developing loving kindness - eventsforce · 2019. 9. 1. · •very little data exists on...

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Developing Loving Kindness: Can we do it …and why bother?

An exploration of loving-kindness methods with service users diagnosed with anorexia nervosa in an

outpatient eating disorders service.Dr Chantal Bailie, Clinical Psychologist Carly Thornton, Assistant PsychologistCornwall Eating Disorders Service


The plan:

• Give you some context: theory & research behind our group

• Experiential exercises: explore your experience, ours, that of our service users & relevant research

• Group discussion


Radically Open-DBT (RO-DBT)(Lynch et al.,2013)

• Adaption of Dialectical Behavioural Therapy for adults with a diagnosis of Anorexia Nervosa developed by Prof. Tom Lynch, used by the Haldon Unit, our closest inpatient unit

• We are a community service only

• We needed to provide follow-on treatment for clients on discharge from the Haldon Unit & wanted to supplement individual therapy & dietetics


Our group• Weekly DBT-RO skills training based group

• For clients with a diagnosis of AN who have been to the Haldon Unit

• Don’t have to commit to weight restore to attend the group, do have to commit to maintenance BMI above 14

• 1 h30 every week & includes: snack time to start - by client request!, a mindfulness exercise, check in & homework, skills training re-fresh, a mindfulness exercise & check out


Current evidence base• Virtually no research has empirically tested whether

DBT is useful for treating Anorexia Nervosa (Wolever &

Best, 2009)

• DBT-RO: Inpatients diagnosed with AN in the Haldon unit: Found significant improvements in weight gain, reductions in eating disorder symptoms, decreases in eating-disorder related psychopathology & increases in eating disorder-related quality of life (Lynch et al. 2013)

• Very little data exists on loving-kindness meditation (LKM) as a clinical intervention method


Our Group: Percentage of sessions attended over 1 year 6 months

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Quantitative measures have not been useful due to:

• Repeated cycles of inpatient admissions & community treatment

• Most clients are involved in multiple treatments (e.g. individual therapy, other groups, dietetics)


Reasons for stopping DBT RO group:inpatient admission (7)

new job (5)

physical illness (1)

felt different to rest of group as never had inpatient admission (1)

left the county (3)

better (1)

did not want ED service (1)

transport (2)


Radically Open-DBT (RO-DBT)(Lynch et al.,2013)

According to Lynch, Anorexia Nervosa is a disorder of over-control linked to:

i) Social isolation, aloofness, social withdrawal,

ii) Poor interpersonal functioning: poor emotional recognition in others & reduced emotional expression,

iv) Hyper-perfectionism, v) Rigidity, vi) Risk aversion,

vii) Lack of emotional expression

Core = emotional loneliness, so we need to use strategies to enhance social skills e.g. to signal cooperation via the body. Emphasis on social signalling & neurophysiological arousal


Start of group Self-compassion Scale (Neff, 2003; 2015).

i) How clients understand pain or failure: low self kindness (KIND) & high self criticism (CRIT)

ii) Cognitively understand their situation: not part of/low levels of common human experience (HUMAN) & very isolating (ISOL)

iii) How they pay attention to their suffering: high levels of over-identification (OVERID), low levels of mindfulness (MIND)

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CRIT ISOL OVERID

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KIND HUMAN MIND


DBT-RO (Lynch et al., 2013)

In theory people with a diagnosis of anorexia nervosa need to activate their safety system before social encounters & what they do (body posture, facial expression) influences how they perceive the environment & switches on their social safety system.

The aim is to learn to generate a loving, warm & kind mood before & during social interactions.

Why? If the Social-safety system, i.e. parasympathetic nervous system, is on - then the sympathetic nervous system, i.e. threat-reward system, is off (Lynch et al., 2013; Wang, 2005)


What is loving kindness meditation/“metta” ?

“ To re-teach a thing its loveliness is the nature of metta…metta is unconditional” Sharon Salzberg (Salzberg, 1995)

“the practice…begins with befriending ourselves. The foundation of metta practice is to know how to be our own friend” Sharon Salzberg (1995)

“The embrace that allows no separation between self, others and events – the affirmation and honoring of a core goodness in others and in oneself” Jon Kabat-Zinn (Salzberg, 1995)

“Practicing loving-kindness is an arduous discipline” Jon Kabat-Zinn

(Salzberg, 1995)


The Half -Smile: Practice

• Accept reality with your body. Relax by letting go or tensing & then relaxing.

