ORIGINAL PAPER

Mindfully Valuing People Now: An Evaluationof Introduction to Mindfulness Workshops for Peoplewith Intellectual Disabilities

Melanie J. Chapman & Duncan Mitchell

Published online: 11 January 2013# Springer Science+Business Media New York 2013

Abstract There is a lack of research exploring the use ofmindfulness groups for people with intellectual and devel-opmental disabilities in a community setting. This paperexplores the experiences of people with intellectual disabil-ities and carers who participated in Introduction to Mindful-ness workshops. The mindfulness workshops consisted ofan introduction to mindfulness and a body scan meditation.Participants were given a leaflet about mindfulness and anaudio CD of mindfulness exercises. A questionnaire surveywas conducted of people who attended the mindfulnessworkshops and qualitative interviews were carried out withsix people with intellectual disabilities (three of whom weresupported by paid or family carers). Feedback on the work-shops was generally positive. Workshop participants valuedthe opportunity to talk to other people about their experi-ences and found the workshops, and in particular the bodyscan, very relaxing. Three of the people with intellectualdisabilities who were interviewed had listened to the audiorecording since the workshops and two of these had found ituseful in aiding them to cope with phobias, stress anddiscrimination. Participants wanted further mindfulness ses-sions and felt that other people with intellectual disabilitiescould benefit from mindfulness training. The interviewsrevealed that people with intellectual disabilities may havevery stressful lives. Mindfulness could be a useful way ofhelping people to manage such stress. The mindfulness

workshops were clearly acceptable to people with intellec-tual disabilities, and further work is needed to develop andevaluate a group mindfulness program that is accessible topeople with intellectual disabilities.

Keywords Mindfulness . Intellectual disabilities . Learningdisabilities .Developmental disabilities . Survey . Interviews

Introduction

Mindfulness involves focusing attention on internal and exter-nal stimuli (e.g. sensations, thoughts, feelings, sights andsounds) as they arise from moment to moment in a non-reactive, non-judgemental way (Kabat-Zinn 1990). Originat-ing from Eastern meditation traditions, mindfulness has beenincreasingly used in the West. In 1981, Jon Kabat-Zinn estab-lished the Centre for Mindfulness at the University of Massa-chusetts (Robertson 2011) and by the end of the twentiethcentury over 200 hospitals and clinics in the USAwere offeringmindfulness-based stress reduction programs (Baer 2003). Inthe UK, the Centre for Mindfulness Research and Practice atBangor University first established professional training inmindfulness in 2001 and the Oxford Mindfulness Centre wasfounded in 2008 within Oxford University. Key mindfulnessconcepts surround impermanence, non-judgement, accep-tance, letting go and focusing on the moment (Kabat-Zinn1990). There is an emphasis on viewing and accepting situa-tions as they are without trying to change them (MelbourneAcademic Mindfulness Interest Group 2006). Mindfulness iscultivated through meditation practices including the bodyscan, mindful breathing and mindful movement.

Mindfulness approaches form the basis of MindfulnessBased Stress Reduction (Kabat-Zinn 1990) and MindfulnessBased Cognitive Therapy (Segal et al. 2002) and are also acentral component within Dialectical Behaviour Training

M. J. Chapman (*)Manchester Learning Disability Partnership, Central ManchesterUniversity Hospitals NHS Foundation Trust, Westwood Street,Moss Side, Manchester M14 4PH, UKe-mail: melanie.chapman@manchester.gov.uk

D. MitchellManchester Metropolitan University and Manchester LearningDisability Partnership, Manchester Metropolitan University,Elizabeth Gaskell Campus, Hathersage Road, ManchesterM13 0JA, UK

Mindfulness (2013) 4:168–178DOI 10.1007/s12671-012-0183-5

(Koerner and Linehan 2000) and Acceptance and Commit-ment Therapy (Hayes et al. 2006). Structured standardisedgroup programs have been developed to introduce mindful-ness and it is increasingly being used to help people manage avariety of difficulties including stress, anxiety, depression,pain and disordered eating (Baer 2003). There is an increasingevidence base about the effectiveness of such mindfulness-based approaches for a range of physical and psycho-logical health conditions (Baer 2003; Chiesa and Serretti2010; Fjorback et al. 2011) and in the UK the NationalInstitute for Health and Clinical Excellence recommendsMindfulness Based Cognitive Therapy for people who haveexperienced depression (National Institute for Healthand Clinical Excellence 2009).

There is evidence that people with intellectual disabilitiesare more likely to experience mental health problems andcertain long-term health conditions (for example, epilepsy)than the general population (Emerson et al. 2011). In addi-tion, people with intellectual disabilities may live in difficultsituations, experiencing loneliness, deprivation, abuse, andlack of choice and control over their lives (Gravell 2012;Smyth and Bell 2006). Mindfulness can help people toaccept symptoms or situations which are difficult to change(Fjorback et al. 2011) and therefore could be of use topeople with intellectual disabilities to help them to managethe range of difficulties which they may face. However, incommon with other psychological therapies (Brown et al.2011), mindfulness appears to be rarely offered to people withintellectual disabilities who often face barriers to primary andsecondary health services (Alborz et al. 2005).

