Orientation and Assessment in MBCT

Ethical Issues in MBPs

Two-part masterclass

Ruth Baer
Oxford Mindfulness Centre
18 May 2019
 Part 1
Orientation and Assessment in MBCT
 What is orientation?

• Telling your potential participants about the course

• What do they need to know?
 What is assessment?

• Finding out about your potential participants

• What do you need to know about them?
 Purposes of orientation

• Discussion (15 minutes, small groups then large)

• What are the purposes of orientation?
• Advantages of doing this in a thoughtful way?
 Purposes of orientation

• Overview of course
• what to expect
• how it might help
• rationales
• Build rapport with teacher
• Discuss experiences of depression or ?
• Concerns, questions
• Build interest, motivation, commitment
 Methods of orientation

• How to provide info to potential participants?

• What methods have you used or experienced?
 Methods of orientation

• Individual interviews
• In person or by phone
• Website
• Taster sessions
• Other group sessions
• Handouts
 Individual pre-class interviews

• Example
• Based on “green book”
 Individual pre-class interview

• Welcome and overview

• What we will do in this session
 Individual pre-class interview

• What brings you here?

• History of depression
• Triggers, pattern of symptoms
How does
• Reactions to depression this
• How he/she explains the depression knowledge
help you?
• Habitual ways of coping
 Individual pre-class interview

• Explain how we understand recurrent depression

• Incorporate participants’ experiences and examples
• Explore if this makes sense for them

What skills do you need to

do this effectively?
 Individual pre-class interview

• Explain how MBCT might be helpful

• Incorporate
• participant’s expectations, hopes, concerns
• previous knowledge or experience
• meditation, CBT, depression
 Individual pre-class interview

• Discuss home practice

• what is expected
• why it’s important
• challenges
 Individual pre-class interview

• Discuss other potential challenges

• Discomfort in a group
• Expectations about speaking
• Difficult thoughts and feelings arising
• Wanting to quit
• Share
• previous participants say stick with it!
 Individual pre-class interview

• Explore
• Is this the right course or the right time?
• Time, motivation for practice
• Severity of symptoms, other symptoms
• Life circumstances, stressors
• (This question involves assessment – more later)
 Individual pre-class interview

• Discuss confidentiality
• General assurances
• Info for a contact person & consent to contact them
• in case of emergency
• Supervision
• Video
 Individual pre-class interview

• Discuss practical arrangements

• Times, location, where to park
• The all-day
• Phone if will miss a session
• Permission to call participant if doesn’t come or phone
 Individual pre-class interviews

• Reflections
 Websites

• Example
• OMC’s website for MBCT courses for general public
 OMC website

Learn to deal more skilfully with the stresses and strains of

daily living, by practising the skill of deliberately paying
attention to what happens in mind and body, to become
more familiar with the workings of our own mind patterns
and habits. This helps plan for how best to respond, rather
than react in our old familiar, often unhelpful ways.
 OMC website

• Is this course for me?

• What will I learn?
• Does it work?
• Who will teach me?
 OMC website

• Course details
• How often do we meet?
• Who is the course for?
• Where is the course?
• How many people on each course?
• How much does the course cost?
 OMC website

• The MBCT course includes

• …automatic pilot
• …‘chatter of the mind’
• ...being more focused and gathered
• … take a wider perspective, relate differently to experience
• …attitude of acceptance … taking care of oneself
• …what to do when depression, anxiety or stress threaten…
• …maintaining a balance in life
 OMC website
Handout for printing

• Is this the right course/right time for me to attend?

• Not suitable if:
• Mania or hypomanic episode last 6 months
• Current self-harm or suicidal thoughts
• Alcohol and drug use
• Daily practice while not under influence
 OMC website
Handout for printing

• Is this the right course/right time for me to attend?

• Discuss with course lead:
• Current depression
• Bereavement in past year
• Other ongoing psychological treatment
• Stressful life events – current
• Insulin-dependent diabetes
 OMC website
Another handout for printing

• What skills will you learn during the MBCT Course?

