‘Third-wave’ therapies

In the past 10–15 years, the development of acceptance and mindfulness-based treatmentsFootnote ‡ has spearheaded a new approach to psychotherapies within the cognitive–behavioural tradition (Reference OstOst 2008; Reference Williams and RabbittWilliams 2008a). These so-called third-wave approaches represent a shift of paradigm in the cognitive–behavioural framework, expanding the field in ways that lead to:

1. • less emphasis on first-order change (changing the content of negative cognitions)

2. • a more contextualised approach to clinical phenomena

3. • a focus on experiential and indirect strategies for change, in addition to direct strategies

4. • a broader focus of change: changing the emotional context within which negative cognitions function, rather than merely changing the contents of the negative emotions; this is called second-order change (Reference Hayes, Hayes, Follette and LinehanHayes 2004).

A common feature of the third wave is the emphasis on mindfulness, radical acceptance and spirituality. Aside from differences in the philosophical foundation, the critical difference between cognitive–behavioural therapy (CBT) and third-wave psychotherapies is that CBT techniques are primarily antecedent-emotion focused (modifying initial feelings by changing the situation or the cognitions of the situation), whereas mindfulness approaches are primarily response-focused (modifying behaviour once emotions are experienced) (Reference Hofmann and AsmundsonHofmann 2008). The techniques of CBT promote adaptive antecedent-focused emotional regulation strategies by focusing on reappraisal of the emotional stimuli. In contrast, mindfulness-based therapies target maladaptive response-focused strategies by discouraging emotional submission (Reference Hofmann and AsmundsonHofmann 2008).

Most scholars agree that mindfulness practice has its roots in Buddhism (Reference Ludwig and Kabat-ZinnLudwig 2008), a philosophical tradition that originated in India some 2600 years ago. In Buddhism, mindfulness is considered a vehicle for alleviating suffering, cultivating compassion and attaining wisdom. The traditions of Buddhism postulate that, without being aware of oneself and one's surroundings, one cannot understand the natural laws of life.

Contemporary psychologists have described mindfulness as ‘the awareness that arises from paying attention on purpose, in the present moment, non-judgementally, to things as they are’ (Reference Williams, Teasdale and SegalWilliams 2007: p. 47). They further expand the concept as not paying more attention, but paying attention ‘wisely’. Reference Ludwig and Kabat-ZinnLudwig & Kabat-Zinn (2008) describe mindfulness as ‘attending to relevant aspects of experience in a nonjudgmental manner’ which would ‘foster clear thinking and open-heartedness’. Accordingly, the goal of mindfulness is to ‘maintain awareness moment by moment, disengaging oneself from strong attachment to beliefs, thoughts or emotions thereby developing a greater sense of emotional well-being’.

A key feature of psychological and psychotherapeutic accounts of mindfulness is the assumption that distress and psychopathology are associated with mental activity that is either hypoactive, hyperactive or stuck in an unhelpful pattern of responding. The mind is ‘doing’ something that is unhealthy, and it needs to stop ‘doing’ and pay more attention to ‘being’. Mindfulness-based therapies can promote and support the ‘being’ mode. Reference WilliamsWilliams (2008b) illustrates six distinctive differences between the doing and being modes of mind (Table 1).

TABLE 1 The ‘doing’ and ‘being’ modes of the mind

Mindfulness and mentalisation

Mentalisation-based treatment (MBT)Footnote § is another therapy that has been increasingly used to good effect in forensic settings during the past few years. Mentalising (Reference Fonagy, Gergely and JuristFonagy 2002) and mindfulness are, to a degree, overlapping constructs in their openness to examining mental states and reflecting without acting. Both involve directing one's attention to one's own experience as a way of mitigating tendencies towards impulsivity and reactivity. Mindfulness and mentalisation equally emphasise the integration of cognitive and affective aspects of mental states in encouraging simultaneous recognition and participation in internal experience. Reference Choi-Kain and GundersonChoi-Kain & Gunderson (2008) identify three distinctions between the two concepts, in terms of interactions, temporal focus and relationship to internal experiences, and these are listed in Table 2.

TABLE 2 Key distinctions between mindfulness and mentalisation

Therapeutic actions of mindfulness

The early therapeutic use of mindfulness techniques for psychopathology was in teaching mindfulness-based stress reduction (MBSR) to general medical patients with chronic stress due to physical health conditions that were considered untreatable (Reference Kabat-ZinnKabat-Zinn 1990). Early studies suggested that patients who practised regularly experienced reduced pain and stress from their conditions; even though they were still ill, they managed their distress better. Similarly, Marsha Reference LinehanLinehan's (1993) programme of dialectical behaviour therapy (DBT) uses mindfulness-based techniques to improve affect regulation in those who seem to struggle with their negative affects, and to reduce their tendency to act impulsively when experiencing strong negative emotions (Reference Robins, Ivanoff, Linehan and LivesleyRobins 2001; Reference Lynch, Trost and SalsmanLynch 2007).