In contrast with the growing evidence base on the use ofmindfulness with a range of client groups, there is little re-search exploring the use of mindfulness with people withintellectual disabilities. Nirbhay Singh and colleagues in theUSA have carried out some small-scale research projectsevaluating the use ofmindfulness with people with intellectualdisabilities, their family members and paid carers. Their find-ings suggest that teaching mindfulness approaches to peoplewith intellectual disabilities can lead to positive outcomes inrelation to physical and verbal aggression (Adkins et al. 2010;Singh et al. 2003, 2007, 2008, 2011b), sexual arousal (Singhet al. 2011) and lifestyle changes (Singh et al. 2008, 2011a). Inthese studies, mindfulness training was provided to peoplewith intellectual disabilities on an individual one-to-one basis.A British study also found improvements in incidents ofaggression when a structured group mindfulness programwas introduced to women with intellectual disabilities in aforensic medium secure psychiatric unit (Chilvers et al. 2011).

The feedback from people with intellectual disabilitieswho have participated in these studies suggests that al-though it might be difficult to understand mindfulness tech-niques at first, it becomes easier with time and practice.They value being provided with techniques that enable them

to control and manage their own behaviour rather thanhaving to be directed by other people (Singh et al. 2011a, b).

Whilst the findings from these studies indicate that mind-fulness approaches may have a range of benefits for peoplewith intellectual disabilities and those who support them, theexisting evidence base is small. The majority of studies havebeen carried out by one research team and in these studies themindfulness teaching has usually been provided by NirbhaySingh; therefore, positive findings may be a consequence ofthe skills and personality of this mindfulness trainer. Most ofthe studies have been conducted in the USA and there may bedifferences in culture and service provision which wouldimpact on the acceptability and impact of mindfulness in othercountries. In addition, the qualitative feedback gathered frompeople with intellectual disabilities on mindfulness has oftenbeen ad hoc and there has been little detail about how thisinformation has been gathered and analysed. It is thereforeimportant that further research is carried out to widen theevidence base around the impact and acceptability of mind-fulness for people with intellectual disabilities.

The present study evaluated the impact of one-off mind-fulness workshops provided to groups of people with intel-lectual disabilities and their carers in community settingsacross the North West of England. It aimed to get detailedfeedback from people with intellectual disabilities about theacceptability of group mindfulness workshops and to ex-plore their experiences of mindfulness.

Method

The methods used by the study were a questionnaire survey ofpeople who attended mindfulness workshops and qualitativeinterviews with randomly selected workshop participants.

The Mindfulness Workshops

The mindfulness workshops were developed and providedas part of a project which aimed to raise awareness ofmindfulness amongst people with intellectual disabilities,their families and staff across the North West of England.The Introduction to Mindfulness workshops consisted of anintroductory section where the facilitator and workshopparticipants introduced themselves and the facilitator gavean outline of the workshop content and the evaluationmethods. The facilitator found out what participants alreadyknew about mindfulness and gave a brief background tomindfulness and its potential benefits. Participants then tookpart in a 20-min body scan where they were led through aguided relaxation exercise focusing on different parts oftheir body. After this exercise, the facilitator discussed withparticipants their experiences of the body scan (i.e. whatthey were thinking and feeling during the body scan, how

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they felt after the body scan). Finally, participants wereinvited to complete the evaluation questionnaires, with sup-port if needed. The workshops took between one and one anda half hours depending on how long people wanted to speak.They were one-off workshops which were designed to beprovided to a group. Straightforward language was used andabstract concepts were removed to make the workshops easierto understand for people with intellectual disabilities. An easy-read leaflet on mindfulness was produced for workshop par-ticipants to take home and participants were also given amindfulness CD which included audio recordings of an intro-duction to mindfulness, a mindful body scan and a mindfulbreathing exercise.

Twelve workshops were provided as part of the project.One hundred seventy one people took part in the work-shops: approximately 114 people with intellectual disabil-ities and 57 family carers and staff. Six workshops wereheld with self-advocacy groups; one session was held at aregional conference for self advocates, two workshops wereheld as part of health events organised by local intellectualdisability services and three workshops were held withcarers groups. The majority of workshops were facilitatedby a certified Mindfulness Based Stress Reduction teacherwho has led mindfulness groups since 2004. One workshopwas facilitated by two community intellectual disabilitynurses who had attended an introductory workshop.

