Post on 26-Jan-2015
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MiT For Anxiety & Trauma Disorders
Cameron Aggs Clinical Psychologist & DirectorMindfulness Training Australia Cam @bemindful.com.au In collaboration with the Australian College of Community Services
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Overview• Session 1:
– Overview of mindfulness and key concepts– Experiential exercises: 3MBS, 2H and 4B techs
• Session 2: – Mindfulness, Clinical Algorithm and Case Formulation– Mindfulness in the context of trauma and other
anxiety disorders • Session 3:
– Mindfulness-Informed Interventions: Video– Facilitating the 3MBS, 2h and 4B techs
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Materials and Process
• Slides • Experiential activities
– Participate as much as you feel comfortable– Volunteering for demonstrations
• Choose a client to keep in mind• Video• Password resources
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Beginning with the end in mind
• Mindfulness and the Magic Question
• Safety, Safety, Safety…
• Mindfulness should be embodied (RB2RB)
• Enhancing a willingness to feel into and to safely
experience SIFT experiences
– Importance of the breath
– Relevance of Self-As-Context
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Beginning with the end in mind
• Know your mechanisms!
• Socialise early. Find your entry point. Scaffold.
• Jigsaw metaphor
• Make sure you have access to enough resources to
build the capacities you are seeking to foster
• Make sure you can do what you are asking of your
clients (or are cognisant of how hard it can be!)
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Who here can come into a state of presence at will?
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4Breaths Technique
Coming into a state of presence:
• Lightly, mindfully watching the breath
• Coordinating with the fingers: Motor-movement
• Rounds of 4
“These 4-Breaths are Mine”
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What does mindfulness mean to you ?
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“Bringing one’s complete attention to the experiences
occurring in the present moment, in a nonjudgmental or
accepting way”
(Brown & Ryan, 2003; Kabat-Zinn, 1990).
What is Mindfulness?
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Our “map”: IAA model of mindfulness
(Shapiro et al., 2006)
Intention
Attention Attitude
Paying attention in a particular way…
Kabat-Zinn, 1994, p4
and non-judgmentally.
on purpose, in the present moment,
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Holding in Mind: Intentions
• What do you want from mindfulness?
• This moment…?
• This meditation / workshop / this session…?
• More generally inc this treatment episode?
Tip #1: Mindfulness is an intentional activity
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Attending Skills
Placing your attention where you want it…
• Attentional placement:
– Shifting and sustaining attention
• Non-judgmental Awareness
– Inhibiting secondary appraisals
• Noticing and Naming
– Ability to put inner experience into words
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The process of mindfulness (the WHAT and HOW)
Noticing and naming with
mindful attitudes (internal & external
experiences)
Letting go (creating space)
Focus/Re-focus attention
Choose an aspect of internal or
external experience to
focus attention on
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Attending:
• Using your faculty of attention as a tool: Disengaging from worry and rumination
• Fostering Internal Attunement / Meta-CognItive Awareness: What’s happening for me now..?
• The ability to come into a state of “Presence”
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3 Qualities of Presence
• Light: As in buoyant in the Mind– Unencumbered by past and future and fixation
• Relaxed: As in soft in the body– Particularly the belly, chest, shoulders, jaw
• Grounded: The bum in the chair and the feet on the floor– Mind ‘riding’ the breath
Light. Relaxed. Grounded.
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Presence…
“The mind if not stirred, will become clear”
Sogyal Rinpoche
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Points of ContactBecoming Present:
• Feet on the floor
• Bottom in the Chair
• The breath moving in and out of the body
Grounded inwardly, focused outwardly…
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Mindful Attitudes: More than just Attention
The Flavour of Mindfulness: The anesthetic of internal attunement….
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Attitudes
GOAL
• Curiosity : • Openness • Acceptance • Love
Metaphor / key principles
• Curious Explorer• “It is already here: Let
me feel it• As an active state• Friendliness
Saying ‘Yes’ to Experience
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3 Minute Breathing Space = Making a Space for What is Happening now
Step 1: Taking stock / Gathering the mind
Step 2: Focusing and redirecting the attention
Step 3: Expanding awareness and returning
Hot tip: Bookmark: youtube “3 minute breathing space” (it’s the first one that comes up)
Experiential Exercise: 3MBS:
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I-SIFT
• I (me)• Sensations• Images• Feelings• Thoughts
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MINDFULNESS: COMPONENTS AND CENTRAL CONCEPTS
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Central Concepts• The ubiquity of human suffering
• Internal experiences are transient and change with time
• Thoughts and emotions are not facts
• Though some are very ‘sticky’
• They happen within a larger context: The ‘Space of the Mind’
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A Central task
• To disengage from fixation on verbally-
based mental content and fusion with
emotional material
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And again…
“The mind if not stirred will become clear” -Sogyal Rinpoche
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But!• Before ‘Letting-Go’, of thoughts we must
learn to ‘Be-With’ our primary emotional experiences
Saying ‘Yes’ to experience - Tara Brach
“It’s already here…. Let me feel it”-John Kabat-Zinn
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‘Being – With’
• Feeling into …
• Going deeper….
