Mindfulness-Based Occupational Therapy

Complementary and alternative medicine (CAM) and integrative medicine (IM) have been growing rapidly in the psychodynamic and humanistic traditions of psychotherapy to help meet the needs of our growing chronic public physical and mental health disease crisis. The current demand for highly qualified professionals who teach the skills of mindfulness has grown exponentially in recent years. The year 1990 was a watershed, after which "mindfulness" as a discrete term began to take hold in the discourse of academic medicine and psychology (Dryden and Still, 2006). This is the publication date for Jon Kabat-Zinn’s book Full Catastrophe Living, describing the mindfulness-based stress reduction (MBSR) program that he developed in 1979 at the University of Massachusetts Medical Center. The curriculum started at the University of Massachusetts Medical Center has produced nearly 1,000 certified MBSR instructors who are in nearly every state in the US and more than 30 countries.  

Almost every major medical center in the US currently has an IM center and many include mindfulness and or MBSR as an integral component to their programming. MBSR is now used as a therapeutic intervention in over 700 hospitals worldwide. Meditation and mindfulness have been featured in cover stories in the Scientific American, New York Times, Time Magazine, and Newsweek (Kalb, 2003, Stein, 2003). MBSR and other mindfulness-based approaches are now considered "evidence-based treatment" due to the extensive amount and quality of research with randomized, controlled clinical trials that has abounded over the past 10 years. In fact, 52 papers were published in 2003, rising to 477 by 2012. Nearly 100 randomized controlled trials had published by early 2014.

Clinical trials that are currently underway studying the efficacy of MBIs are with the following: asthma, bone marrow transplant, breast cancer, chronic pain, chronic obstructive pulmonary disease (COPD), HIV/AIDS, hot flashes, hypertension, immune response to HPV, IBS, lupus, myocardial ischemia, obesity, cancer, arthritis, organ transplant, type-2 diabetes, other medical conditions including psychiatric disorders, such as anxiety disorders, eating disorders, personality disorders, PTSD, schizophrenia, suicidality, and others (Clinical Trials, 2008). Grossman et al. (2004) characterized the current research findings with this statement, “Thus far, the literature seems to clearly slant toward support for basic hypothesis concerning the effects of mindfulness on mental and physical well-being.” (Fang, C. Y., 2010; Morgan, N., 2014).

Mindfulness and MBSR are not just in Western medicine. More than 2,000 people from companies like Google, Facebook and Instagram showed up earlier this year in San Francisco for a mindfulness conference called Wisdom 2.0. Google now offers their 52,000 employees free lessons in mindfulness. Corporations such as General Mills have made it available to their employees and set aside rooms for meditation. Democratic Congressman Tim Ryan published a book in 2012 titled A Mindful Nation and he has helped organize regular group meditation periods on Capitol Hill. An all-party parliamentary mindfulness group was developed in the UK for the House of Lords. In the UK, three universities offer master’s level post-graduate professional training in mindfulness-based approaches: The University of Exeter and Oxford University Mindfulness Centre in England, and Bangor University Center for Mindfulness, Research, and Practice in Wales.

Mindfulness-Based Interventions (MBIs) are growing in number as well. Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavioral Therapy (DBT), and Acceptance and Commitment Therapy (ACT) are three MBIs that are drawing the most cultural attention at this moment. Occupational therapists are currently using all three of these MBIs as interventions within their practice. It is clear that the time is right for the profession of occupational therapy to embrace this emerging demand and create it's own path by merging the therapeutic skills of mindfulness with the depth and complexity of the profession of occupational therapy to create a new practice area called Mindfulness-Based Occupational Therapy (MBOT).

Health professionals including occupational therapists are working in increasingly fast-paced, production-oriented, resource-driven environments that disproportionately value hard work and self sacrifice. Increased productivity standards, increased client loads, and self-care discrepancy measures among health professionals demonstrate staggering and unfortunate impacts on the health professional’s mental and physical health and research has demonstrated that burnout among health professionals significantly impacts and reduces client outcomes, the development of the therapeutic use of self, and rapport building (Brice, 2001; Maslach, 1986; Raquepaw and Miller, 1989; Soderfeldt et al., 1995; Valente and Marotta, 2005). Burnout refers to a state of emotional exhaustion in health and mental health workers that can manifest in the form of mental health problems, physical ailments, illness, and disease and it is on the rise (Freudenberger, 1974; Maslach, 1986; Maslach et al., 1978; Pines & Maslach, 1978; Sturgess & Poulsen, 1983). Depression, suicide, substance abuse, sexual misconduct, burnout, and relational problems can all be realistic and serious concerns for therapists who do not effectively care for themselves and do not have the skills to effectively engage with the unique and staggering occupational stressors they face (Brady, Guy, & Norcross, 1994). The knowledge that therapists can do harm to their clients and themselves by not being aware of, and attending to, their own needs and not having developed the skills to be in relationship to this degree of intensity they participate in has driven this growing body of research.