The Questionnaire Survey

At the end of each workshop, participants were asked tocomplete a brief easy-read questionnaire. The questionnaireasked for information about the reasons that people hadcome to the workshop, what people thought was good aboutthe workshop and if people thought that anything could beimproved about the workshop. The questionnaire used afive-point scale (very good to very bad) to rate the overallquality of the workshop and open questions for people toprovide qualitative feedback about the workshops. Thequestionnaire also asked if workshop participants would bewilling to take part in an interview about the workshop. Theworkshop participants with intellectual disabilities weresupported to complete the questionnaires when necessary.

Content analysis (Kassarjian 1977) was carried out on thequalitative data from the questionnaires. Responses to theopen questions were categorised into themes. Codes wereset up for each theme and each person’s response was thencoded and entered onto a Statistical Package for the SocialSciences (SPSS) database (V12) to enable the frequenciesfor each theme to be calculated. Twenty two questionnaires(20 %) were randomly selected using SPSS for inde-pendent analysis by the second author. This approachimproves the validity and the reliability of content anal-ysis (Greenhalgh and Taylor 1997). No additional themes

were identified by the second author, and inter-rater agree-ment between the two researchers in coding the themesranged between good and excellent (kappa range 0.70–1.0, mean agreement = 0.99).

Qualitative Interviews

The second component of the study involved conductingin-depth qualitative interviews with people with intellec-tual disabilities who had taken part in the mindfulnessworkshops.

Sample Selection The SPSS random selection tool was usedto randomly select two people from each workshop who hadindicated on the evaluation form that they were willing totake part in an interview. An initial screening interview wasconducted to find out whether people remembered the work-shops and whether they would be willing to take part in afurther face-to-face interview. If people did not rememberthe workshops or did not want to take part in a furtherinterview, then another person from the workshop was ran-domly selected. Thirteen screening interviews were carriedout in total; eight screening interviews were carried out overthe telephone by the first author and five screening inter-views were completed with an advocacy group supporter. Itwas not possible to carry out a screening interview with afurther five people who were randomly selected during thetime frame of the project (usually because no one answeredthe telephone or responded to answer-machine messages).

Interviews A face-to-face interview was arranged with sixpeople with intellectual disabilities who wanted to talk furtherabout the workshops. An interview schedule was used toexplore (1) why people went to the mindfulness workshop,(2) what they remembered about the workshop, (3) what theythought was good about the workshop, (4) whether theythought anything could be improved, (5) whether they werestill using the mindfulness techniques they were taught at theworkshop, (6) whether they felt that anything had changed asa result of what they learnt at the workshop and (7) what theimpact of using the mindfulness techniques had been.

An additional follow-up telephone interview was con-ducted with one person to find out if they had used themindfulness CD they were given at the initial interview asthey had misplaced the original CD.

Analysis The face-to-face interviews were audio-recordedwith participants’ permission and transcribed verbatim. Asone participant did not wish the interview to be recorded,detailed notes were taken during the interview; a largeproportion of these notes were verbatim. Thematic analysisof the interviews was carried out to explore the impact of themindfulness workshops and any other issues raised by

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participants relating to the workshops. Thematic analysisidentifies, analyses and reports patterns within data. Thismethod of qualitative analysis involves moving back andforth throughout the following different phases: familiarisa-tion with the data; generating initial codes; searching for,reviewing, defining and naming themes; and writing thereport (Braun and Clarke 2006). The first author led theanalysis; however, the second author read through threeinterview transcripts independently to identify patterns inorder to ensure that important themes were not omitted andto strengthen the validity of the analysis.

Results

This section presents the findings from the questionnairesurvey and then the findings from the qualitative interviews.

Questionnaire Survey Findings

One hundred ten questionnaires were filled in at eightworkshops; six of these workshops were organisedthrough self-advocacy groups and two workshops wereprovided at two healthy lifestyles days organised bylocal intellectual disability services. People with intellec-tual disabilities completed 76 questionnaires, 28 question-naires were completed by paid carers and supportersfrom a self-advocacy group and two questionnaires werecompleted by a family carer. Demographic details werenot available for all participants. Questionnaires werecompleted by 41 men and 19 women with intellectualdisabilities (N=60). The mean age of people with intellectualdisabilities was 42 years (range 20–67 years; N=26). Twopeople with intellectual disabilities were in full-time paidemployment, eight were in part-time paid employment andtwo were in part-time voluntary employment (N=52); there-fore, the majority would have been in receipt of state benefits.All were White British (N=74). The majority of participantsare likely to have been labelled as having mild to moderateintellectual disabilities as they were recruited from self-advocacy groups.

The most common reasons people gave for attending theworkshops were as follows: to learn to relax or deal withstress, anxiety, panic attacks or mood swings (n=38); theworkshops were being held as part of a meeting or eventthey were attending (n=35); to support people with intellec-tual disabilities attending the workshop (n=17); and to findout about mindfulness (n=17).

Feedback about the workshops was generally positive.Sixty one percent of people felt that the workshops werevery good, 27 % of people felt that the workshops weregood and 11 % of people felt that the workshops were OK.Only 1 % of people felt that the workshops were very bad.