• What actually happens during an MBCT Course?
• What is covered in each session?
• What does home practice involve?
• What are the challenges?
• Who will teach me?
• Practicalities
• Attendance, arrival on the day, what to wear, tea/biscuits, practice day
• Terms & conditions (payment, cancellation, etc)
 Websites

• Reflections
Taster sessions
 Taster sessions

• Considerations
• Who is the audience?
• What will appeal to them?
• What are your goals?
• What info do you want to provide and how?
• Experiential, interactive, didactic
• Powerpoint? Handouts?
 Taster sessions

• Have you attended a taster session for a

mindfulness course?
• What were its ingredients?
• Were they helpful?
 Taster sessions

• Small group activity (15 minutes)

• Choose a setting or population for offering MBCT
• Create an outline for a taster session

• Large group discussion (15 minutes)

 Taster sessions

• Potential ingredients
• Welcome, introductions
• What is mindfulness? (and what is it not?)
• Practices
• Benefits of doing an 8-week course
• How it helps, evidence base
• What else?
Assessment
 Assessment

• What would you like to know

about your potential
participants?

• What is the purpose of this

information?
 Assessment

• Example
• Pre-course questionnaire for MBCT courses at OMC
• Completed online
• Follow-up phone call if concerns emerge
 Pre-course questionnaire

• Personal info: name, address, DOB, occupation…

• Emergency contact person: name & phone
• Physical or sensory limitation that might affect
your participation?
• Please confirm you have read the information on
the website under the heading "Is this the right
course or the right time for me to attend?"
 Pre-course questionnaire
• Health Questions
• The health information you provide is used to assess your
suitability for this course. It is kept as confidential and is
available to OMC staff, who may need to contact you for
further discussion … if the course is appropriate for you to
attend at this time. If you mutually decide that it is not, you
will be refunded in full.
• "I undertake to be responsible for my own wellbeing during
the course and agree to bring any concerns to the course
teachers in the first instance, and contact my GP or relevant
health professional, should I continue to have concerns
about my wellbeing."
 Pre-course questionnaire

• Health Questions
• Do you have Diabetes Type 1?
• Have you experienced depression in the past 6 months?
• Are you currently experiencing depression?
• Have you experienced psychotic episode/s in the past?
• Have you experienced a manic/hypomanic episode in
the past 6 months?
 Pre-course questionnaire

• Health Questions (continued)

• Are you currently receiving psychiatric or psychological
treatment?
• Are you currently taking any medication?
• Are you currently receiving any talking therapy?
• Have you deliberately harmed yourself in the past year?
• Have you ever attempted to take your own life?
 Pre-course questionnaire

• Health Questions (continued)

• Have you ever experienced a severely traumatic event
which is currently affecting you?
• Have you experienced bereavement in the past year?
• Are you currently using alcohol or drugs to manage your
stress/distress?
 Pre-course questionnaire

• Health Questions (continued)

• Are there any current life changes (loss of home, job,
relationship breakdown, too many work commitments
etc.) that may be placing you under additional stress?
 Pre-course questionnaire

• Resource for more examples

• Meditation Safety Toolbox
• Willoughby Britton, Brown University
• https://www.brown.edu/research/labs/britton/resources/
meditation-safety-toolbox
 Some possible decisions
• OK for MBCT
• Refer to mental health treatment (maybe MBCT later)
• Refer to more specialized MBP if available
• OK for MBCT if in psychotherapy and therapist agrees
• Consent for MBCT teacher and therapist to communicate
• OK for MBCT with monitoring of potential difficulties
• Weekly questionnaire (depression, PTSD, dissociation, etc)
• Weekly check in some other form
• OK for MBCT if teacher has consultation/supervision
 Pre-course questionnaire

• Reflections
 Conclusion

• Orientation and assessment

are ethical necessities
• Preventing harm
• Informed consent
• Truth in advertising
• Confidentiality
• Practicing within scope of
competence
 Part 2
Ethical issues in mindfulness-based
interventions
 Topics for Part 2

• Harm and adverse events in MBPs

• Professional ethics for mindfulness teachers
• Buddhist roots and secular adaptations
• Working with self-identified values
• Ethical communication about mindfulness
 My perspective

• Psychological science
• Professional ethics
• Clinical psychology
• American
 Harm and adverse events
Protecting mindfulness participants
 What is harm?

• sustained deterioration in an individual’s

functioning that is caused by the treatment
program
Duggan et al, 2014

• an outcome that is damaging, injurious, or worse

than it would have been without treatment
Dimidjian & Hollon, 2010
 What are adverse events?

• specific occurrences
• suicide attempts, hospitalizations, etc
 What are adverse events?

• specific occurrences
• suicide attempts, hospitalizations, etc
• might be caused by the program
• or might be unrelated
 What are adverse events?