• A half-smile is: slightly up-turned lips, a relaxed face

• Don’t force it• Adopt a serene expression

What was your experience of doing it now?


Patient experience: The half-smile“I don't like it, it makes me want to giggle... it does work as it makes me laugh.”

“I find that really hard, but I find that it is easier to do in the group. I try doing the half smile outside of the group, but I find that I just break into a full smile. I do find myself thinking that others’ are thinking that I’m stupid.”

“I use this one and mentioned it to my friends. You can’t change the thoughts you are having, but you can change your physiology... I found that you are not arguing with your thoughts ..it helps you to not keep feeling angry with someone.”


Our experience: The half-smile

Chantal: “I find it easy to do, but I can see how hard it is for clients. What amazes me is that I can see them go from hating it - in isolation - at the beginning of groups … to laughing as a group and being playful, in time…and it seems that in every group, they have become more socially open outside the group as this happens…”

Carly: “I found practicing the half -smile in the DBT group quite difficult at first. It felt strange not doing a full smile. After a while of practicing this technique, I found it helped my mood and allowed me to accept how I was feeling and let it go.”


Body language: Practice• Mindful breath

• The eyebrow wag (eyebrow tilted upwards)

• Half-smile

• Willing hands

• All 3 with your neighbour

What was your experience of this?

How are you feeling? How do you feel about your neighbour?


Patient experience: Body language

“It took me a while to do it, at first I would sit there with my body language closed. It took me several years to uncover my tummy. Chantal told me to do one step at a time, for example, to start by uncurling my hands. It sounds so easy, but it was probably one of the hardest parts of DBT.”

“…not something that comes naturally to me. I need to really think and catch myself in a situation…A good example came up the other day; I wanted to do something different, but didn’t want to go out of my comfort zone. Now I go against that and do something. I have enrolled on a training course. If you go with actions then the feelings will follow. DBT certainly helped me with taking the plunge.”

“One of the hardest parts of DBT”

“Difficult…I am not an open person …Leaves me feeling a bit vulnerable”

“if you go with the actions,then the feelings will follow”


Our experience: Body languageChantal: “ I try to think about it consciously as a therapist, sometimes things get hectic, and you are less…mindful of it…doing this in the group reminds me to… anchor, because I need to embody it for the group”

Carly: “…challenging to begin with. At first I felt silly or that maybe my neighbour would find it uncomfortable, however after practicing it on a few occasions, it became easier. It helped when Chantal asked us to describe to the group how we interpreted our neighbour’s behaviour and hearing that my half-smile, willing hands and eyebrow wag was positively received, it helped me to see how changing my behaviour can help elicit

positive responses in those around me.”


Play: Practice

• “Puppies”

• Broken telephone


Patient experience: Play

“the puppies exercise was helpful…I had the space to think about my thoughts... if I dropped a dog, nobody minded. It showed me that you don’t have to be perfect, no-one else minds…others in the group found it endearing if I dropped the puppy. I learnt you don’t have to be perfect to be accepted.”

“A forced smile is one thing that keeps you trapped...it has helped me to be more open and has been a huge difference. .. I would like to do a bit more. I can’t forget xxx coming in with her clothes on inside out (laughs)… I found it fun. It has helped me to break out of my enclosed little world. It‘s about trying something different and being open.”


Our experience: Play

Carly: “the broken telephone… felt a nice way to get to know group members and feel part of the group. I liked how it enabled us to laugh at ourselves and what we had said. It felt important for bonding, but also to model that it is OK to get things wrong and this is a normal part of life. When doing the puppies exercise, I recall feeling anxious at first, worrying about not catching the puppy. This was helpful in normalising anxiety and not wanting to feel humiliated in front of others. It ended up…where we were all able to giggle at dropping the puppy.”

Chantal: “it has helped me to … let things go, because I realise it now – I can see it, and more importantly I have to model this approach for the group…it doesn’t mean I still don’t get the feeling..”

What was your experience of doing it now?


Loving-kindness meditation: PracticeMay i/this person be at ease

May i/they be content with their life

May i/they be joyful

May i/they feel safe and secure

What was your experience of this exercise?


Patient experience: LKM

004: quite uncomfortable….but…helpful in exploring…things...that you find hard…unfamiliar…emotionally uncomfortable...that you have… or…that it is ok to have those feelings…it’s kind of a safe way of trying those out…and helps you think about people or little creatures that you care about a lot. It gets easier with time…you feel bit cautious at first…

“a struggle/difficult/lingering sadness after”

“Emotionally uncomfortable, but something you need to work through”

“Now I have (baby) it is easy to do. It provokes nice feelings.”