The most common responses to the question aboutthe positive aspects of the workshops were that theworkshops helped people to relax (n=53), the body scanexercise (n=20), sharing experiences and talking aboutfeelings (n=16), learning new skills and techniques (n=11),and the facilitator (n=10).

The comments on the questionnaires showed that partic-ipants found the workshop relaxing and that the body scancould help them with their breathing and help them to focustheir mind on the present moment. One respondent statedthat ‘I enjoyed it. It helped me to relax my mind and breatheasy’ (ID74) and another described how the body scan‘taught you how to not think about anything. Just thinkabout the present. I did feel my mind wandering but I couldbring it back. I will use it in the future’ (ID79). Additionalcomments on the questionnaire showed that people felt thatother people would also benefit from mindfulness work-shops (n=5). Participants valued being given the leafletand CD (n=7) and some stated that they intended to usethe CD and techniques they have learnt (n=4).

However, not all of the feedback was positive. Whilstsome people commented that the workshop was easy tounderstand, two people felt that the language needed to bemore accessible. Three people wanted more guidance andsupport throughout the body scan; one person felt thatthe body scan instructions could be clearer as ‘I haveASD [Autistic Spectrum Disorder] and the instructionswere a bit confusing as they said breathe in, but didn’tsay breathe out so I was holding my breath a lot’(ID94). One person felt that the workshop ‘didn’t helpme relax’ (ID59) and another person felt that it was ‘abit difficult’ (ID83). Forty one people made suggestionsabout how the workshops could be improved. The mostcommon suggestions for improvement were that the work-shop should be longer (n=19) or that there should be moreworkshops (n=9). Other suggestions related to the appropri-ateness and comfort of the venue (i.e. noise, size of venue,comfort of flooring).

Interview Findings

Interviews were held with six people with intellectual dis-abilities as follows (all names have been changed to ensureanonymity):

Peter, a 37-year-old man who lives in 24 h supportedhousing with three other men.Juliet, a 41-year-old woman who lives with her parents.She has severe visual impairments and is closely in-volved with her local self-advocacy group.Patrick, a 22-year-old man who lives in a residentialcare service for young adults, aged 19 to 25 years whohave severe intellectual difficulties and complex needs,

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including those arising fromAutism SpectrumCondition.He shares a house with another young man.Roger, a 29-year-old man who lives at home with hisparents. He is closely involved with the local self-advocacy group and goes to a day centre twice a week.Lucy, a 55-year-old woman who lives alone in a hous-ing association flat. She is closely involved with a localchurch.Jeannette, a 36-year-old woman who has Down Syn-drome and lives at home with her parents.

A mother, a community intellectual disability nurse and aservice manager were present during three of the interviews;whilst they were primarily present to support the personwith intellectual disabilities, they also gave their own viewsabout mindfulness and the workshops. All of the partici-pants were White British.

Participants talked about the reasons that they went to themindfulness workshops and their experiences of the work-shops. They were asked whether they had used the mind-fulness CD since the workshops and they talked aboutreasons they had or had not done so. They spoke aboutsome of the difficulties which they faced in their lives andhow they coped.

Reasons for Going to the Workshops Two of the people whowere interviewed went to the workshops because it was part ofa self-advocacy group meeting that they regularly attended.Four people went to a workshop which was being held duringa health event. All of the participants had attended the work-shop to help them to cope with stress, anxiety and depression.Patrick wrote on his evaluation questionnaire that he had goneto the workshop because he felt stressed, Roger describedhimself as ‘a stress head’, Juliet wanted to find out aboutmindfulness and relaxation because of her experiences ofdepression, whilst Peter explained how he had gone to theworkshop for ‘Managing with how I feel. Sometimes I getreally down, sometimes I don’t.’

Three people had been encouraged to go to the mindful-ness session by their intellectual disability nurse, again tohelp them to cope with stress and anxiety. Jeannette’s nursefelt that mindfulness would help her with a weather phobiawhilst Lucy’s nurse felt that mindfulness would help hercope with stress.

It was clear from the interviews that all of the people withintellectual disabilities had significant sources of stress intheir lives which had the potential to impact on their mentalhealth and quality of life. Roger talked about how a majorsource of stress was lack of employment opportunities andinappropriate day services, making him feel:

…trapped in some respects. Particularly at the daycentre. Because I ended up going to a day centrewhich isn’t really suitable. In the meantime before

you know, while I wait to get a job and I don’t reallywant to and it’s not really relevant for me reallybecause one group of people’s there [puts his handdown] and, I hate the use of the word normal, butpeople with more abilities there [puts his hand up] andI’m somewhere in between, in the middle and it’s not agood place to be.

People also talked about how work or living situations,managing money, separation from family, life events such asbereavement, not being listened to or being told what to do,and a lack of control over one’s life could be stressful. Somepeople found it difficult if they felt let down by other people,or if they thought that they were letting others down. Somesources of stress were directly related to the impact ofdisability. For example:

Juliet: I think it all started really because of my dis-ability. I’ve always had to overcome obstacles andthen when my sight deteriorated quite rapidly about15 years ago I think I just got to that stage, I can’t dothis, I just can’t do this anymore.