• specific occurrences
• suicide attempts, hospitalizations, etc
• might be caused by the program
• or might be unrelated
• example:
• suicide during a course of treatment
• treatment didn’t necessarily cause the suicide
 Expected discomfort

• Psychological change is difficult

• confront painful experiences
• learn new skills
• apply skills in stressful situations
 Expected discomforts:
Mindfulness practice

• Difficult thoughts, emotions, sensations

• part of normal human experience
• learning to work with them skilfully is central
Harm from meditation
beyond expected discomfort
 Harm from meditation
Lindahl et al

• 60 Western practitioners of Buddhist meditation

• Challenging, distressing, impairing experiences
associated with meditation
• 72% during/after retreat
• 28% daily practice
• None MBIs
 Harm from meditation
Lindahl et al

• Findings from interviews

• Many types of difficult experiences
• delusions, hallucinations
• intense emotion
• bodily symptoms
• changes in motivation, sense of self, relationships
 Harm from meditation
Lindahl et al

• Findings from interviews

• 73% moderate to severe impairment
• 17% reported suicidality
• 17% required inpatient hospitalization

• Median duration of impairment 1-3 years

• Range: a few days to more than 10 years
 Harm from meditation
other studies

• 1% - 7% of meditators
• quit meditation because of negative effects
• sought professional help
• or were hospitalized

• Many others have unpleasant, difficult experiences

• but describe them as transitory, helpful, learning
experiences
 Comparison
other approaches to health & wellbeing

Psychotherapy 3% - 10% deteriorate

 Comparison
other approaches to health & wellbeing

Psychotherapy 3% - 10% deteriorate

Pharmacotherapy 5% - 10% of hospitalized patients have adverse
drug reactions
 Comparison
other approaches to health & wellbeing

Psychotherapy 3% - 10% deteriorate

Pharmacotherapy 5% - 10% of hospitalized patients have adverse
drug reactions
Physical exercise Musculoskeletal:
2.6% of Americans annually receive medical
attention for sports or recreation injury

Cardiovascular:
1/500,000 – 1/2,600,000 hours of exercise
What about evidence-based MBPs?
literature reviews

• Negative or unwanted effects

• 0 – 10.6% of participants
• Most transitory, not clinically significant, not harmful,
not attributable to MBP

• Many studies don’t monitor

• May ask to narrowly
 Preventing harm

Factors to consider Example

Program factors Unclear theoretical foundation
Participant factors Pre-existing vulnerabilities
Teacher factors Competence to teach MBPs
 Unclear theoretical foundation
Example

• How should mindfulness help with insomnia?

• Decentring from insomnia-related thoughts/feelings
• Equanimity about sleep
• Reduced arousal

• RCTs support MBPs for insomnia

Unclear theoretical foundation
Example

• BUT…
• In Buddhist traditions, mindfulness balances hyper- and
hypo-arousal
• Brain imaging studies suggest higher-dose meditation
may increase wakefulness
• “Buddhist meditation practices are associated with
activation/enlargement of the areas that underlie tonic
alertness and/or prevent sleep” (Britton et al 2014, p. 69).
 Pre-existing vulnerabilities

Vulnerabilities and standard MBPs

MBCT • larger effect for people with higher baseline symptoms

MBRP • better than CBT: higher levels substance use, anxiety,
depression
• similar to CBT for people with lower levels
MBSR • better than CBT for comorbid anxiety/depression
• equivalent to CBT for anxiety only
 Pre-existing vulnerabilities

• MBPs adapted for vulnerabilities

• Psychosis, post traumatic stress, suicidality
 Pre-existing vulnerabilities

• MBPs adapted for vulnerabilities

• Psychosis, post traumatic stress, suicidality
• Consistent benefits
 Pre-existing vulnerabilities

• MBPs adapted for vulnerabilities

• Psychosis, post traumatic stress, suicidality
• Consistent benefits
• Harm often not examined
• AEs/SAEs in 0–10% of participants
• No more common in MBPs than control groups
• Not attributable to the MBP
 Teacher competence

• Good practice guidelines

• UK Network for Mindfulness-Based Teachers
• MBI-TAC
• Mindfulness-Based Interventions – Teaching Assessment
Criteria
• No relationship between competence and outcomes
• Ongoing discussion
 Skills for safe teaching