Since this early work, there has been extensive study of mindfulness-based interventions applied to different types of psychopathology and practised in many types of clinical mental health setting. The most recent and most compelling evidence relates to the use of mindfulness-based cognitive therapy (MBCT) for the treatment of chronic depression, and this now features in national guidelines for the treatment of depression (National Institute for Health and Clinical Excellence 2009).

Psychological actions

Reference MaceMace (2008) describes three therapeutic actions resulting from mindfulness practice that may be influential in achieving beneficial outcomes for patients (Box 1).

BOX 1 Therapeutic actions resulting from mindfulness practice

Dechaining	Objective observation of psychological events, to break the cycle of ruminations and anxiety responses
Resensing	The capacity to accept experiences with equanimity and without fear or aversion
Decentring	The capacity to observe one's thoughts and feelings as temporary mental phenomena, rather than necessarily true reflections of reality

(Reference MaceMace 2008)

Dechaining

Dechaining entails the close objective observation of psychological events that the ‘bare attention’ brings. Dechaining explains a mindfulness practitioner's ability to experience an event in full detail, in a slowed down way, but also how each event is seen to be less firmly linked to things that precede and follow it than ordinary perception suggests. Developing this quality has been found to be important in reducing ruminations and in breaking the cycle of anxiety response typically found in behavioural disorders.

Resensing

In resensing, the individual learns to relate to exposure to situations and feelings in a different manner and to welcome experiences as they are attended to, with acceptance and equanimity and without fear and aversion. The freshness of the experience here reflects the absence of old reactions of distress or fear, a feature that is important in treating anxiety and phobic disorders.

Decentring

Mindfulness approaches emphasise the adverse effects of believing that one's thoughts necessarily reflect reality and of reacting to them accordingly. Decentring is the capacity to observe one's thoughts and feelings as temporary mental phenomena rather than reflections of the self that are necessarily true. Decentring includes taking a non-judgemental, here-and-now approach towards thoughts and feelings and accepting them as they are. This seems to form the basis of the effectiveness of mindfulness-based approaches in dealing with problematic thoughts such as obsessional or depressive ruminations.

Unstable negative affect and impulsivity

Negative affects include anger, rage, pain, panic, disgust, shame and hatred. Early childhood attachments are thought to influence the development of negative affect regulatory systems in the human brain (Reference SchoreSchore 2001). A key aspect of affect regulation is the capacity to experience a feeling without acting on it and to reflect on that experience as it is occurring. Those who cannot do this tend to act as soon as they have a thought or feeling (usually negative), and this significantly increases the risk of boundary- and criminal rule-breaking. Impulsivity is influenced by both temperament and genes, and some studies suggest that those who are impulsive have low levels of serotonin (Reference Schweighofer, Bertin and ShishidaSchweighofer 2008).

A combination of negative affect dysregulation and impulsivity will put a person at high risk of ‘acting out’ their feelings. The most common types of acting out in this context are behaviours that later affect states and also put the self at risk in some way: substance misuse, self-cutting and overdosing. These behaviours are especially common in mood disorders, and are characteristic of disorders of mood regulation such as borderline personality disorder. A subgroup of those who harm themselves also act out against other people, impulsively hitting or attacking. Such behaviours are, of course, more likely when an individual is disinhibited by alcohol or illicit drugs, especially those that increase central monoamine levels.

Severe negative affect dysregulation and impulsivity are difficult to treat with cognitive approaches because patients cannot ‘hang on to’ cognitions and/or affects long enough to reflect on them and consider alternatives. Reference Wright, Day and HowellsWright et al (2009) discuss the difficulty of choosing an alternative conscious response to a trigger stimulus when the individual has limited self-awareness. It can be hard to use cognitive–behavioural interventions to activate an alternative behaviour or thought when the individual reacts too quickly in an emotionally charged situation. Reference GolemanGoleman (1995) refers to this phenomenon as the hijacking of the cognitive system by the emotional system. Mentalisation-based therapies have had some success in this area because they increase self-reflective function (Reference LevyLevy 2008), which allows people to pause before they act.

Mindfulness-based approaches such as DBT have been shown to be successful in reducing the frequency of impulsive self-harm and antisocial behaviour. A number of mechanisms of action have been proposed to explain this, and we consider some of them (Box 2) here.