Other people talked about the stress caused by otherpeople’s reactions to disabled people and the social stigmathat they experienced:

Mother: Very often some of them are very affected bywhat other people do and say. Like [my daughter,Jeannette] doesn’t like to be stared at do you?Jeannette: No I don’tMother: And very often. Tell [the interviewer] whatyou did that one day that you came back from theshops. Do you want to tell her?Jeannette: You willMother: You want me to. She actually said she wantedto die. It’s children staring at her you see and it annoysme that mothers don’t teach the children that noteverything’s perfect in this world and to stare at peopleisn’t nice.… Cos she will say I hate being a Downs. Isay to her well most Downs are wonderful people. It’sthe other people that have got the problem not you. Soit’s very difficult for her I think.

One participant described the impact of long-term harass-ment from the local community:

Lucy: I’m having quite a lot of problems with neigh-bours at home. Name-calling….Intellectual disability nurse: It’s difficult with the chil-dren when they’re outsideLucy: And then you get the parents and the people inthe flats turned against me. The neighbours.Everybody…..Interviewer: How long’s this been going on?Lucy: Years.

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Intellectual disability nurse: You’ve moved haven’tyou?Lucy: Several times because of it. Where I used to liveI got it every day. Every night. Soon as they wake upthey start. Soon as they come out of the door they start.Interviewer: How does it make you feel that namecalling?Lucy: I hate it. I just hate it. Sometimes I hate evenliving.Intellectual disability nurse: It makes you poorlysometimes doesn’t it?

The people who took part in the interviews had experi-enced low self-confidence, anxiety, depression, mood swings,phobias, obsessions, anger and frustration and feelings ofbeing trapped. This could impact on their own quality of lifeand that of family members or housemates and was a clearreason for their interest in the mindfulness workshop.

Experiences of the Workshops Some people felt nervousabout going to the workshop because they did not knowthe other people there or were not sure about what wouldhappen during the workshop. However, the overwhelmingimpression was that people found the workshops enjoyableand relaxing. The body scan exercise was particularly relax-ing and could help people to take their mind off theirproblems:

Patrick: I laid on the floor and listened to some music.Relaxing music.Interviewer: How did you feel after listening to themusic?Patrick: Quite settled.Interviewer: Would you like to do it again?Patrick: YesInterviewer: Why?Patrick: Because it was nice and relaxing

Juliet: I liked that [the body scan]. I found that veryrelaxing that part of it. And you know when you sortof get up afterwards, because it was so relaxing yourbrain feels a little bit sort of foggy, well not foggy, butit’s like until you sort of start pulling yourself togetheryou think where am I? You know a bit like if you’vebeen asleep or something it was that sort of feeling.And I think some people, I’m sure some people didnearly fall asleep [laughs]

However, some people found some parts of the workshopdifficult to understand:

Peter: At some parts where we felt it was hard tounderstand, you know, to follow it, but it might justhave been zoning out you know going into a relaxedstate. I don’t know.

This may have been due to participants feeling so re-laxed, or due to some sessions being noisy or rushed due tolimited time being available (see below).

People found it useful to share their experiences andfeelings during the workshop:

Interviewer: What do you remember about thesession?Peter: So easy to talk to somebody who had similarproblems to myself, certain things frightened them.Nice to talk about things with other people.

Jeanette also said how it was ‘good’ to find out thatother people were ‘the same as me really’ and it seemedthat some participants benefited from the realisation thatother people have similar experiences or difficulties tothemselves.

Qualities of the Mindfulness Trainer The personality andskills of the mindfulness trainer were clearly important.People were unanimously positive about the personal qual-ities of the facilitator. They felt that he had a relaxingmanner and a very calming voice. Peter commented, ‘Can’tforget [the facilitator]. Very good. Very laid back.’ Juliet ‘…thought [the facilitator] was really good actually at that.Because he’s got a nice calming voice hasn’t he?’

Venue Characteristics The interviews showed that it is im-portant that mindfulness workshops are held in a quietvenue that is large enough for the number of people whoare taking part:

Community intellectual disability team nurse: Be-cause it was such a busy day and so well attendedthe session was a bit noisy. There were about 20people in the session. It was a bit rushed as they had ahalf hour time slot.

Roger felt that there was not enough space for the numberof people who attended one of the workshops he attended,whilst Louise contrasted the ‘nice and quiet’ mindfulnessworkshop with a different meditation session she had onceattended which was ‘noisy’ with people walking through tothe next room.

Duration and Number of Mindfulness Sessions Some peo-ple felt that the workshop could have been longer. Peoplewanted further mindfulness workshops; these would beuseful for ‘refreshing your memory’ (Juliet) about mindful-ness and the body scan technique and for learning moreabout mindfulness:

Interviewer: And do you think that one session like[the mindfulness trainer] did was enough or do youthink he should do more than one session with people?

