Adolescence represents a difficult development period in one's life, characterized by numerous changes that are omnipresent, occurring almost in all possible domains of life: From physical to psychological to interpersonal. Interventions based on mindfulness aim to encourage attention and awareness of present moment experience. Mindfulness-based Cognitive therapy (MBCT) is a set of techniques designed to encourage deliberate, non-evaluative contact with events that are 'here and now'.
To enhance mindfulness skills, emotional regulation and self-esteem in an adolescent with substance abuse and depression using MBCT.
Miss S.X. was a 20-years-old girl, with complains of consuming brown sugar, irritability, abusive behavior towards mother and elder brother, excessive weight loss, not attending college and basketball practice and disturbed sleep. The girl was diagnosed as Mental and Behavioral Disorder due to use of Opioids with Dependence Syndrome and Moderate Depressive Episode with Somatic Symptoms as per ICD-10.
The course of MBCT spanned for a period of 14 weeks. First half of the program focused on learning to bring attention to "internal'' experience and seeing what happens during the process. Second half of the program emphasized more on teaching how to handle mood shifts by employing cognitive approaches as well as mindfulness.
Techniques like activity scheduling with the 'pleasant and nourishing' and daily mindfulness activities also were helpful for dealing with the negative emotions.
MBCT is effective in teaching the mindfulness skills and improving the emotion regulation.
Mindfulness, Depression, Substance abuse, Cognition, Non-judgment
Mindfulness is increasingly conceptualized in terms of its regulatory function with research suggesting that mindfulness may have a constructive effect on psychological well-being. A systematic review of the few existing MBCT randomized controlled trials concluded that MBCT has an additive benefit to usual care in preventing depressive relapse for individuals with three or more previous depressive episodes [1]. Mindfulness is an effective tool which help people with addiction because it is a simple skill that anyone can practice multiple times throughout a day regardless of the life challenges that arise. Appel stated that mindfulness is helpful, but not a sufficient factor as a means to address substance abuse. Thus, the present study focused on finding the effectiveness of mindfulness based cognitive behavior therapy on symptoms of depression and substance abuse [2].
Miss S.X. is a 20-year-old girl, studying in graduation 2nd year, unmarried, living with her mother and elder brother. She was brought for psychiatric consultation because she used to sniff brown sugar from past 2 years, with persistent low mood, anxiety and worry. She also had a pervasive sense of worthlessness form last 2 years. She started to remain irritable most of the day from 6 months and was getting abusive on trivial issue towards mother and brother. She also had excessive weight loss and she was not attending her college and basketball practice. She was not able to fall asleep most often and had difficulty concentrating.
Mental and Behavioural Disorder due to use of Opioids with Dependence Syndrome and Moderate Depressive Episode with Somatic Symptoms as per ICD-10 [3].
For her symptoms she had received only pharmacological treatment. Her response to drugs tended to be quite slow, and not successful in the end due to poor compliance.
Client mentioned that she had been living with her mother and elder brother. Mostly, since childhood client experienced stress of not being recognized of her achievements by her mother. Client's father had been the person whom client always looked upon for any kind of support. Although her father was caring but he had less time to give to the client. As he had been remaining away from home for his job since the client was very young. But he would come home every weekend. For last 3 years he had been posted in another state and he would be visiting home for 7 to 10 days in 6 months. Client had been feeling that her mother had always done gender discrimination between her brother and herself. She thought that her mother probably resented having to look after two children and especially a girl child. She developed the belief that she was a 'burden' to others and was not really worthy or loveable. During her childhood, she developed the idea that she might prove her worth by scoring higher than her brother and achieving more than him. Although she mentioned that her brother was a supportive figure too, but for last 3-4 years he had also been criticizing her and not supporting her. When she tried to go out with friends or go to college she would be not allowed to do so. Often her brother would scout her. Thus, her relationship with her mother and brother got stained. Gradually, she was losing her confidence and felt like she would not be able to play basketball like before and would be thrown out of the state basketball team. She was struggling with her brother and trying to work out the problems in her game. This was then she first had been exposed to brown sugar which gave her a sense of relief from her pain. She started to continue taking brown sugar whenever she had a fight with her brother or when her mother made critical comments on her. Initially her substance taking behavior was not their when her father was around. She was trying hard to continue her studies and her basketball practice but her father's transfer to another state was the point when her sense of worthlessness combined with her intake of brown sugar, irritability and depressed mood. This combination led to depletion and near collapse. She would not take food and have problem falling and maintaining her sleep. She would feel low and would not be able to concentrate on her studies, had weight loss and would feel tired on doing any work.