• Helping participants work with normal discomforts

• Knowing what may arise in people with various
conditions
• Skills for managing adverse events
• Unexpected occurrences
• Unusually severe experiences
• Knowledge of professional ethics
 Professional ethics
How should mindfulness teachers be
trained?
 Professional ethics codes

• Purposes
• Educate members of the profession
• Guide decision making in ethically challenging situations
• Communicate to public about standards of professional
behavior
 Psychological ethics codes
General principles

APA BPS
• Beneficence and non- • Respect
maleficence
• Competence
• Fidelity and responsibility • Responsibility
• Integrity • Integrity
• Justice
• Respect for rights and
dignity
 Psychological Ethics Codes
Standards of conduct

• Confidentiality
• Informed consent
• Limits of competence
• Continuity of care
• Multiple relationships
• Working with organizations or other third parties
• etc
 Training in professional ethics
Working with scenarios

A psychologist who also owns an apartment building

discovers that one of his tenants has signed up for a
mindfulness course he will be teaching soon.

• What are the ethical issues?

 Training in professional ethics
Working with scenarios

A member of a mindfulness class says that his home

practice is often disturbed by sounds of distress from
the house next door; he suspects that his neighbour is
beating his children.

• What are the ethical issues?

 Training in professional ethics
Working with scenarios

A member of a mindfulness class for employees of a large

business tells her mindfulness teacher that she has been
taking small amounts from petty cash for years.

• What are the ethical issues?

 Three scenarios
discuss in small groups

1. A psychologist who also owns an apartment building

discovers that one of his tenants has signed up for a
mindfulness course he will be teaching soon.
2. A member of a mindfulness class says that his home
practice is often disturbed by sounds of distress from
the house next door; he suspects that his neighbour is
beating his children.
3. A member of a mindfulness class for employees of a
large business tells her mindfulness teacher that she
has been taking small amounts from petty cash for
years.
 Professional ethics
Standards of conduct

• Multiple relationships
• Avoid if:
• might impair psychologist’s objectivity or effectiveness
• might create harm or distress for the client
• risk of exploitation or conflict of interest
 Professional ethics
Standards of conduct

• Confidentiality and its legal limits

• Disclose confidential information only when required by
law
• or necessary to protect client or others
• Discuss limits of confidentiality at outset
• e.g., legally mandated abuse reporting
 Professional ethics
Standards of conduct

• Third-party requests for services

• Clarify:
• professional’s role (teacher, therapist, consultant)
• who is the client
• how confidentiality will be handled
 What ethics code should
mindfulness teachers use?
• Good practice guidelines:*
• adherence to the ethical framework appropriate to the
teacher’s professional background and working context

*UK Network for Mindfulness-Based Teachers

 What ethics code should
mindfulness teachers use?
• Code of Conduct*
• Respect for participants
• Communication
• Working with GPGs
• Managing risk
• Respecting confidentiality
*UK Network for Mindfulness-Based Teachers
 Buddhist roots and secular
adaptations
Are MBIs too Buddhist or not Buddhist enough?
What are the ethical issues?
Origins of mindfulness

“Mindfulness is the
fundamental attentional
stance underlying all
streams of Buddhist
meditative practice”

Kabat-Zinn, 2003
 Adaptation for mainstream
settings

MBSR:

… attempts to present it as
commonsensical, evidence-
based, and ordinary, and
ultimately a legitimate
element of mainstream
medical care
Kabat-Zinn, 2011
 Adaptation for mainstream
settings
DBT mindfulness skills:

…psychological and
behavioral translations of
meditation practices from
Eastern spiritual traditions…

…purposely provided in a
secular format
Linehan, 2015
 Evidence-based MBPs

• Has too much of the Buddhism been lost?

• Does this lead to harmful applications?
 Eight-fold path

Right:
leads to reduced
suffering for self
and others

From www.minimalstudent.com
 Five ethical precepts

• Refrain from:
• killing
• lying
• stealing
• harmful sexual behaviour
• misuse of intoxicants
 Second-generation MBIs

• Overtly spiritual
• Explicitly teach:
• ethical awareness from Buddhist perspective
• 8-fold path, 5 ethical precepts
• impermanence
• emptiness/non-self
 Second-generation MBIs