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Roger: If he could manage it, 2 or 3 sessions, multiplesessions might be better. But it might be impossibleInterviewer: Is there a reason that you think it wouldbe better to have more than one session?Roger: Just to give a better picture. A better feelingabout mindfulness.

One participant felt that it would be useful to develop amanual or a toolkit that could be used to guide mindfulnesstraining with people with intellectual disabilities:

Service manager: It would be good to have an instruc-tional thing on how to run a session and have the toolsto do it so that care workers could catch the right timeto do it. A toolkit people could use with the individ-uals they work with would be great. Something forcareworkers. It would need to be individualistic, notgeneric, something that is adaptable and changeable.

The Potential of Mindfulness for People with IntellectualDisabilities Generally, participants felt that other peoplewith intellectual disabilities would benefit from attendingmindfulness workshops as this would give them an oppor-tunity to talk about their experiences, ‘let their fears out’(Jeannette) and assist ‘with helping them to calm down andunwind and relax’ (Lucy). One participant felt that it wasimportant that mindfulness was introduced to people withintellectual disabilities as it was not available currently:

Interviewer: What was good about the workshop?Roger: The way it’s trying to break new groundInterviewer: In what way?Roger. You know. Trying to develop something that’salready been used, you know, for, you know, forpeople, because I understand that it’s only been usedelsewhere in other areas, used, you know, trying tohelp people with disabilities and the such like

Another participant felt that it should be possible to makemindfulness training accessible to people with intellectualdisabilities:

Interviewer: Do you think that other people wouldbenefit from learning about mindfulness?Juliet: I definitely think that they would because Ithink, I mean I’m a firm believer in there’s nothing,because people say, oh people with learning disabil-ities they won’t understand that or they won’t under-stand this, or whatever. And that was what part of the[self advocacy group] women’s group was about.Unpicking information and putting it into a way thatpeople could understand. Because it was often feltthat, particularly health issues, people slipped throughthe net because it was assumed that people would notunderstand what they’re telling them. But I’m actually

a firm believer that it’s not the information that’s theproblem, it’s actually the way it’s been given. You don’thave to come up with all these jargon words and all thisyou know, whatever, but plain and simple

The participant clearly felt that it was important to makeadjustments to ensure that mindfulness was accessible topeople with intellectual disabilities.

However, some people did not feel that everybody wouldbenefit from mindfulness or felt that some people wouldbenefit more than others:

Service manager: I think that it would be good to havemindfulness but I don’t think that a group would workwell with all of the people here. Patrick would go to agroup because he’d done it before and I think hishousemate would be keen to try it out. Another youngman would do it because he was asked to but wouldhave no understanding of why or the purpose behind it.The people we support are at the severe end of learningdisabilities and can have challenging behaviour andautism. Patrick is the most able.

Peter did not feel that his housemates would find mind-fulness useful whilst Lucy felt that one of her friends wouldnot benefit because of her mood swings.

Use of Mindfulness Techniques and the MindfulnessCD Participants were asked if they had used anything thatthey had learnt about mindfulness since the workshops andwhether they had listened to the CD they were given. Theirresponses indicated that the workshops had raised the bene-fits of relaxation and that some people had found the CDparticularly useful. Three people had listened to the CDsince the workshop; one person had been encouraged todo so by their mother and another by their communityintellectual disability nurse. Two of these people found thatregularly listening to the CD had helped them to relax andcope with phobias and discrimination from the local com-munity. Another person had listened to the recording to tryto cope with the pain of toothache; however, this had notbeen helpful.

Two people had not used the CD; one had misplaced theCD and one person did not remember getting a CD (it wasdifficult to determine whether the sixth person was using theCD or not as their regular support worker was not present).Two people felt that they did not need to listen to therecording at the moment but that they would do so in futureif they were experiencing stress:

Interviewer: Have you used anything you learnt at theworkshop to help?Juliet: I have actually. I do try and relax when I canand I have got one of those CDs, that mindful, and Ikeep meaning to do it. I keep saying I’m going to do it

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one day and you know what it’s like you just don’t getround to doing it but I do plan on doing it that CD…. Ithink if I did find that I was stressed then I wouldprobably do it then. You know if I was feeling quitestressed to calm my nerves down…. At the momentthings have settled down for me as well. Yes it wouldbe good to have there but I don’t feel like I really need toat the moment.

It was important that people had a private, quiet spacewhere they could listen to the recording on their own; thiswas often the person’s bedroom. One person felt it would bedifficult to find a quiet time to listen to the CD due to thenoise made by the other people he shared the house with andthe lack of time he spent on his own:

Interviewer: Do you have something you can listen tothe CD on?Peter: Yes, but everyone would have to be downstairsor out because it would be hard if there was noise orbanging. I sometimes get half an hour on my own. It’snot that long, only 20 minutes.