Many studies have demonstrated the potential beneficial effects of mindfulness training on health care professional’s personal self-care, improvements in interpersonal relationships, they are markedly more fully present with clients and their needs, less resentful, less reactive and less defensive, increased positive affect and self-compassion, more self-aware and accepting, they demonstrate improved attention and concentration, improved morale, enhanced meaning, performance and decision making, improved self-regulation and impulse control, improved empathic responses, enhanced creativity, improved sense of self-mastery, self-esteem, self-trust, and mental flexibility. These specific qualities of attention, attitude, and intentions are foundational components in the development of mindful awareness in one’s life and work and can have profound and far reaching effects (Baker, 2003; Christopher et. al, 2006; Valente and Marotta, 2005; Shapiro, Brown, & Biegel, 2007).

Advanced training in Mindfulness in Occupational Therapy (or Mindfulness-Based Occupational Therapy - MBOT) would provide occupational therapists with in-depth training in foundations of mindfulness practice and mentorship to develop evidence-based MBOT interventions for their unique practice settings. This kind of training will ensure a depth of personal mindfulness practice combined with the intellectual, theoretical, and historical underpinnings of mindfulness practice and skills for facilitating mindfulness in clinical settings unique to occupational therapy. It would fulfill the growing demand for training specifically designed for occupational therapists who wish to include mindfulness as a significant part of their clinical practice in mental and physical health settings, and would set a standard demonstrating competency and international collegial collaboration in combining mindfulness and occupational therapy. Contact Rochelle McLaughlin to inquire about such training programs in development. 

This emerging therapeutic approach, Mindfulness-Based Occupational Therapy (MBOT) blends the two therapeutic disciplines of occupational therapy (OT) and mindfulness into a new Mindfulness-Based Intervention (MBI). MBOT’s focus is multifactorial. Elements of mindfulness foundations are woven into the fabric of skillful occupational engagement “interoccupational relationships”, effective interpersonal therapeutic relations, the enhancement of the therapeutic use of self, and the development compassionate care of oneself and other. Application of mindfulness-based practices is an essential aspect of this intensive MBOT training certificate program. Integration of mindfulness-based methods and skills are appropriately merged with occupational therapy interventions using evidence-based approaches.

  It can be a profound realization to recognize that the capacity to build mindful awareness of one's body and mind can be assistive in addressing many of the the underlying problems of modern diseases. Mindfulness is the practice of purposefully attending to the present moment with an attitude of openness and curiosity. When we teach the heartfulness and skillfulness of mindfulness as occupational therapists, we become healing facilitators of our client's capacity to become co-healers using the wisdom of their own body and mind. This can be incredibly empowering.

Mindfulness-Based Occupational Therapy (MBOT) explores true healing as a journey of learning and connecting. It is not a model of fixing, correcting, or repairing. MBOT is steeped in a model of cultivating deeper levels of personal understanding and greater degrees of insight. The skills of mindful awareness are tools that help us all engage in close connectivity with ourselves and our infinitely vast and complex human experience in each moment. The skills shed light on our present moment experience and help us build trust in our capacity to heal ourselves, our communities, and the world.

Occupational therapists work on the front lines of incredible human suffering. An occupational therapist who has his or her own personal mindfulness practice will be more able to remain present to his or her own internal mental and emotional experience and physical wellbeing from one moment to the next thereby reducing potential for burnout and enhancing self-efficacy.  Dr. Dan Siegel, researcher, author, and director of The Mindsight Institute at UCLA describes this process as neurological "integration". He invites us to "connect rather than correct." Learning to be in wise relationship to our experience in each moment without needing it to be any other way and developing deeper levels of understanding. In this way, we are capable of learning, growing, and healing ourselves and cultivating a more wise relationship to our work as OTs. 