“emotionally uncomfortable… that it is ok to have those feelings, it’s kind of a

safe way of trying those out and helps you think about people or little

creatures that you care about a lot. It gets easier with time…you feel bit

cautious at first…”

“very difficult …easier when I did it towards someone else… put all those feelings on someone else…When I have tried to do that on myself, I’m hit with a brick wall… It’s just a work in progress.”

“At first it was rubbish, I didn’t get it to begin with. ..this meditation takes the most practice and commitment. However once I focused on my nephew then I found it easier. It took several years before I was able to turn the loving kindness meditation onto me. It felt wrong doing it for me, I used to feel angry, it took me a while to feel this was an acceptable thing to do.”


Our experience: LKM

Carly: “it enabled me to spend time thinking about my needs and allowing them to be prioritised in a kind and compassionate way. It felt different to do this at first as I tend to often think of other people and their needs. It was helpful directing the meditation to someone else first and then toward myself”

Chantal: “I first encountered this in a yoga class…it was the hardest thing, it has taken me many years to do it to the other and the self. My gateway was ..my cat! – unconditional love, I have found directing clients to think of pets and children seems to really help them start ”


Research: Processes in LKMBrain imaging (fMRI):

• Novices & long term meditators engaged different brain regions during loving-kindness meditation, suggesting they use different cognitive strategies

• Novices engaged regions involved in empathy, social cognition, inner speech, memory, self-related processing & mind wandering

• While long term meditators used these regions less & used those involved with present centred & selfless focus more (Garrison et al., 2014)

• This seems to suggest that initially, outward directed strategies are used, but in time inward strategies are used


Research: Processes in LKM

Brain imaging (fMRI):

• Increased activation of circuits linked to empathy & theory of mind in experts (Lutz et al., 2008)

• This means that affective processes like empathy and theory of mind can be trained (Lutz et al., 2008; Wang, 2005)

• Research using brain imaging regarding mindfulness based therapies & meditation has generated similar findings (See: Gilbert, 2005)


Research: Outcomes of LKMAfter 6 weeks of loving-kindness meditation by healthy students:

• Decreased indicators of stress-induced immune response (plasma concentrations of interleukin & cortisol)

• Increased levels of practice correlated with decreased levels of stress-induced immune indicators & reported distress (Pace et al. 2009)


Research: Outcomes of LKM

• Increased daily experiences of positive emotions, mindfulness, sense of purpose in life, social support & life satisfaction in healthy working adults (Fredrickson et al. ,

2008)

• Increase feelings of social connection & decrease self focus in students (Seppala et al. , 2014)

• Increased explicit & implicit positivity towards neutral strangers & acceptance of self in healthy volunteers (Hutcherson et al.,2008)


Research: Outcomes of LKM

Increased acceptance of the present moment in patients diagnosed with borderline personality disorder, significant improvements in symptom severity, reduced self-criticism; increased mindfulness, acceptance & self-kindness (Feliu-

Soler et al., 2016)


The group:

“It’s a safe environment… I know now that I’m entitled to speak… equally, so is everyone. …in the past, I didn’t want to speak out. I would think that everyone had used this better than me. But now I think, if I say something that is silly, then “so what?” It has changed that thinking in me.”


A voice:“I felt.. more assertive. I have the right. I can speak my mind. Whereas, I may have isolated myself before... It’s given me more confidence.”

“Anorexia …numbs emotions and I can wear a mask all the time…people think I’m happy when I am not. It has …impacted on my true emotions...particularly with mum… I didn’t realise this before, but now I recognise it. Inside I’m screaming ‘I’m not alright’, although happy on the outside. I’m able to voice the inner feelings. This lessens the grip that anorexia has on me…“


Endings & saying no:

“Being a people pleaser, I think bringing relationships to a close has been really important, which I have been able to do recently. I wouldn’t have done this before… I can now speak more of how I’m feeling to people who are important.”

“Mum found it quite difficult, I was a dutiful daughter and now I have learnt to say ‘no’…Also when I say ‘yes’ people know I really mean ’yes’.”


Confidence to try new things:

“It has enabled me to get involved in things and not to run away.”

“When I have been invited to go somewhere and I’m thinking “No!” I force myself to do it. I’m always glad I did it. It has helped me to go out and now I get about more.”


