Powerpoint Thematic analysis of the effectiveness of an inpatient

interventions have also been found to be effective with

diverse client populations including children (Burke 2010),

adolescents (Biegel 2009) and people with intellectual dis-

abilities (Singh et al. 2007).

The growing evidence base for people with intellectual

disabilities is of particular interest to this paper. There is

increasing evidence for the ‘Soles of the Feet’ programme

(Singh et al. 2003) which encourages people to shift their

attention from their angry thoughts to a neutral point on

their body – soles of their feet. The benefits of involvement

in the programme have included people with moderate

intellectual disabilities being able to manage their anger in

constructive ways and thus avoiding their community

placements from breaking down (Singh et al. 2007).

An interesting additional benefit of mindfulness can be

seen when looking into the effects it has on staff caring for

people with intellectual disabilities. This is particularly

relevant in the light of the recent Winterbourne View abuse

scandal of 2011, which identified frequent use of inappropri-

ate restraint (Care Quality Commission 2011). Although

factors contributing to the abuse at Winterbourne View are

complex and systemic, frequent use of restraint has been

linked to staff stress caused by work related issues (Paterson

et al. 2011). There is evidence that mindfulness is effective in

reducing psychological distress for staff workingwith people

with intellectual disabilities. In particular, the promotion of

acceptance in carers and teachers has been found to be

effective with staff reporting less stress, particularly those

who did not have a professional qualification and may have

been more vulnerable (Noone & Hastings 2010). Further

benefits of mindfulness for staff and services include reduc-

tion in physical restraint by staff (Singh et al. 2009) and cost

effectiveness by reducing sick days and medical rehabilita-

tion for staff who have been injured (Singh et al. 2008).

The effectiveness of mindfulness in intellectual disabili-

ties has been attributed to the experiential nature of the

activities which do not require sophisticated verbal reason-

ing skills as some traditional psychotherapies warrant such

as cognitive behaviour therapy (Brown & Hooper 2009).

Current interest in the field appears to be in relation to

further adaptations of mindfulness to suit the needs of

people with intellectual disabilities. However, research is at

the early stages, and further investigations are needed in the

area of adaptations (Robertson 2011).

The current study aimed to explore people with intellec-

tual disabilities’ understanding of mindfulness, including

the benefits and difficulties they experienced in their use of

mindfulness exercises.

Methods

The current study explored a range of mindfulness exer-

cises, taught and practiced during a weekly relaxation and

mindfulness group. The group was held on an inpatient

assessment and treatment unit for people with intellectual

disabilities and acute mental health problems. The inpatient

therapy room was transformed into a space which was

separate from other clinical activities which took place there

(e.g. one-to-one sessions) with input from participants.

Sensory lamps and light background music were used to

transform the space.

One exercise was an adaptation of the raisin exercise

(Kabat-Zinn 2012). The raisin script was generalised to fruits.

Participants were prompted to focus on different sensory

features of the fruit. They were prompted to focus on what it

feels like in their hand, what colours they can see, what

shape it was, focus on the scent, taste and sounds whilst

eating the fruit. The fruit was used as a tangible focal point

for participants to orient themselves to the present moment.

The group members focused on a different fruit each week.

The relaxation and mindfulness group also involved

other mindfulness-related exercises. Muscle tension and

relaxation was used with a mindfulness element including a

body scan; participants were prompted to notice the

changes in their bodies and locate where the warm feelings

were. Deep breathing whilst meditating on the breath was

also used in the group; participants were prompted to focus

on the tip of thei r nose, noticing the sound of the breath and

the air on the face. Further olfactory experiences were

explored in the group; incense sticks and candles were used

to focus on scents; participants were prompted to focus their

attention on the scents of fruits and flowers.

During times where it was evident that participants’

thoughts drifted away from the present moment, they were

reminded to bring their focus back to the tangible anchor

point used in the exercises which included fruits, incense

and candle sticks, warm feelings in their body and the tip of

their nose.

The group was facilitated by trainee and assistant clinical

psychologists. It had been running for 1.5 years at the time

the interviews took place for this study.

Participants

Seven inpatients who had taken part in the group were

invited to take part in the study. Group participants who

had been discharged from the inpatient unit were not

contacted due to the potential difficulties (such as possible

confusion and misinterpretation of being contacted by the

inpatient team). One participant was discharged during the

study phase and was interviewed in their community

placement.