Occupational therapy promotes health by enabling people to perform meaningful and purposeful occupations. [1] However it is often the case that we are not present or "conscious" during these meaningful occupations. Not only are we not present but we are often lost in ruminative thoughts and unacknowledged judgements. This mental phenomena can often be dysfunctional or destructive to our emotional, mental, and physical health. We can be significantly limiting our experience of our lives by living only in the unacknowledged, often habitual, cognitive domain of experience. We can be drawn away and disconnected from our experience for long periods of time and even life times. 

When we are disconnected from our lives we are unable to fully experience our daily activities even those that we might consider “meaningful” and the quality of participation in meaningful occupations can suffer. MBOT invites us to live the following questions as a journey of inquiry, healing, growth, and learning:

"What is my quality of participation and engagement in my daily occupations?" 

“How can I cultivate a healthy and meaningful relationship to my daily activities?”  

“How can I assist my client in cultivating a higher quality of participation, engagement, and relationship to their occupations?” 

As the occupational therapist integrates mindful awareness into his or her own daily personal and professional life they begin to become aware of their personal quality of participation in daily occupations. Through the engaged participation in meaningful occupations the OT will gain insight into the significance of the healing nature of being more aware and present with our unfolding experience in each given moment. Establishing connection to our experience during daily occupations gives us the opportunity to develop deeper levels of understanding of the significance of daily occupations in one's life and deeper levels of awareness of our own habitual patterns of behavior and the effect of these patterns on our health and wellbeing. The enhanced awareness allows us to notice our relationship to our daily occupations and offers us the opportunity to choose and establish deeper levels of wise relationship to the fullness of our lives. Through this gained insight, the seeds of awareness are then infused into all clinical interventions as well as personal and professional interactions. 

MBOT is appropriate for any population an occupational therapist would work with: pediatric to geriatric populations, stroke survivors to individuals on the autistic spectrum. MBOT is a valuable practice to help improve clinical outcomes and reduce stress and anxiety on the part of the clinician and the patient. MBOT draws from awareness-based practices and somatic approaches to healing. It incorporates features of mindfulness into interventions: awareness, compassion, acceptance, motivation, embodiment, and learning skills and tools for how to be in wise relationship to intensity for vastly varying expressions of physical and mental suffering.  

Ways for Occupational Therapists to incorporate mindfulness into their work:

  • Mindfulness of Self:  Awareness of body/needs of body, breath, thoughts, emotions, clarity of values during the participation in daily occupations (interoccupational relationships - IOR). Awareness of interpersonal relationships: approach, personal communication styles, verbal cues, body language, presence. Weaving mindfulness practices into informal aspects of OT interventions and other OT daily work activities. Continue to develop the foundations of mindfulness in one’s life and build the practices into one's life.
  • Maintaining awareness of self and state of being, not needing to be drawn into other’s state of being.
  • Daily Practice of Mindfulness Practice and Skills
  • Situational Awareness even during “active experimentation” during interventions.
  • Awareness of Self
  • Self compassion
  • Mindful Yoga for Flexibility of Body and Mind
  • Therapeutic Use of Self
    • openness, kindness
    • active listening, warmth
    • acceptance
    • non-judgmental
    • remaining present
    • awareness of energy levels
    • capacity to build rapport
    • model appropriate emotional regulation skills
    • awareness of own affect, body & facial, awareness of affect on others.
    • mindful listening
    • reflective observation
  • Being mindful of acknowledging and recognizing sadness and grief, learning to be with it.
  • Embracing the beauty/power of enabling a client to engage in occupation.
  • Not needing to take things personally, not about “you”.
  • Awareness of client’s verbal & physical expressions, be sensitive, moved by them. Still staying firm in how you feel, not needing to be “drawn in” and yet still "touched" by the experience/interpersonal interaction.
  • Validating and honoring own feelings and experiences.
  • Awareness of biases, fears, etc. See them for what they are. Bracketing them when unable to let them go. 
  • Checking in with self regarding intensions for session.
  • Awareness of self-esteem levels, understanding we are always doing the best we can in the moment with what we know at the time, vow of imperfection, self-compassion and kindness.
  • Awareness of contraindications and precautions, intention to “do no harm”.
  • Occupational-Relationship Awareness, make adjustments to those inter-occupational relationships that do not fit with your values and intensions, desire for health and wellbeing.
  • Reflection on experiences
  • Reflection on reactions
  • Implement strategies for balance and calmness
  • Patience
  • Share experiences with those that support you, allow you to be who you are, appropriate “mirror models”.
    • Taking time to be in community
    • Slowing down, connecting with the breath
  • Awareness Tools and Skills: Share what you "know". The skills and tools must be embodied in order to be modeled or shared authentically. If any mindfulness skills, tools, or practices do not ring true for you, don’t use them. If you bring an awareness tool, practice, or skill as a therapeutic modality bring it with the intention that you will also benefit and grow from the practice. The OT becomes a part of the process of the authentic healing relationship.  

