
• Improve lifestyle choices.
• Present a range of alternative choices and opportunities to increase psychological flexibility.
Outcome measures
Hospital Anxiety and Depression Scale (Zigmond &
Snaith 1983)
The Hospital Anxiety and Depression Scale
(HADS) is a 14-item interview questionnaire that
Session 6
Session 7
Session 8
Session 9
Session 10
Labelling emotions and increasing
awareness of both positive and
distressing emotions. Introduction to
breathing meditation and home
assignments.
Noticing thoughts and worries and impact
on behaviour. Fostering gentle acceptance
and ‘letting go’ of troubling thoughts,
emotions and experiences.
Managing difficult emotions such as anger
with mindfulness. Introduction to
meditation on the soles of the feet.
Introduction to diary keeping of pleasant
and unpleasant emotions.
Compassion and kindness, learning to
self-sooth and respond to the ‘critical
voice’ with kindness, fostering positive
self-affirmation and positive self-regard.
Home assignment focus on unpleasant
diary with examples of compassion and
kindness as an alternative response to
situations.
Dealing with problems in mindfulness
practice – introducing expressive art
such as Mandalas for use in times when
levels of arousal are high and not
conducive to meditation.
Mindfulness and a healthy lifestyle.
Introduction to simply yoga stretches.
Noticing, experiencing and observing,
staying in the present. The raisin
exercise.
Mindfulness everyday and positive activities.
Consolidating, reflecting and planning ahead.
Feedback session and reflection on what
works, revisit of all mindfulness practice
tools. Planning for the future.
MBCT, mindfulness-based cognitive therapy.
measures depression, anxiety and the severity of the
emotional disorder. The questionnaire was chosen
in order to compare scores at baseline, intervention
and at follow-up stages and to investigate the effectiveness of the intervention.
The Compassion Scale (Neff 2003a)
The Compassion Scale is a self-report questionnaire
consisting of 12 cluster items measuring compassion, self-compassion and kindness to the suffering
of self and others. The scale was adapted and
© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
volume 59 part 2 february 2015
Journal of Intellectual Disability Research
99
H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
shortened for the purpose of the group and the following cluster items were selected for use: SelfKindness, Mindfulness and Kindness items. The
questionnaire was used in order to investigate the
effect of the intervention on the participants’ compassion for others and for themselves.
Facilitators
The facilitators consisted of a qualified clinical psychologist with training in mindfulness-based
therapies, an assistant psychologist and two trainee
clinical psychologists who had attended workshops
on mindfulness and observed the lead facilitator in
practice as part of their training for co-facilitating
and facilitating the groups. Group 1 was facilitated
by a clinical psychologist, an assistant psychologist
and one of the trainees. Group 2 was facilitated by
the assistant psychologist and a trainee clinical psychologist with supervision provided by the clinical
psychologist.
Procedure
The participants were invited to a one on one pregroup session where they were told about the group
and invited to complete the therapy outcome measures at the end of the pre group meeting. They
were invited to participate in the evaluation and
given the opportunity to ask questions. Written
consent was obtained from participants who agreed
to both attend the group and allow their data to be
used in the evaluation. They were informed of their
right to attend the group without participating in
the evaluation, and to withdraw from the intervention at any point as well as the right to withdraw
their data. The participants were provided with
easy-read materials that the facilitators developed
on mindfulness, the outline of the group programme and the evaluation.
from an emotionally arousing (angry) thought,
event or situation to an emotionally neutral part of
one’s body, the soles of the feet (Singh et al. 2003).
In order to master both procedures to the point of
automaticity, the participants were provided with
CDs with both meditations to listen to daily in
between the sessions. The original MBCT MBSR
programmes consist of many more meditation exercises and yoga stretches such as the body scan and
mindful walking. For people with ID repetition
and mastery is of the essence and restricting the
programme to a total of three repetitive exercises
(mindfulness of the breath, meditation on the soles
of the feet and basic yoga stretches) reduced confusion and the chances of people feeling overwhelmed
by the number of home exercises expected of them.
The group therapy programme ran for a period of
9 weeks with a post group follow-up at 6 weeks.
Each weekly session ran for one hour 30 minutes
with a 10-min tea break. Participants were encouraged to attend with a carer who could commit to
participating in the 10-week programme. Studies
have shown that support staff and carers of people
with ID experience work related stress (Hastings
2002; Hastings et al. 2004). Noone & Hastings
(2010) found that such carers and support workers
benefitted from attending a mindfulness and acceptance and commitment workshop and experienced
reduced psychological distress as a result. Therefore
staff and carers supporting the participants were
invited to actively participate in the group programme in the hope that (1) they would themselves
learn new skills for managing work related stress;
(2) would disseminate their new knowledge and
experience to fellow colleagues, thus influencing the
psychological mindedness of the support team; (3)
impact positively on the participant’s experience of
support.
Design
Intervention
Each and every session consisted of practising one
of two meditations. The first, Meditation on the
Breath, is a well known practice used in MBCT
(Segal et al. 2002) as well as MBSR (Kuyken et al.