Another person, Lucy, was concerned that her neighbourswould complain about the noise when she listened to theCD, even when using headphones.

It was also important that people had appropriate technol-ogy to listen to the CD on. One person used the CD player intheir bedroom. However, a range of technologies exists now-adays; one person had bought a portable CD player, oneperson had put a copy of the CD onto their mobile telephone,and another person would have needed help to put a copy ofthe recording onto their MP3 player. Such portable devicesallow people to listen to the recording wherever they may be;for example, away from home and on holiday.

Other Methods of Coping Those people who were inter-viewed had therefore used mindfulness to varying degrees.It was clear from the interviews that they had already de-veloped a range of ways to other ways to cope with thestress that they faced in their lives. Sometimes people mightignore a problem for a while or remove themselves from asituation, for example, by going on holiday. However, thisrarely worked in the long term. Support from family andfriends and having somebody to talk to was important:

Juliet: I think talking to people helps, you know, sortof, when things do get tough, I do talk to people. Imean after saying that I don’t to start with and thenonce I acknowledge that there is something there thenI do…. I’ve got [my friend] and I’ve got my supportworker and I do talk to me mum sometimes but I thinkwho does talk to their parents? But me mum is there tolisten when I need her to.

Services had provided useful support; for example com-munity intellectual disability nurses, counsellors, generalpractitioners and social workers. However, such supportwas often time-limited, mainstream services may not bemade available to or considered appropriate for peoplewith intellectual disabilities, and there could be longwaiting times or complicated processes to access services.Some people had found medication useful. Other strategiesincluded putting in place structure, rules and clear boundariesand distraction. Some people tried to alter their ways ofthinking:

Roger: To try and concentrate, well it’s difficult, but totry and concentrate on the good things rather than thenot so good I would guess

Another person had drawn on self-help literature.Behavioural techniques such as monitoring behavioursand desensitisation had been tried with regards to pho-bias. Lifestyle factors could play an important part, suchas improving work-life balance or doing exercise. Twopeople talked about how they turned to food when theywere stressed, ‘comfort-eating’, whilst other ways ofrelaxing including listening to music, watching televisionand reading.

Discussion

This study adds to the existing evidence base on the useof mindfulness with people with intellectual disabilities.The study shows that people with intellectual disabilitiesexperience various sources of stress in their lives.Whilst interview participants described a range of waysin which they tried to cope with stress, they still expe-rienced anxiety, depression and phobias. Mindfulnessapproaches are increasingly being used to help peoplemanage such difficulties and this study demonstrates that itis feasible to provide introductory mindfulness workshops topeople with intellectual disabilities and that these were gener-ally well received.

There are a number of methodological limitations withthe study. It was a small-scale study and as many of thesurvey respondents were people who attended self-advocacygroups and most of the interview participants had goodverbal communication skills the findings may not be gen-eralisable to other people with intellectual disabilities. Thequestionnaires were completed at the end of each workshopwhilst the mindfulness trainer was still present which mayhave led to more positive responses. However, the over-whelming response was positive and four people who hadno apparent contact with self-advocacy groups, including aperson with more severe intellectual disabilities and

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communication needs, participated in the interviews so arange of people were represented.

The focus of the study was on people with intellectualdisabilities’ subjective experiences and opinions of mindful-ness rather than quantifiable, measurable outcomes. Qualita-tive methods were appropriate for this study as it is unlikelythat measurable change would have been witnessed at the endof one workshop. It is also important that the views of peoplewith intellectual disabilities are included in the evidence baseand that qualitative information is collected on their opinionsand experiences to ensure that mindfulness training is accept-able to them and to gain their perspectives on important out-comes and the reasons for the success or otherwise ofmindfulness interventions. This is the only published studyfrom the UK that we are aware of on the provision of groupmindfulness training directly to people with intellectual dis-abilities in a community setting and the only study on the topicthat has systematically gathered qualitative data from peoplewith intellectual disabilities.

It is clear from the interviews that people with intellectualdisabilities may have significant sources of stress in their livesand that this can negatively impact on their psychologicalwell-being and quality of life. Interview participants had trieda range of ways to cope with their sources of stress withvarying success. It was clear that it could sometimes be diffi-cult or take time to access mainstream health services. Asmindfulness techniques are increasingly being used with thegeneral population in relation to stress management, mindful-ness could play an important role in helping people withintellectual disabilities to cope with the stresses they may facein their lives. However, as recognised by some of the interviewparticipants, mindfulness programs are rarely made availableto people with intellectual disabilities and existing programsmay not be accessible (for example, due to the length ofworkshops and the language and abstract concepts used).