Clinical depression, psychological distress and self-harm

Prisons and secure psychiatric residential settings are psychologically demanding environments that require people to draw on a range of internal and external resources in order to survive – resources that many will lack, given the level of psychiatric and psychological morbidity in this population (Reference Singleton, Meltzer and GatwardSingleton 1998). In prisons, there are high rates of both self-harm and suicide (Reference Shaw, Baker and HuntShaw 2004): 22 459 incidents of self-harm were recorded among women in UK prisons in 2007 (Reference Short, Cooper and ShawShort 2009). Men are equally at risk. Reference Fazel, Benning and DaneshFazel et al (2005) noted a rise in completed suicide in prison between 1978 and 2003. However, with new measures in place to reduce suicides in prisons, this trend appears to have reversed by 2008 (Reference Brooker, Flynn and FoxBrooker 2010).

A large proportion of prisoners experience a high level of psychological distress (Reference HarveyHarvey 2007): in one study, 65% of women and 52% of men obtained scores indicative of distress on the 12-item General Health Questionnaire (HM Inspectorate of Prisons 2007). Prisoners experience isolation, shame and social exclusion, as well as psychiatric diagnoses such as depression and borderline personality disorder, all of which are risk factors for both self-harm and suicide. In addition, the index offence itself may be a ‘disaster’ for the prisoner/patient, causing both acute and long-term stress. This is particularly the case for family violence and homicide.

A survey of suicides in UK high secure hospitals spanning 29 years (1972 to 2000) found increased rates of suicide among in-patients compared with the general population (Reference Jones, Hales and ButwellJones 2011). More interestingly, it found that women in high security were more than twice as likely to complete suicide than men, which is a significant deviation from the trend seen in general population. In a survey of suicides in medium secure units in Britain, Reference JamesJames (1996) recorded that 9 out of the 19 units that responded reported a death by suicide. James noted that patients in medium secure units often have multiple risk factors for suicide although, in fact, completed suicide in medium security is rare. It is reasonable to infer that, thanks to close observation and stringent patient management techniques in secure hospitals, far more suicides are prevented than actually succeed.

This evidence from prisons and secure psychiatric services clearly suggests that there is a significant subgroup of individuals who are suffering distress, may have clinical depression and may be at enhanced risk of suicide. The therapeutic effectiveness of mindfulness practice for affective disorders has been well demonstrated and an evidence base is firmly established (National Institute for Health and Clinical Excellence 2009). For example, MBCT is effective for chronic depression, especially in reducing the risk of relapse. Mindfulness practice has been shown to increase positive affect and reduce stress reactivity, producing demonstrable effects on brain function. One study reported significant leftward shift in resting electroencephalogram (EEG) patterns of healthy people after 8 weeks of mindfulness practice, which persisted at 4-month follow-up (Reference Davidson, Kabat-Zinn and SchumacherDavidson 2003). Similar changes in brain activity, together with reduced distress, were recorded in individuals with a history of suicidal depression who completed an 8-week course of MBCT (Reference Barnhofer, Duggan and CraneBarnhofer 2007).

Stress reactions with a psychosomatic component

There have been few studies of stress in forensic populations, although by inference from prison data, it seems reasonable to assume that a substantial number of forensic patients experience stress on a daily basis. Having a personality disorder or a psychotic disorder reduces the capacity to manage stress, and the personality disorder diagnosis in particular is associated with psychosomatic dysfunction and medically unexplained symptoms (Reference Crimlisk, Bhatia and CopeCrimlisk 1998). Mindfulness-based techniques might therefore be of use in this group of forensic patients. Mindfulness training could also form part of healthy living programmes addressing patients' physical health by making them more aware of their bodies.

Other possible indications for mindfulness practice in forensic settings

In addition to the conditions described above, it is theoretically possible that mindfulness-based therapies might be effective in people who lack compassion for themselves or others, as developing compassion is a key goal of mindfulness practice. Mindfulness practice has an effect on midline prefrontal regions of the brain, which have been implicated in controlling aspects of empathy and insight (Reference Beer, John and DonatellaBeer 2006; Reference Heisel and BeattyHeisel 2006) and moral reasoning (Reference Anderson, Bechara and DamasioAnderson 1999; Reference Bechara, Damasio and DamasioBechara 2000; Reference Moll, De Oliveira-Souza and EslingerMoll 2002; Reference Greene, Nystrom and EngellGreene 2004). Furthermore, there is evidence to suggest that conscientiousness – one of the positive ‘Big Five’ personality traitsFootnote ¶ – is correlated with trait mindfulness (Reference GilukGiluk 2009) and, in theory, could therefore be improved by mindfulness practice. (Trait mindfulness is when mindfulness is measured as a personality attribute – a trait – that varies from person to person). However, it is complicated to study the therapeutic efficacy of new modes of treatment in groups that are often reluctant to engage in therapy or are contemptuous of attempts to help (Reference McGauley and HumphreyMcGauley 2003). It is also not certain that profoundly antisocial offenders lack empathy; rather, they might prefer not to use it.