• Making a space…
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BREAK!
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Review…
Mindfulness is the capacity to come into a state of
presence, to not be overly judgmental (non-
catastrophic) about our encounters with suffering, and
to make space for whole range of affectively-engaged
living, with the confidence that SIFT experiences are
passing on through…. and, that we are the conscious,
cognisant space within which that all happens
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Correlational ResearchGreater mindfulness associated with higher:
• Healthy self-regulation• Emotion regulation• Positive affect• Quality of life & life
satisfaction• Social skills • Relationship Satisfaction• Academic competence
Mindfulness interventions resulting in greater:
• Feelings of calm/relaxation
• Social skills• Personal and social
well-being• Self-esteem and self-
acceptance• Awareness and
recognition of types of emotions
• Self-efficacy for reducing substance use
• Sleep quality
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Mindfulness: Does it Matter?Greater mindfulness associated with lower:
• Depressive symptoms• Anxiety• Stress• Internalizing symptoms• Externalizing behaviour
problems• Worry and rumination• Negative affect• Substance use coping• Somatic complaints• Psychological inflexibility
and thought suppression and control
Mindfulness interventions resulting in lower:
• Depressive symptoms and low mood
• Anxiety• Stress• Internalizing symptoms• Externalizing behaviour
problems• Difficulties with emotion
regulation• Problem behaviours in the
classroom
• Keng, S.L. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review. 31, 1041-1056
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What: spectrum of mindfulness-informed interventions
Mindfulness-informed interventions
• Acceptance and Commitment Therapy (ACT)
• Dialectical Behaviour Therapy – adolescents (DBT-A)
• Individualised intervention plan: (e.g. MiT)
Mindfulness-based interventions
• Mindfulness-based stress reduction (MBSR)
• Mindfulness-based cognitive therapy (MBCT)
• Independently developed mindfulness programs (MiCBT)
Embodying and modelling of mindfulness with clients
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Modelling Mindfulness, Psychotherapy ProcessMentalising the Clinical Algorithm
Mindfulness Informed Therapy
Mindfulness as metaphor, psychoeducation and
technique
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Mindfulness and Psychotherapy Process: Clinical Algorithm
Client Characteristics:
• What is the client’s presenting problem?
• Severity and Level of impairment?
• Stage of Change?
• Client’s theory of Change?
• Character organisation? - Joe Coyne
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Mindfulness and Therapist Factors
• Service in which we are embedded
• Theoretical orientation
• Access to training and supervision
• Clinical / Couseling / Case-work assumptions
• Presence of a personal practice
• How we deal with our own suffering
• Access to Resources
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Mindfulness and Systemic Factors
• Nature of the Services
• Type and scope of intervention
• Frequency of contact
• Broader social, economic and political
context
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My Clinical Assumptions
• The Importance of following the clients lead: What moment is this?
• Live Company: A mind-minded other..• Client engagement as co-regulation• Hypothesis testing: Integrative and client-centered
treatments• Behavioural Activation• Scaffolding:• Importance of Understanding Mechanisms• Entry Point >>>> Consolidating Gains
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Self Audit
What I do well:• Patients feel heard, feel felt…• A mind-minded other: ‘Live Company’• Engendering hope• A sense of “We”
What I struggle with: • A consistent psychotherapy frame• Intellectualising
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Tailoring individual treatments
• Anxiety specifically and psychopathology generally
initially develop in invalidating developmental
contexts
– Clinical Algorithm
• Skills based vs relationally focused treatments
– Healing nature of attuned relationships
– Emotional processing vs building new capacities
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Mindfulness and anxiety….
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Mindfulness and Anxiety Disorders
• PTSD
• OCD
• GAD
• Phobias
• Panic Disorder
• Social Anxiety Disorder
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Experiential Avoidance: A Primary Target for Anxiety Disorders
• Anxiety disorders are developed and maintained by a complex array of factors including experiential avoidance (EA)
• EA: Defined as an unwillingness to experience unwanted internal events.
• Habitual attempts to anxiety trauma-related thoughts, emotions and memories lead to the core symptoms of Anxiety.
• Target = Affect Regulation Capacity
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Mindfulness and Treatment Planning
• Establishing a platform of accurate attunement and
(therefore) safety
• Assessment inc client theory of change
• PsychoEducation
• Mindfulness as Metaphore / Deepening the Narrative
• Experiential
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Assessment, psycho-education and experiential techniques
Throughout the psychotherapy journey point is the same:
“ We can become curious about your experience together, that your what you are going through is understandable, and that this is a safe place to feel into those parts of your inner experience that are you find frightening, and which you avoid, and/or have been experienced in isolation. Through gaining mastery in here we can help you to generalise it out-there (and visa versa)…
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Mindfulness and CBT
• Moreso than changing maladaptive beliefs, the target
of MiT is changing ‘maladaptive’ ways of avoiding
anxiety-provoking stimuli: ie avoidance.