2010). The second, ‘Mindfulness on the Soles of the
Feet’ which enables the individual to divert attention
This was an evaluation of a 10-week mindfulnessbased cognitive therapy group programme for adults
with intellectual disabilities. Within group comparisons for scores obtained at baseline, intervention
and follow-up stages of treatment were performed.
T-tests were used to compare mean scores where
appropriate.
© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
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volume 59 part 2 february 2015
Journal of Intellectual Disability Research
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H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
Results
Statistical analysis
Data analysis consisted of a number of within
group comparisons for pre-group and post-group
scores, post group and 6-week follow-up scores and
pre-group and 6-week follow-up scores. All data
were tested for normal distribution. Where the
sample was normally distributed, related t-tests were
used to compare mean scores. Where the sample
was non-parametric the Wilcoxon rank-sum was
conducted to determine significance. Because of the
small sample size (n = 12) the exact output was
reported.
Compassion scale
Post-group scores were significantly higher than
pre-group compassion scores z = −2.20, P < 0.02,
r = −0.64, indicating that the 10-week mindfulness
programme significantly improved participant’s
compassion and kindness for themselves and others.
Further, there was no significant difference between
post-group scores and the 6-week follow-up scores
z = −0.426, P = 0.73, r = −0.13, indicating that participant compassion and kindness for themselves
and others had not significantly changed at the
6-week follow-up compared to post-group. Pregroup and 6-week follow-up compassion scale
scores did not differ significantly z = −1.07,
P = 0.31, r = −0.39, however the pattern of results
does suggest that participants compassion scores
remain higher at the 6-week follow-up compared to
pre-group.
Hospital Anxiety and Depression Scale
anxiety scores
The HADS anxiety scores were significantly lower
post-group (M = 8.00, SD = 4.61), compared to
pre-group (M = 11.50, SD = 5.27) t(11) = 3.29,
P < 0.01, r = −0.70, indicating participants were
experiencing lower anxiety levels post-group
compared to pre-group. Post-group (M = 8.00,
SD = 4.74) and 6-week follow-up (M = 7.80,
SD = 3.71) HADS anxiety scores did not differ significantly t(9) = 0.215, P = 0.834, r = −0.07, indicating that participants did not experience a significant
change in anxiety levels, as measured by the HADS,
from post-group to the 6-week follow-up. In addition, HADS anxiety scores were significantly lower
at the 6-week follow-up (M = 7.80, SD = 3.71)
compared to pre group (M = 11.30, SD = 5.76),
t(9) = 2.73, P < 0.05, r = −0.67, indicating participants continued to experience lower anxiety levels,
as measured by the HADS, at 6 weeks post group
compared to pre-group.
Hospital Anxiety and Depression Scale
depression scores
The HADS depression scores were significantly
lower post-group compared to pre-group z = −2.36,
P < 0.05, r = −0.68, indicating participants were
experiencing lower levels of depression post-group
compared to pre-group. Post-group and 6-week
follow-up HADS depression scores did not differ
significantly z = −1.586, P = 0.13, r = −0.48, indicating that participants did not experience a significant change in levels of depression, as measured by
the HADS, from post-group to the 6-week followup. HADS depression scores were not significantly
lower at the 6-week follow-up compared to pre
group z = −2.05, P = 0.06, r = −0.64, however the
pattern of results suggest that participants continued to experience lower levels of depression, as
measured by the HADS, at 6 weeks post group
compared to pre-group.
Qualitative feedback
Feedback on the experience of service user participation in the group was requested from those who
completed the programme and those that dropped
out from the programme. The carers of two participants with a moderate disability who dropped out
within the first 6 weeks of the group stated that the
programme did not meet the needs of people with a
moderate disability. Two participants with mild disabilities who dropped out after the first session
stated that they did not like the meditation practice.
All the participants except those with a moderate
disability stated that they found the content of the
programme on the whole easy to understand and
the summary information provided at the end of
each session easy to follow. All participants including those that dropped out stated that they were
treated with respect, kindness, understanding and
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with interest. Those that completed the programme
preferred meditation on the breath to meditation on
the soles of the feet which they found more difficult
to do. Eight participants (53%) stated that they
would continue practising the breathing meditation.
Seven participants (47%) stated that they would
continue doing the yoga stretches, and one person
stated that the illustrated yoga stretches where now
firmly placed on their bedroom wall for daily use.
Five participants (33%) found the pleasant and
unpleasant diaries easy to use and helpful and ten
participants (67%) found the amount of paper work
including the diaries overwhelming. All the participants enjoyed using the Mandalas and planned to
continue using them after the group. One participant stated ‘they help me to concentrate and my mind
is clear afterwards’. The facilitators considered the
session on compassion the most challenging session
and to their surprise all those who attended this
session enjoyed it. One participant commented
‘compassion and kindness are easy to follow if you learn
to love yourself and what you are’. Ten participants
(67%) found the group really helpful and would
recommend it to a friend. One participant stated
that the group had helped them a lot in responding
to everyday life. Most importantly, two participants
who were reticent about group therapy and indeed
any psychological intervention stated that they had
a wonderful experience and would not be reluctant
to attend future group therapy programmes if
invited. Two family members who completed the
programme stated that meditation on the breath in
particular helped them with managing physical
health problems and stress.