“The core problem in anorexia nervosa is emotional loneliness” (Lynch et al., 2013)

“when most people think of anorexia they think of thinness. Pre-DBT I was always on the outskirts, I was never really with people. I was on the periphery of the group. I was really lonely. I am still not the life and soul of the party, but I don’t want to be that …I do feel connected with people…By tackling needing friends and having a social world, you are starting to loosen the grip the anorexia fingers have on you. Too much therapy is focussed on the eating disorder, what you weigh and what you are eating. You don’t see the person doing this, you just see the weight, which reinforces the eating disorder. DBT focuses on me, you don’t even realise you are letting go of your eating disorder.”


Group discussionAll: Discuss your personal experience of loving-kindness meditation & your experience with clients with Anorexia Nervosa

Group 1: Gilbert (2005) suggests just being in a group can help to cultivate “we-ness”. Do we need loving-kindness interventions or will just being in a group do this?

Group 2: Is it useful to think about emotional loneliness, loving-kindness and Anorexia Nervosa – How?

Group 3: Can we develop loving-kindness? Do you do it already? Why bother?

All: What will you take from this session?


Thank you to our lovely clients who have given so freely of their time & thoughts


References• Fredrickson, L.B., Cohn, M.A., Coffey, K.A., Pek, J., & Finkel, S.M. (2008). Open hearts build

lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources, Journal of Personality and Social Psychology, 95 (5), 1045 -1062.

• Feliu-Soler, A., Pascual, J.C., Elices, M., Martín-Blanco, A. , Carmona,C., Cebolla, A., Simón, V., & Soler, J. (2016). Fostering Self-Compassion and Loving-Kindness in Patients With Borderline Personality Disorder: A Randomized Pilot Study, Clinical Psychology and Psychotherapy, Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.2000.

• Garrison, K.A., Scheinost, D., Constable, R.T., & Brewer, J.A. (2014). BOLD signal and functional connectivity associated with loving kindness meditation, Brain and Behaviour,4 (3), 337-347.

• Gilbert, P. (Ed.)(2005). Compassion: Conceptualisations, Research and Use in Psychotherapy, Hove: Routledge.

• Hutcherson, C.A., Seppala, E.M., & Gross, J.J. (2008). Loving-Kindness meditation increases social connectedness, Emotion, 8 (5), 720-724.

• Lutz, A., Brefcyzynski-Lewis, J., Johnstone, T., & Davidson, R.J. (2008). Regulation of the neural circuitry of emotion by compassion meditation: Effects of meditative expertise,Public Library of Science, 3, 1-5.

• Levine, M.P. (2012).Loneliness and Eating Disorders, The Journal of Psychology, 146(1–2), 243–257.


References

• Lynch, T.R., Gray, K.L.H., Hempel, R., Titley, M., Chen, E.Y., & O’Mahen, H. (2013). Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an outpatient program, BMC Psychiatry, 13, 293 (http://biomedcentral.com/1471-244x/13/293).

• Neff, K. D. (2003). Development and validation of a scale to measure self-compassion. Self and Identity, 2, 223-250.

• Neff, K.D. (2015).The Self-Compassion Scale is a Valid and Theoretically Coherent Measure of Self-Compassion, Mindfulness, http://self-compassion.org/wp-content/uploads/2015/12/ScaleMindfulness.pdf

• Salzberg, S. (1995). Loving-kindness: The Revolutionary Art of Happiness, Shambala Classics: Boston & London.

• Pace, T.W.W., Negi, L.T., Adame, D.D., Cole, S.P., Sivilli, A.B., Brown, T.D., Issa, M.J., & Raison, C.L. (2009). Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress, Psych neuroendocrinology, 34 (1), 87-98.

• Seppala, E.M., Hutcherson, C.A., Nguygen, D.T.H., Doty, J.R., & Gross, J.J. (2014). Loving-kindness meditation: a tool to improve healthcare provider compassion, resilience and patient care, Journal of Compassionate Health Care, 1 (5), 1-9.

• Wang, (2005). A conceptual framework for integrating research related to the physiology of compassion and the wisdom of Buddhist teachings, In P. Gilbert, P. (Ed.) Compassion: Conceptualisations, Research and Use in Psychotherapy, Hove: Routledge.

• Wolever, R. Q., & Best, J. L. (2009). Mindfulness-based approaches to eating disorders. In F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 259–287). New York: Springer.

http://biomedcentral.com/1471-244x/13/293

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