• Examples
• Spiritual Self-Schema Therapy
• Meditation Awareness Training

• 8-week groups
• Support from RCTs
 Second generation MBIs
Questions, concerns

• No comparisons to MBSR, MBCT

• No evidence of increased ability to resist unethical

working environment

• Might be too Buddhist for some settings

Can MBIs be too Buddhist?
Ethical issues
• Mindfulness program, Massachusetts public
school
• Threatened with legal challenge
• Buddhist-based program, falsely described as secular
• Violates separation of church and state
• Evidence cited (media quotes from experts):
• “What is practiced in Buddhist monasteries is essentially no
different from what is taught in MBSR” (Kabat-Zinn, 2015)
 Too Buddhist?
Professional ethics

• Relevant standards
• Informed consent
• Truth in advertising

• If a program is Buddhist-based
• descriptive material & informed consent must say so
• stealth Buddhism
 Stealth Buddhism

▪ “…this is a conversation we need to have. …we’re

going to …add to the body of knowledge of how to
create a secular mindfulness program that is
watertight for public school systems.”

--Fiona Jenson, Calmer Choice

 Too Buddhist?
Professional ethics

• Respect for cultural diversity and self-

determination
• Don’t impose ethical/moral standards
• Instead, help participants:
• clarify their own values
• strengthen values-consistent behaviour
 Contrasting voices
in the mindfulness field

• Contemporary MBPs
are too far away from
their Buddhist roots.
• Too much of the
Buddhism has been
stripped away.
• This is an ethical
problem.
 Contrasting voices
in the mindfulness field

• Contemporary MBPs • Contemporary MBPs

are too far away from are too close to their
their Buddhist roots. Buddhist roots.
• Too much of the • Buddhist elements are
Buddhism has been unacknowledged or
stripped away. intentionally hidden.
• This is an ethical • This is an ethical
problem. problem.
Working with personal values
Psychological science perspective
 What are values?
MBP perspective

Personal choices: what matters most to you in life

Domains: Qualities:

• Relationships • Loving, kind

• Work • Open, honest
• Community • Competent, productive, helpful
• Personal growth • Assertive, strong
• Other • Other
 Why values are important
Mental health perspective

Values intrinsically motivate behaviour that leads to a deep sense

of meaning, vitality, and engagement
Identifying values

“…Tell me, what is it you plan to do

with your one wild and precious life?”

Mary Oliver
 Identifying values
birthday speeches

• It’s your future birthday

• Friends and family are gathered
• Giving loving speeches about you
• What would you like them to say?
 Identifying values
birthday speeches

“John is a great family man.

He guided his children with “Through her
love, patience, and respect environmental work,
and shared with his wife all Susan has made our
the joy and heartache life world cleaner and
presented them.” safer for all living
beings”
 Self-identified values
research findings

• Focusing on self-identified values

• Increases autonomy
• Essential for wellbeing
• Improves goal attainment
• Improves response to stress
 Self-identified values
in MBI participants

• Almost always prosocial

• Meaningful work
• Loving relationships
• Contributions to a community
 Values & ethical behaviour
Research in organizational psychology

• When organizations engage in unethical practices

• employees are the best source of corrective action
 Characteristics of
whistle blowers
• Autonomy
• Clarity about personal values
• Willingness to act in values-consistent ways

• Qualities cultivated by mindfulness practice MAY

encourage whistle-blowing
 Conclusions about values

• IF we want training to cultivate ethical behaviour

• consideration of self-identified values may be helpful
 Ethical communication
What can we say about mindfulness-based
programs?
 Ethical communication
• “Psychologists do not make false, deceptive, or fraudulent
statements concerning…their services…the scientific or clinical
basis for, or results or degree of success of, their services…”
APA ethics code

• “Psychologists should…be honest and accurate in conveying

professional conclusions, opinions, and research findings, and
in acknowledging the potential limitations.”
BPS ethics code
 Ways to mislead

• Claim MBI is Buddhist-based

• When it’s secularized, adapted, distant from teachings
• Claim MBI is secular
• When it’s Buddhist-based
• Positive or negative hype
• It fixes everything
• It’s dangerous
 Ethical communication
Statements for counteracting hype

• Mindfulness practice is not intended to be blissful

• Mindfulness is not a panacea
• Mindfulness practice is invitational and empirical
 Conclusions
Ethical issues in MBIs
 Enhancing ethics in MBPs

Optional Essential
• Training in Buddhist • Increased attention to
ethics professional ethics codes
• Potentially problematic • Understanding harm and
• Science-based methods adverse events
for cultivating values- • Ethical communication
consistent behaviour about mindfulness
Questions and discussion