A few suggestions were made on how the group
could be improved for future participants. Regular
feedback from participants on clarity of the session
and materials was one suggestion, more repetition
and more role play of the important aspects of the
group was another. A family carer of one client with
a moderate disability thought that the facilitators
would need to cater separately for people with different levels of ability as the ‘one size fits all’
approach did not work.
Discussion
This pilot MBCT group programme aimed to
evaluate the effectiveness of offering mindfulness
as a complete stand alone therapy to adults with
ID with a history of depression and anxiety. Our
results indicate that the therapy was effective in
reducing the symptoms of both anxiety and
depression. These findings are consistent with
MBCT outcomes for people without ID (Finucane
& Mercer 2006; Eisendrath et al. 2008). Positive
outcomes were also found in the participants willingness to be more compassionate towards the self
and others which is consistent with a pilot study
on MBCT and compassion in a non-ID population (Lee & Bang 2010).
Research investigating the efficacy of MBCT for
people with ID is still in its infancy and there are
many strengths and limitations to the existing
literature. This current evaluation also has many
strengths and a number of limitations similar to the
studies that precede it. This programme evaluation
has made an accepted evidenced-based intervention
that is widely available to people without ID in most
statutory mental health services and non-statutory
organisations, accessible and available to adults with
ID. The adaptations and additions made to the
original 8-week MBCT programme has had no
adverse effect on the efficacy of the therapy for this
client group as evidenced by statistical analysis. The
programme’s effectiveness was evaluated at baseline,
end of therapy and at 6 weeks’ follow-up; rarely
reported in mindfulness-based intervention outcome
studies for people with ID. Furthermore, the facilitators have attempted to elicit from participants
aspects of the programme they considered the most
beneficial in self-management post intervention.
The outcome of this study concurs with research
which strongly suggests that people with intellectual
disabilities can and do benefit from psychological
interventions in the same way that people without
intellectual disabilities do (Prout & Nowak-Drabik
2003; Willner 2005) so long as reasonable adaptations are made to increase accessibility (Dodd et al.
2011).
The limitations to this study concur with the
problems identified in the existing literature on
therapy outcomes for this population. Many of
the studies on mindfulness and other therapy
approaches for people with ID consist of reports on
single case studies, evaluations of small sample sizes
and no randomised controlled trials in the last 5
years that the authors are aware of. Existing studies
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H. Idusohan-Moizer et al. • Mindfulness for adults with intellectual disabilities
rarely address the issue of which components of
therapy were appraised by participants as the most
meaningful and effective in instigating long term
change. Likewise, the current study is unable to
comment on whether an increased awareness of the
present (mindfulness) or developing self-compassion
or both meditate improved ability to self-regulate
and thus manage depression and anxiety symptomatology better. The present study like many studies
before it is based on a small sample size and so the
outcome data must be interpreted with caution.
Similarly, the universality of the findings is questionable as the participants were all ‘White British’
therefore the outcomes could not be said to generalise to people with ID from black and minority
ethnic groups. Furthermore, feedback from participants and carers who dropped out of therapy suggests that the intervention is not suitable for people
with moderate intellectual disabilities and only suitable for those with borderline and mild intellectual
disabilities who are able to read and write. It further
suggests that people with moderate disabilities may
need a more tailored one-to-one programme consisting of expressive arts and intensive meditation
practice.
Feedback from those with moderate disabilities
accompanied by their carers merits further discussion based on the observations of the facilitators.
The service users who dropped out of therapy
were those accompanied to the session by support
workers or a family member. These participants
were observed to have support workers who were
not consistent in their attendance because of staff
rota issues and struggled themselves to participate
in the therapy, especially engaging in meditation.
Given the importance of home practice and the
explicit expectation that carers/support staff would
model the meditation and assist the participants in
between sessions, the facilitators wondered how
much the disengagement of the support staff
impacted on the motivation of those they cared
for in the group. Likewise, participants who completed the treatment and reported benefitting
from it were accompanied by family members who
themselves reported benefitting from the therapy.
These family members were proactive in ensuring
that the participant completed their homework and
meditated with them to reinforce the expected
daily practice. Our opinion is that carer/support
worker participation or lack of it greatly influences
the participants’ motivation for therapy.
To the authors’ knowledge, this is the first
attempt to adapt and evaluate the effectiveness of a
structured MBCT group programme for adults with
ID and the results are very promising though it is
accepted that the findings must be interpreted with
caution given the noted limitations of the evaluation. Future studies we hope will build on these
preliminary findings and contribute further to the
development of mindfulness-based therapies for this
population.
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