• Its also about the provision of a relationship that can
feel into and cope with that which is more often
excluded from awareness
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Mindfulness and CBT
Promoting the willingness to stay with it for ‘one-
more moment’ in the service of values-based
living
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Mechanism 1: Exposure
Safety Exposure H* / Emotional Processing
Repeated Exposure Mastery / H*
• Biological mechanisms• The Breath: Entering the relaxation response • IA: Decreasing stress and strain (bracing) in the body
*H = Habituation
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Exposure
Psychological Mechanisms
• Experiential contact: Feelings can be felt, memories can be integrated into coherent narrative– Ie inner experiences can be felt, named, and
shared• One-moment at a time: The benefits of staying
present• Acting with Awareness: Availability of safety cues in
the world• Curious Explorer: SIFT
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Exposure
Relationally
• The Therapy Relationship is safe: – Live Company: A Mind-Minded Other– Accurate Attunement: Following Lead– Containing, Reframing, Exploring, Debriefing– At the client’s pace
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Mechanism 2: Decentering
• Self-as-Context
• Meta-cognitive Awareness
• ‘Thoughts are not facts’: Undermining
thought/action fusion
• ‘Being-Mode’
• Agency
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Potentiating Mechanism 3: Compassion
• Mindfulness and Self-Attunement
• Friendly Self-Object
• Self-Efficacy
• Potentiating mechanism for Acceptance
• Revolution in self-concept and attachment
security: Self is Good, Safe and Loveable
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Interventions
• 2-Hands
• Therapist behaviours: Reframing
• The psychotherapy Narrative / psychoeducation
• Mini thought experiments:
• 4-breaths
• POC – with modifications
• 3MBS- with modifications
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Mindfulness Practice: 2 Hands
• Place one hand is on the chest and the other hand on the abdomen.
• Breathe and notice:–Where is the breath moving?– Is the breath deep or shallow? Fast or
slow?–Which hand is moving more?
• Rate our of 100%
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POC: Points of Contact – Inward focus
Noticing the feeling of your feet on the floor, bottom in the chair and your breathing…
For clients:
• Engenders safety (groundedness and an ‘inward focus’• De-stabilising aspect of mindfulness practice• Deepens the impact of the therapy relationship,
potentiates the therapy hour
For the therapist:
• The how of ‘Therapeutic Presence’• Enables frustration tolerance
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4Breaths Technique
Coming into a state of presence:
• Lightly, mindfully watching the breath
• Coordinating with the fingers: Motor-movement
• Rounds of 4
“These 4-Breaths are Mine”
Copyright (c) 2013 Mindfulness Training Australia, All Rights Reserved | info@bemindful.com.au
3 Minute Breathing Space = Making a Space for What is Happening now
Step 1: Taking stock / Gathering the mind
Step 2: Focusing and redirecting the attention
Step 3: Expanding awareness and returning
Working With Discomfort: Exposure to negative affect modification: Presenter demonstration
Experiential Exercise: 3MBS:
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Safety – Modification • Severity of impairment assessment • Working Alliance assessment • POC Exercise: Agency• Eyes Open Modification• Relational Exercises
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Practice!
• Coach each other through an exercise of your choosing
• Provide a rationale: Link to assessment and ongoing socialisation process
• Encourage partner (You are fostering a trajectory to end in a sense of Mastery)
• Provide feedback• Swap
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Clinical Markers **
• Viewing, trauma-related thoughts and feelings from a nonjudgmental perspective
• Increase their contact with the present moment: The trauma is not now.
• A felt awareness that thought suppression, avoidance etc is unnecessary and counter productive
• Behavioural Activation / Acting with Awareness: Moving on into a values congruent future
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Mindfulness as Assessment
• Assess trauma type and severity
• What is the clients theory of change, level
of impairment etc?
• Mindfulness and a sense of agency and
safety
–Modifying Points of Contact exercise
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Potential Experiential Mindfulness Trajectory
2 Hands > P.O.C > 4 Breaths > T.E.’s
3Rs > 3MBS > Body Scan >
Breathing Meditation > Sitting with
discomfort
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Potential Experiential Mindfulness Trajectory
2 Hands > P.O.C > 4 Breaths > T.E.’s
3Rs > 3MBS > Body Scan >
Breathing Meditation > Sitting with
discomfort
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Psychoeducation: IAA terms
Intention
Attention Attitude
Focusing/refocusing on the here and now
Noticing and naming
Letting go and creating space
Checking in
Curiosity
Kindness
Willingness
Choosing
Slowing down
Remembering
Knowing why
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Psycho-Education: Knowing your Mechanisms!