Miss SX were a state level basketball player and had a good academic track record. She was intelligent, sensitive, inspired, and had loyal friendship from her peers. According to her family and friends she had been a very sensitive person and had been a very good sister. She had been playing her role very well before she got stuck with substance and depression. Though her relationship with her mother had been stained since her childhood.
The core of Miss SX's problems lay in her chronic lack of self-worth and self-esteem resulting from the relationship with mother and her father's distance. She solved her lack of self-worth by becoming a good basketball player where her team needs her and values her. She tried to boost her self-confidence by working very hard and dedicating herself in getting good marks. She also started to make too many friends for solving her sense of worthlessness. This pattern, twinned with her substance taking behavior and a lack of appropriately assertive behaviors, lead to periods of depletion, collapse and depression. In this instance, her father's accident and there after his transfer made the situations worse for her.
1. Intake of brown sugar
2. Lack of appropriate assertive behaviors
3. Depression and negative thinking about the self
4. Not attending basketball practice and college
5. Over-commitment to the needs of her friends
1. Conceptualization of presenting problem
2. Focus on here and now
3. Become more aware of bodily sensations, feelings, and thoughts, from moment to moment
4. Develop a different way of relating to sensations, thoughts, and feelings; specifically, mindful acceptance and acknowledgment of unwanted feelings and thoughts, rather than habitual, automatic and pre-programmed responses
5. Choose the most skilful response to any unpleasant thoughts, feelings, or situations experienced
6. Decrease rumination
7. Increase distance from thoughts that are not facts
8. Learn appropriate assertive behavior
9. Learn to regulate schema and attentional bias linked to craving
10. Enhanced self-compassion and become gentle with self
1. Treatment began with psycho education and activity scheduling
2. Followed by ventilation of emotions
3. Conceptualizing of present problem
4. Dealing with Barriers
5. Mindfulness of the Breath
6. Staying in Present
7. Allowing/Letting Be
8. Thoughts Are Not Facts
9. How Can I best take care of Myself?
10. Using What Has Been Learned To Deal With Future Moods
Homework was a vital part of therapy, and the therapist measured the client's progress both by objective means (e.g. Beck Depression Inventory; observing her success in solving problems in her life) and subjective data (her self-report of her symptoms, and changes in her maladaptive beliefs) [4].
Her doubts concerning about failing her homework assignments and facing difficulties in completing the agreed-upon tasks were also discussed. She was able to pay attention to her unique vulnerabilities, such as her mother's expectations from her and tendency for believing she is a failure. She was informed about the necessary breaks in the therapy well in advanced, while she was given the potential opportunity for her to practice her skills on her own.
Therapy continued for 16 weeks. Sessions were conducted once a week. The sessions lasted for 45-55 minutes.
Initial sessions were focused on building therapeutic relationship between the patient, her family members and the therapist. Patient and her family members were allowed to express their feelings and realize each other's distress. Therapist motivated patient and her family members to share their experience and the nature of problem which they were facing.
Psycho education regarding patient's illness was imparted. Many misconceptions about the illness were explained. They were especially told about the early sign and symptoms.
Following this therapy focused on making a structured activity scheduling for the patient. Patient prepared a list of activities according to her interest. Therapist helped her to have a structured and well planed schedule for the whole day accordingly. Patient's brother helped the patient in implementing the schedule.
Further focus was on the body. She was explained and shown more clearly how the chatter of the mind begins and how it tends to control our reactions to everyday events.
She was again given a greater awareness of how the mind can be busy and scattered. She was taught how she could intentionally focus on the breath.