For some offenders, incarceration in secure services is painfully lengthy. An average stay for a patient in a UK high secure hospital is about 8 years. A more palliative, long-term psychological input may be necessary to alleviate the suffering of these individuals (Reference McGauley and HumphreyMcGauley 2003). Mindfulness-based interventions in their current forms are usually brief, time-limited and delivered to groups. A possible solution to cater for long-term patients would be to offer identified groups of patients a standard brief course, followed by less frequent maintenance therapy sessions for the duration of the patient's stay in hospital.

Mindfulness practice could also be useful for staff, who have to manage their own negative affects while working with challenging and frightening patients (Reference Lowdell, Adshead, Aiyeghusi and Clarke-MooreLowdell 2009). Staff working in secure settings identify the threat of violence by inmates as their most frequent source of stress. This stress is often exacerbated by the challenges of dealing with offenders who denigrate or attack those who give them care. Staff may label the symptoms of mental illness as ‘bad behaviour’ and resort to retaliating with punitive measures (Reference CohenCohen 2003). Mindfulness-based stress reduction has been used in other healthcare professional groups to good effect (Reference Shapiro, Brown and BiegelShapiro 2007), and could therefore theoretically play a role in helping forensic staff manage stress and reduce burnout (Box 4).

Concept and criterion validity

Theoretical challenges include ongoing confusion about the definition and conceptualisation of mindfulness, especially in research. There are debates as to whether mindfulness has been sufficiently operationalised to make research possible (Reference BishopBishop 2002; Reference BaerBaer 2003; Reference Coffey, Hartman and FredricksonCoffey 2010). Some have questioned the external and internal criterion validity of mindfulness research altogether (Reference Singh, Lancioni and WahlerSingh 2008). No one has carried out a proper trial involving forensic patients, not least because it has not yet been possible to show definitively that they have specific mindfulness deficits.

Risk of adverse effects

One of the practical challenges is the possibility that mindfulness techniques might have a negative effect, making patients worse (Reference MaceMace 2008). This is a particular concern with forensic patients, who are likely to have severe psychiatric illness. Both mentally ill and healthy people have reported exacerbated restlessness, anxiety, depression, guilt and hallucinosis during meditation training retreats (Reference Albeniz and HolmesAlbeniz 2000). Experienced meditators have reported restlessness, self-criticism and self-doubt during early phases of their meditation training (Reference MaceMace 2008). In our experience, negative side-effects such as anxiety, depression and psychotic breakdown can occur in forensic patients during psychodynamic psychotherapy; hence, extensive exploratory psychotherapy is often not used in this group of patients. The possibility of generating distressing and underresearched side-effects in patients raises concerns, particularly in a medico-legally sensitive secure therapeutic environment.

Cultural acceptability

Another practical challenge may be the cultural acceptability of mindfulness-based interventions to patients, carers and professionals in Western mental health systems (Reference Howells, Tennant and DayHowells 2010). Until 15–20 years ago, the word ‘meditation’ was considered by many to be suspect and associated with images of fraudulent mysticism (Reference Kabat-ZinnKabat-Zinn 1990); and this, albeit to a lesser degree, may still remain the case in some quarters. Mindfulness is taught and practised in the Western world independently of the rich religious and cultural tradition of its origins (Reference LinehanLinehan 1993). Reference Howells, Tennant and DayHowells et al (2010) alerts us to the dangers of severing mindfulness from its roots and treating it in relative isolation from the deeper philosophical and psychological system that generated the concept. Whether mindfulness in isolation of the Buddhist cultural tradition would deliver expected outcomes, beyond a narrow therapeutic remit, remains to be seen.

Qualities such as inwardness, reflection and introspection (which are core aspects of mindfulness) are not widely valued or practised in Western societies, which emphasise action and striving for objects or goals. This might be particularly true in forensic settings, where psychological practice is underpinned by punishment-oriented values. Whether a more extensive and widespread use of mindfulness-based interventions that primarily focus on compassion and acceptance beyond the narrow remits of DBT would create a greater resistance in forensic settings remains to be seen.