Self-Compassion
DefusionPositive Affect
Acceptance
Interoceptive Exposure
Agency
RelaxationAttention Switching
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Mindfulness & Metaphor • Using metaphors to illustrate and explore mindfulness concepts
– Keep it simple and Don’t overload with too many or varied metaphors
Metaphor Target area
Clouds in the sky Self as Context: Interoceptive Experiences are safe
Leaves on a stream / River Bank
Internal experiences are constantly changing + Observer Self
Training the Puppy
Gentle and Firm orientation to attentional control. Forming a relationship with the self
Narrowing focus – widening lense
Attention is a tool
‘Turning Towards’, Saying ‘Yes’
Mobilising acceptance in behavioral terms
Train of thought Internal experiences are constantly changing
Making space / feeling into…
Mobilising acceptance in behavioral terms
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Clinical Uses for Meditation
• Selling meditation: Finding a way of talking about
meditation that makes sense.
• Constraining gains: starting with FBB +4B
• To focus a session: Do at Beginning
– Establish a narrative for this early on and stick with it.
• As treatment: Emotional processing, attention training,
synergies with schema-focused and cognitive work
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• As homework: Start with diaphragmatic breathing (Crawl and/or two breaths) prior to doing guided meditations
• Using meditation like a Personal Trainer. Discourse: Building neural circuits
• Trajectory: – Start with Body scan (relaxation– > breathing meditation (attention regulation),– > noticing thoughts and feelings (meta-
cognitive awareness – > guided imagery (creating a safe place)– > sitting with discomfort (interoceptive
exposure / emotional processing
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Meditation-Check list: Learning Opportunities
Attention• Thoughts will continue to be there and that is okay• You can learn to let go of thoughts
Attitude• My feelings are okay as they are
Experiential• The present moment can be a nice place to be• Your ally is close at hand: Diaphragmatic breathing:
Long, deep and slow • Feeling it at a physical level
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In-session meditation:Emotional Processing
• Discuss a worry - Find the bottom line /what is the essential
message?
– Eg. “I am not good enough”
• Guide a meditation starting with relaxing into FBB
• Evoke the message: “Imagine it like a radio station….”
• Notice feelings and body sensation. Special attention to belly
and chest.
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Using MetaphorsClouds in the Sky
Mentally “placing” internal experiences (usually thoughts) on the object and allow it to move (or not move) as it naturally wants to.
– Does … (object) stick around? – Does it feel ok if … (object) is not moving on?
– Background (sky) is ‘observing self’/‘self-as-context’– Noticing that the background can observe the objects that move
through it– Are you the … (object) or the … (background)? [‘self-as-context’
rather than ‘self-as-content’]
If the child has the capacity, you can link other internal experiences (e.g., feelings) to other objects/events that occur in the background
– Are you still able to be … (the background) even when … (feeling) is also happening?
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No Pest Control(reactions happen)
• Imagine your distressing or unwanted thoughts, feelings, body sensations are like … cockroaches…
• Being able to let the experience be…– Not feeling bad that it is here – Not trying to get rid of it – Not running away from it– Not letting the cockroaches control how you act – Not trying to make the experience positive (e.g., a
butterfly)
• Being ok with the experience coming and going… like cockroaches running around you...
• Being able to notice the experience and still being able to chose what to do
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Nature of Attention
Spotlight
• Shining light on where you want to focus your attention
Puppy on a leash• Like a puppy attention
naturally wanders (jumps around)
• It takes time to train a puppy (attention) to be able stay in the one place for any length of time
• Getting angry at the puppy doesn’t help
• Be kind to your wandering mind
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Train of thought• Thoughts don’t stop and they often jump from one
topic to another.
• The train of thought can be fast or slow
• Creating Space: “Are you standing on the platform or
are you riding on the train?”
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Thought Parade
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Beginning with the end in mind
• Mindfulness and the Magic Question• Safety, Safety, Safety…• Mindfulness should be embodied (RB2RB)• Enhancing a willingness to feel into and to safely
experience SIFT experiences– Importance of the breath– Relevance of Self-As-Context
Copyright (c) 2013 Mindfulness Training Australia, All Rights Reserved | info@bemindful.com.au
Beginning with the end in mind
• Know your mechanisms!
• Socialise early. Find your entry point. Scaffold.
• Jigsaw metaphor
• Make sure you have access to enough resources
to build the capacities you are seeking to foster
• Make sure you can do what you are asking of your
clients (or are cognisant of how hard it can be!)
Copyright (c) 2013 Mindfulness Training Australia, All Rights Reserved | info@bemindful.com.au
Thank You!
More information at www.bemindful.com.au
Email me: cam@bemindful.com.au