  Explicitly guiding MBSR practices such as the body scan, formal sitting practice, mindful yoga, mindful walking. Practice with your client with the intention of authentically working with the practices as well. OTs must teach the formal practices from the inside meaning that they have a well- establish personal mindfulness practice first. Also using informal practices of mindfulness as a therapeutic modality.  

  • Mindfulness of Client: 
  • Breathing/breath awareness
  • Emotional role play
  • Expressive Arts
  • Mindful Yoga, Qi-gong, Mindful movement
  • Mindful of body as much as possible
  • Encouraging client to practice kindness and acceptance, modeling this for them.
  • Body Scan practices, practice with your clients.
  • Walking meditation, kind, patient, increased balance, and safety.
  • Noticing how emotions manifest in his/her own body, educate client or simply ask, “How are you feeling?”
  • Moving/guiding client into their body
    • sensory diet
    • mindfulness practices & exercises
    • awareness of feet on floor
    • awarenee of breath
  • Educate family about validating emotions in child, significance of interpersonal attunement, slowing down, simplifying, healthy attachments and bond formation.
  • Reaction vs. responding education. 
  • Recognizing different communication styles
  • Introspection, reflection, “dropping in”, tuning in. 
  • Teaching self-acceptance, acceptance of emotions. 
  • Recognizing and acknowledging emotional reactions in others. Not needing to take it personally. 
  • Allowing other’s to have their own experiences, not needing to imprint your desires for them to have a particular experience.
  • Letting it, them be.
  • Modeling frustration tolerance, distress tolerance.
  • Compassionate body perceptions
  • Nonjudgment of abilities, being with things as they, putting out the welcome mat for what is.
  • Understand complexities of stress response, teach this, educate others.
  • Not projecting or assuming. Asking for explicit self-reflections, help them articulate their experience if they have difficulty doing this.
  • Trying to understand what works best for client. 
  • Reflecting on what they can still do.
    • “There is more right with you than wrong with you.”
    • “Let’s pour energy in the form of attention into what is right with you”.
    • Activities that highlight sensory experiences, getting client in their body.
    • Allow them to experience what is right with them, adjusting environment in this way and adjusting activity to support this awareness.
  • Mindfulness Context/Situation: In-tune with client's experience by slowing down enough to be aware of subtleties of the situation, the context, and client in the moment. "Connecting rather than correcting" (Siegel, 2013), expressing compassion, and being motivated by personal empathic drives that are developed through personal awareness practices. Becoming present to the unfolding experience. Allowing the client to be fully seen and heard. 
  • Minimize distractions to improve awareness
  • Create spaces/pauses into temporal context
  • Intentional set-up of objects in environment
  • Being mindful of the day to day reality of the setting.
  • Letting things go, recognizing what you have control over (your perceptions/thoughts/beliefs/actions) and what you do not have control over.
  • Being present with the client.
  • Encouraging colleagues to practice mindfulness, take MBSR or MBCT courses, do inservices to introduce settings to mindfulness, educating staff.
  • Mindful and accepting of cultures and embrace diversity.
  • Be open to learning new things.
  • Recognizing, honoring, and acknowledging cultural expectations/implications. 
  • Non-identification: not taking things personally.
  • Situational awareness, awareness of environment, whole context, bigger picture. 
  • Recognizing perceptions and thoughts that may be limiting, letting go.
  • Sensory diet menu
  • Identifying environmental triggers, noticing when wanting to numb or subjugate one’s experience. 
  • Noticing when it is difficult to “show up for” another’s suffering, extending self-compassion.
  • Timliness/mindfulness of routines (not too late or too early)
  • Noticing present experiences and sensations.
  • Caring for one’s body, making adjustments to stay safe.
  • Understanding of others in living environment
    • changing harmful environments
    • changing harmful reactions
    • accepting self in the situation as you/they are.
  • Right food, sleep, therapy
  • Letting the situation to be as it is, not needing it to be any other way.
  • Beginner’s mind, seeing things from fresh eyes, expanded context, new and fresh perceptions.
  • Each experience will be new and fresh, not needing to mentally label/limit the experience. 
  • Taking time to process events of the day throughout the day, recognizing how they “sit” with you, letting it be, extending self-compassion.
  • Environmental modifications to support mindfulness. Make small and incremental adjustments to foster this intension.
    • reduce chaos, busyness, noise, stimulations, simplify
    • fish tanks, gardens, plants
  • Recognize and take advantage of environmental supports
    • including supportive and inspiring “mirroring models”, surround yourself with those that inspire you. 
    • Those that have qualities that resonate with your deepest values and hopes.
  • Mindfulness breaks
  • Help everyone have permission to manage stress skillfully.
  • Research: Mindfulness and MBSR are very well researched. Use evidence-based knowledge to back up your recommendations. In 2012 there were 477 peer reviewed studies published on mindfulness. Nearly 100 randomized controlled trials had published by early 2014. Here is a link to a resource for Mindfulness Research:  http://www.mindfulexperience.org/