Six service users chose to participate in the study. Smaller

sample sizes are accepted in the literature for qualitative

research as evidenced in the following quote:

Qualitative research methods differ from quantitative

approaches in many important aspects … Quantitative

ª 2014 John Wiley & Sons Ltd, British Journal of Learning Disabilities, 43, 49–54

50 H. Yildiran and R. R. Holt

researchers capture a shallow band of information from

a wide swath of people and seek … to understand,

predict, or influence what people do. Qualitative

researchers generally study many fewer people, but

delve more deeply into those individuals, settings,

subcultures … hoping to generate a subjective under-

standing of how and why people perceive … interpret,

and interact … both approaches are theoretically

valuable(Barker & Edwards 2012).

Participants had diagnoses of mild or moderate intellec-

tual disabilities. All the participants had additional diagno-

ses including paranoid personality disorder, autism,

recurrent depressive disorder, anxiety disorder and epi-

lepsy. They were all inpatients at a specialist assessment

and treatment unit for people with intellectual disabilities

and acute mental health problems. The sample consisted of

four females and two males. The age range was 21–64 years

(mean age 44 years). The number of sessions of mindfulness

that the participants had attended was between 2 and 23

(mean number of sessions attended was 10).

Procedure

All participants were deemed to have capacity to consent by

their Clinical team. Informed consent was given by all the

participants. Semi-structured interviews were used for data

collection during June 2012. The interview schedule was

developed by the first author generating topics relevant to

the experience of mindfulness in a group setting – which

included topics about understanding of the intervention,

benefits and difficulties. The interview schedule was dis-

cussed and agreed by both authors. The interview included

open questions (e.g. ‘What do you do in the group’) and

closed questions related to the practicalities of the group

(e.g. ‘The relaxation and mindfulness group is at 4 pm on

Wednesdays. Are you happy with this time and date? Yes/

No’).

The first author carried out all the interviews one-to-one

with participants, in a quiet area of the inpatient unit. All

participants knew the main interviewer, who was one of the

facilitators of the group. The participants’ responses were

written verbatim by the first author during the interviews,

due to anticipated distress that audio recordings may cause,

particularly participants with paranoid personality disor-

ders. Written transcripts were anonymised and stored in a

locked filing cabinet.

Materials from the relaxation and mindfulness group

were used to aid participants’ understanding of the ques-

tions and to aid their memory (the first author gave a visual

demonstration of holding the fruit by cupping her hand and

showed participants the CDs, incense sticks and candles).

These aids were used as it was thought that the participants

may have difficulties with orientating themselves to the

topic of discussion and to associating the questions to their

experiences in the group.

Results

The data were analysed using thematic analysis. This is a

method for identifying and analysing patterns in qualitative

data (Braun & Clarke 2013). Thematic analysis was used

because it is relatively quick to do and accessible to novice

researchers (Braun & Clarke 2006) and thus suitable for the

two authors who are both primarily clinicians rather than

researchers. Further advantages are its flexibility and

potential to generate unanticipated insights.

The current study used the six phases of thematic analysis

proposed by Braun & Clarke (2013). The first phase of

‘familiarisation’ of the data was achieved by the first author

conducting the interviews and both authors reading and

rereading the interview transcripts. The second phase,

‘coding’ involved collating and coding quotes taken from

the interviews. ‘Searching for themes’ was achieved by

looking for similarity between the codes and grouping

similar codes together. This was initially done by the two

authors individually. ‘Reviewing themes’ was achieved by

both authors sharing their analyses of the data and

comparing and discussing themes. Themes that emerged

in both authors analyses and worked in relation to the

coded extracts and the entire data set were retained. Themes

that had only emerged in one analysis were discussed and

checked to see whether they met the threshold of working in

relation to the data. Themes that were similar and did not

provide additional information about the data were col-

lapsed together. ‘Defining and naming themes’ was

achieved by ongoing analysis. It was decided to use quotes

taken from the data as theme headings. The authors felt this

was an important aspect of giving people with intellectual

disabilities a greater presence in this article.