The study shows that mindfulness is clearly an acceptableapproach to many people with intellectual disabilities. Therewere very positive reactions to mindfulness workshops fromthe majority of participants. The workshops demonstratedthat people with intellectual disabilities can participate ingroup workshops on mindfulness and the body scan exercise,and the questionnaire comments demonstrated that many par-ticipants found the workshops, and the body scan inparticular, very relaxing. People wanted more than onesession and felt that other people with intellectual dis-abilities could benefit from mindfulness. The study find-ings indicate that the mindfulness trainer’s personal mannerand qualities may be important, as are venue characteristics(for example, size, noise, being able to lie down or sit downcomfortably to do the meditation exercises).

The study also indicated that workshop participants val-ued being given a CD that included an overview of mind-fulness and mindfulness techniques. Home practice is an

important component of mindfulness treatment packagesand it is encouraging that half of the people interviewedhad listened to the CD since the workshops and that thiscould be useful in managing phobias, anxiety and stressresulting from perceived discrimination in the local commu-nity. However, the findings also show that other people mayneed encouragement to listen to the CD and that it is impor-tant that people have an appropriate, quiet place and equip-ment to listen to the recording at a time that they will not bedisturbed. It is important that when mindfulness trainingincludes audio recordings for people to listen to, trainersencourage people to routinely practice the meditation exer-cises and identify and explore means of overcoming anybarriers to listening to the recording.

These findings indicate a need to develop a program ofmindfulness sessions, incorporating sustained practice athome and/or in other settings (e.g. day services). The bodyscan is only one mindfulness technique commonly taught inmindfulness-based group programs, and it would be impor-tant to develop further sessions that introduce differenttechniques. Designing a manual to guide a program wouldform an important part of the development of further mind-fulness training and is a common component of existingmindfulness group programs. Such a manual could supportthe provision of mindfulness in a range of settings (forexample, day services, supported housing) and would helpto equip service providers and practitioners with tools toprovide mindfulness training and to support people withintellectual disabilities with mindful practice.

Current Mindfulness Based Stress Reduction and Mind-fulness Based Cognitive Therapy manualised programs arenot readily accessible to people with intellectual disabilities,and the feedback from workshop participants demonstratesthe importance of the use of simple, concrete language andclear instructions. When developing a manualised program,it would be useful to learn from the experiences of adaptingother programs; for example, ensuring that the trainingincluded simplified concepts, a focus on experiential prac-tice and reflection, repetition, creativity and variety, smallgroups and handouts using symbols and pictures (Morrisseyand Ingamells 2011). Nirbhay Singh and colleagues haverecently published a trainer’s manual for the Meditation onthe Soles of the Feet technique for anger management(Singh et al. 2012) and the use of this technique has beenevaluated with people with intellectual disabilities (Adkinset al. 2010; Singh et al. 2011, 2011, 2008, 2007, 2011a,2011b, 2008, 2003). It would be useful to consult with thismanual and descriptions of other mindfulness techniquesused with people with intellectual disabilities [for example,mindful eating (Singh et al. 2008), Mindful Observation ofThoughts (Singh et al. 2011, 2011a) and visualisation(Singh et al. 2008)] to inform the development of futuremindfulness teaching programs. The impact of a longer

176 Mindfulness (2013) 4:168–178

mindfulness program and the acceptability of different mind-fulness techniques to people with intellectual disabilitieswould need to be evaluated.

It is also important to continue to evaluate the use ofindividualised mindfulness training for people with in-tellectual disabilities. Group programs may not be ap-propriate for everyone and practitioners may want toincorporate mindfulness approaches into their interven-tions with individuals. Future research could usefully in-vestigate appropriate group sizes and when and with whom itis appropriate to use group or individualised interven-tions. Whilst existing case studies show promising pos-itive impacts (Adkins et al. 2010; Singh et al. 2011, 2011,2008, 2007, 2011b, 2008, 2003), these are small scale and donot have comparison groups; larger scale randomised trials inthis area are needed.

Conclusion

This study indicates that it should be feasible to develop agroup mindfulness program for people with intellectual dis-abilities. Any evaluation of such a program would need tobe more methodologically robust with a comparison groupand larger sample sizes. The study shows that it is possibleto gain qualitative information from people with intellectualdisabilities about their opinions and experiences of mindful-ness training, and future research would usefully gather suchqualitative data as well as quantitative outcomes data. Fu-ture research would also need to identify which componentsof mindfulness training participants find most useful (forexample, the body scan, information provision about mind-fulness, the opportunity to talk to other people who hadsimilar experiences, listening to audio recordings) and toexplore which factors impact on the success of mindfulness(e.g. facilitator characteristics, support, communicationneeds and cognitive abilities).

Acknowledgements This study was part of a project carried out byPathways Associates CIC and the North West Training and Develop-ment Team with funding from Improving Access to PsychologicalTherapies (IAPT). Dene Donalds, a mindfulness practitioner, initiatedthe Mindfully Valuing People Now project, developed the workshops,leaflet and audio recording, and facilitated the majority of workshops.We would also like to thank the people who completed questionnairesand took part in the interviews and Carlisle People First for theirassistance with the project.

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