Resources for mindfulness training for OTs:

Links to UMASS's CFM program here and here.

Dr. Brewer's Mindfulness and Addiction Treatment can be found here

Teacher Training Programs in SF Bay Area here.

You can watch a Mindfulness-Based OT video here.

Link to Mindfulness-Based Treatment Approaches resource can be found here.


A few additional resources:

Time Magazine Article: The Mindful Revolution can be found here and here.

Mindfulness on CBS 60 Minutes

A UC Berkeley course on the science of Happiness can be found here.
Video with Dr. Brewer on the Mechanisms of Mindfulness (formerly at Yale and now at UMass CFM) can be found here.
TED video with Dr. Kelly McGonigal on stress beliefs can be found here.
Dr. Jill Bolte Talyor's TED talk can be found here.
Dr. Amy Cuddy's TED talk can be found here.
Dr. Brene Brown's TED talk can be found here.
Shwartzberg Gratitude Video (Cultivating Appreciation in Present Moment) can be found here.
A Few Research Study Links: 

A 2011 study demonstrated that mindfulness practice alters the structure of the brain in 8 weeks. The article can be viewed here.

Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders can be found here.

Mindfulness-Based Relapse Prevention for Alcohol and Substance Use Disorders can be found here.
Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process can be found here.
The clinical use of mindfulness meditation for the self-regulation of chronic pain can be found here.

Here are a few quotes from students following the completion of the MBOT Course at San Jose State University:

"Over the course of this semester I have smelled more flowers than I have in my entire life and it has been glorious. While I have been slow to accept and assimilate mindfulness practices into my personal life, I know that I have begun a journey that will carry throughout my life. The most significant things that I have learned from this course are how to be present in the moment, to enrich the moments I am given, to know myself better by being in touch with myself, and to care for myself."
"Moments make up my life and if I let them pass me by and do not take full advantage of these moments my life will pass me by."

"I truly feel that OCTH 210 has been a precious jewel in my OT education. As I reflect upon my time in graduate school, I consider all other courses as the “mind & body” of the curriculum and OCTH 210 as the “heart & soul” of the curriculum, as it has taught me many things that will help to enhance my therapeutic use of self and enrich my overall life experience."

"These themes identified in this course are a reminder that my body and my mind are powerful. They function in relationship to each other as well as within each entity individually at changing levels to support my existence. The things I do and say in my personal and professional life are even more powerful if I am aware of these functions and how they affect my present moment."

"It is fantastically healing to be engaging in activities with focus and concentration instead of constant interruption and drudgery…I could live whelmed instead of overwhelmed, and here instead of there, and genuinely instead of halfheartedly."

"Thinking about myself in the bigger picture, as I go about my day, I remind myself that everything I do has an effect on everything no matter how big or small."

"Being able to be present with our own suffering, translates into the ability to be present with another’s suffering. Being able to be present with our own storms, enables us to be present with another’s storms. This helps to cultivate an empathic response which informs our therapeutic use of self in OT practice."

"When I started comparing how poorly I did things while multitasking versus when actually focusing on the task, I was shocked by how much better I felt about the time I was spending on tasks and by how much better I was relating to people around me when I was actually engaged."

"Low-quality participation in meaningful occupations may have some benefit over complete occupational deprivation, but high-quality participation in meaningful occupation is medicine for the heart, body, and soul."

"I am learning to tap into the wise mind of the awareness of the impermanence of all things, and this eases me into letting things be as they are without needing them to be different. The unexpected and positive result in my life has been a greater calm and lessened anxiety. Mindfulness practice has improved my personal well-being."