In addition to the six phases, the analysis for this study

also included an additional phase of ‘reflection’. After

conducting the interviews and before starting analysis, the

first author did not feel the study had yielded rich data to

contribute to the evidence base for mindfulness in intellec-

tual disabilities. This was due to assumptions of the first

author in relation to her position as the group facilitator and

interviewer for the study. On reflection, the first author

realised she was expecting to hear explanations of mind-

fulness she had used in the group when she interviewed the

participants. In contrast, the interviewees provided a variety

of accounts of mindfulness which made her doubt the

effectiveness of the group sessions. However, upon revis-

iting the interview transcripts, it became clear that perhaps

the findings produced a stronger case for the effectiveness

of mindfulness in intelle ctual disabilities, as the participants

had attached their own meaning to mindfulness which was

more relevant to their experiences.

ª 2014 John Wiley & Sons Ltd, British Journal of Learning Disabilities, 43, 49–54

Mindfulness in intellectual disabilities 51

Following the analysis, five broad themes were identified

(see Fig. 1).

Focusing on one particular thing

The experience of participants fitted the theoretical aim of

mindfulness, of enabling people to pay attention in a

particular way. This helped participants to have control

over the focus of their attention:

Think about something else because I hear voices

Not think about things from past life

It also enabled one participant to change their mood

based on their orientation towards their experience:

Not worry about what’s around you at the moment

However, the focus of that attention was not always on

the present moment (as mindfulness is defined by e.g.

Kabat-Zinn 1994), but could be on other time or place:

Happy memories

Seeing the future clearly

Smell … think of what country it comes from

Improving skills

Participants recognised a range of skills that they attributed

to participating in mindfulness. Some of these were physical

skills, based on the exercises used. They were connoted in a

positive way by participants:

Makes arms strong

Practice breathing

Other skills were psychological. Participants were able to

use their own words to describe the skills they had learnt:

Learn more relaxation techniques

Close mind … close brain right down and switch off

Helping people

Interestingly, participants reported that their involvement

with mindfulness had enabled them to think about their

relationships with others and to take actions that were

caring towards others.

Brought candle … share with other service users

Want to relax to look after people

Come back … help at group don’t have to pay me

Caring for other people

Get rid of all nasty bad stuff you want to get rid of – staying calm and being happy

Participants attributed improvements in their mood and

reactions to the mindfulness exercises:

More relaxed at night

Improve my anger

If I get angry and agitated … know what to do before

out of control

Talk to people a little bit calmer instead of shouting at

them

Don’t get cross anymore

Help me release tension

Happy in a good mood

Makes you feel alright … feel good

Not very happy … squeeze panda

Bit too late to teach old dog new tricks

Learning mindfulness was effortful for participants. The

theme of ‘bit too late to teach old dog new tricks’

encapsulated all the difficulties encountered whilst using

mindfulness and the things the participants did not like

about it. Some participants doubted their own ability to

learn the techniques:

Figure 1 Five themes which emerged from data set.

ª 2014 John Wiley & Sons Ltd, British Journal of Learning Disabilities, 43, 49–54

52 H. Yildiran and R. R. Holt

Something never done in past life before…bit hard to

do it

Hard to breathe from nose and mouth

Didn’t work for me…tensed in all my muscles

Others felt that there wasn’t a good match between their

personal attributes and mindfulness:

Exercises hurt knee

I find other ways of relaxing in my room listening to

music

I don’t like that kind of music [likes music with words]

Don’t have all the materials

Discussion

In this study, people with intellectual disabilities were able

to form an understanding of mindfulness. The themes that

emerged in the study can be divided into three broad

categories of intrapersonal and interpersonal benefits of

mindfulness, and difficulties of learning and using mind-

fulness. Intrapersonal benefits were about reducing diffi-

culties and increasing positives (in relation to memories,

experiences and thoughts). This included the themes of

‘focusing on one particular thing’, ‘improving skills’, ‘get rid

of all nasty bad stuff you want to get rid of’. Interpersonal

benefits included the theme of ‘helping people’. The

interpersonal benefits may have been pronounced due to

the intervention being offered in a group setting.

Participants’ feedback on their experience of mindfulness

showed a similarity to descriptions of mindfulness in the

literature. This was evident in the themes which emerged in

the study, for example, ‘focusing on one particular thing’

which highlighted the importance of focusing one’s atten-

tion. However, the focus was not always ‘the moment’, but

for some participants was on another time or place. Despite

this, participants showed benefits that are similar to those

associated with being mindful in the moment, such as stress

reduction and reduced emotional reactivity (Davis & Hayes

2011). It is of note that participants were able to benefit from

the techniques even whilst having a different internal

experience to ‘classic’ mindfulness.