• Comfortable posture lying on the back (sitting in later sessions) keeping the spine straight and shoulders drop.
• Eyes closed
• Bring attention to belly, feel it rise or expand gently on the in-breath and fall or recede on the outbreath.
• She was helped to practice the exercise for 15 minutes at a convenient time every day.
She was taught how to stay in the present to widen her perspective on how she relates to experiences. (Mindfulness eating guided her through very slowly eating a familiar object as if never seen it before). After the exercise feedback of experiences was taken. Also, a discussion was done on how it would be to do daily tasks (washing, brushing etc) with this type of awareness and become more aware of bodily sensations, feelings, and thoughts, from moment to moment [5].
Following session focused on teaching how to handle mood shifts by employing cognitive approaches as well as mindfulness.
She was helped in the practice of "allowing" experience or emotion to "just be" without judgment or trying to make it different. This approach allowed her to see things more clearly and to decide what, if anything needed to be changed. Develop a different way of relating to sensations, thoughts, and feelings; specifically, mindful acceptance and acknowledgment of unwanted feelings and thoughts, rather than habitual, automatic and pre-programmed responses [6].
She learned to recognize thoughts as merely thoughts, not reality. She was explained that negative thoughts can restrict our ability to relate differently to experience. She was helped in learning to increase distancing from thoughts that were not facts. She was helped to choose the most skilful response to any unpleasant thoughts, feelings, or situations she experienced.
She learned specific strategies that can be done when depression and craving threaten. She learned her unique warning signs of relapse. She was helped to make plans for how best she could respond to those signs. She was taught to feel her bodily changes while experiencing her emotions. She was taught to observe her thoughts and feelings without conflicting between the right and wrong of the thoughts. And thus, she was helped in reducing frequency of rumination. Only when patient was able to judge her thoughts empathetically, she was made to understand what assertive behavior meant and how she could be assertive. She was explained about the concept of lapse and relapse. She learned to look at situations as opportunities where she was ready to collect new experiences with a positive attitude.
She learned to regulate schemata and attentional bias linked to craving. She was helped in identifying means of self-reinforcement for abstinence. She learned that her pain and distress which she used had some adaptations like bodily sensations. She was taught to focus her attention to her full body. She was then asked to bring to the mind her current problems and continue as: Focusing on some troubling thought or situations and allow self to take some time to tune into any physical sensations in the body that the difficulty evokes. Approach to any sensations that are arising in body; becoming mindful of the physical sensation, deliberately but gently directing the focus of attention to the region of the body where the sensations are the strongest in gesture of a welcoming. Then stay with the awareness of these sensations, breathing with them accepting them and allowing them to be just the way it is [6].
Termination brought a sense of loss; thought therapist was able to normalize patient's feeling at termination. She was reminded that the goals of the therapy were to restore her to the previous level of functioning and to improve social functioning. Also, she could visit the therapist at crisis situations. Patient was pointed out the considerable gains she had made in therapy and sessions were terminated with patient's concern.
• She learned to consciously plan the week to include a balance of work and pleasure
• She learned to think about the self in a more balance and non-judgemental way
• Learned appropriate assertive behaviour
• Learned to regulate attentional bias linked to craving
• Learned to recognize the tendencies to hold onto experiences, whether positive or negative and allowing her to let go of what is not needed or helpful
• She learned that maintaining a balance in life is helped by regular mindfulness practice
We live in a world where much suffering is created by mental health problems, the psychological impact of long-term physical health problems, and the speedy, stressful elements in our culture responsible for many social, economic and environmental problems. Mindfulness and Mindfulness-based approaches could offer much, not just as a tool for developing our health and well-being, but also as a way to foster qualities such as insight, empathy, tolerance and discernment.
The growing recognition of Mindfulness approaches is remarkable. These are grounds for enthusiasm, but also for caution. The enthusiasm is based on the likelihood that Mindfulness-based approaches have much to offer in a very wide range of settings. The caution is based on the knowledge that this is not a top-down approach that can be thrown at any problem. To be effective, Mindfulness practices must be learned and transmitted experientially. Mindfulness needs to be grown carefully.