When considering adaptations of mindfulness for

people with intellectual disabilities, it may be beneficial

for more sessions to be offered, or for different or

additional explanations and/or techniques to be intro-

duced. It would be interesting to see whether this led to

greater benefits.

There were also some themes which were more loosely

related to mindfulness. Some of the participants under-

standing of mindfulness appeared to be in relation to the

relaxation effects it induces (e.g. ‘Learn more relaxation

techniques’, ‘Want to relax to look after people’, ‘More

relaxed at night’).

The literature appears to convey a mixed relationship

between mindfulness and relaxation. Although the relaxing

effect of meditation practices has been documented (Wal-

lace et al. 1984), it is not regarded as the primary purpose of

mindfulness meditation (Shapiro 1982) but rather a second-

ary gain. Jain et al. (2007) compared mindfulness meditation

with relaxation training in relation to their effects on

distress, positive states of mind, rumination and distraction.

They found that both interventions produced similar stress

reduction compared to no treatment control; however,

mindfulness produced an additional benefit in reducing

ruminative thoughts.

People with intellectual disabilities may find it easier to

reportrelaxingeffectsofmeditationastheymayfinditeasierto

identify these from the feedback of their body’s response to it

andmayfindtheabstractnatureofreportingonthoughtsmore

difficult. This difference may be one produced by language

and communication difficulties. It may also have been due to

participants’ relative level of exposure to the two interven-

tions,mindfulnessbeinganewskill theyhadnothadprevious

experience of, whereas all of the participants had experience

of relaxation techniques prior to attending the group.

It surprised the authors that one of the themes ‘helping

people’ described participants becoming more caring

towards others. It has been claimed that mindfulness skills

enhance the capacity for caring relationships with others

(Siegel 2007), which was the experie nce of participants in this

study. This is one of the mechanisms that may enable

mindfulness to increase the skills of staff who support people

with intellectual disabilities. Research has shown that mind-

fulness training enables primary care physicians to be more

empathic and caring of their patients (Krasner et al. 2009).

Perhaps it should have been no surprise that it also happens

for people other than care staff who learn mindfulness.

Some of the difficulties in engaging in mindfulness

described by the theme ‘bit too late to teach old dog new

tricks’ are related to learning. Participants in the study all had

intellectual disabilities and are in a culture where theywould

bemore often described as having ‘learning disabilities’. This

may increase the likelihood of individuals feeling daunted

and lacking confidence about learning new techniques.

Limitations of study

One of the limitations of the study is in relation to the first

author having a dual role as relaxation and mindfulness

group facilitator and interviewer. The dual role of facilitator

and interviewer was used as it was felt that familiarity will

help participants orient themselves to the study. However,

it could have affected the responses of the participants,

biasing them towards the positive (social desirability effect).

An additional limitation was in relation to nature of the

group sessions which combinedmindfulness with relaxation

techniques. This may have contributed to the participants’

ª 2014 John Wiley & Sons Ltd, British Journal of Learning Disabilities, 43, 49–54

Mindfulness in intellectual disabilities 53

reports of the relaxation effects mindfulness induced for

them. The authors decided to offer mindfulness, a relatively

new skill with a familiar intervention of relaxation to encour-

age attendance in the group. It would be interesting to repeat

this study for a mindfulness group without relaxation.

Although staff participated in the sessions along with

service users, they were not interviewed as part of this study.

It would be valuable to analyse their experiences, both in

terms of the effect of mindfulness on their own practice, and

any impact they perceived on the service users.

Implications for practice

The themes identified in the study highlighted that people

with intellectual disabilities can develop an understanding

of mindfulness and identify positive impacts this can have

on their lives. The effectiveness of mindfulness has been

well documented in the literature, and it is encouraging that

people with intellectual disabilities within an inpatient

setting can also benefit from this. There may be a need for

further adaptations to mindfulness to suit the communica-

tion needs of people with intellectual disabilities, for

example, offering more sessions, more visual prompts,

and using objects of reference.

Acknowledgements

Grateful thanks is given to Kathie Parkinson (Chartered

Clinical Psychologist); Rebecca Davenport (Trainee Clinical

Psychologist) and Jesvir Dhillon (Assistant Psychologist) for

supporting in the setting up and facilitating of the group.

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