Assignment #5

Introduction

                  This post is essentially a summary of not only the evaluation study that I conducted for this course, but the circumstances that lead to my choosing the type of study I eventually chose.

My Originally Planned Study

Originally I was going to do my evaluation study on one of the casework clients I have for my field placement position.  My field placement this year is at an agency, one I’ll refer to as A.B.C, which is what is called a “guardianship agency.”  It is a nonprofit organization whose clients are normally people who have been declared as “incompetent” by the courts, meaning essentially they are deemed as incapable of caring for themselves and therefore require another to be their guardian.  Most of our clients are geriatrics who reside in nursing homes.  My job is as a client caseworker.  I visit my clients periodically to determine whether their needs are being met and that they are not being abused or neglected in any way.                 

My clients are generally people who are low-functioning with poor communication and understanding skills who would not be capable of even consenting to an evaluation study.  (Most have severe dementia).  I do have one client however, who seemed as if she might prove an exception to the rule and be a viable evaluation subject.  Mary is a non-demented 72 year-old hoarder residing in a nursing home who suffers from psychosis, depression and anxiety, as well as some other physical problems such as fibromyalgia.  Though she consented initially to a study designed to reduce her anxiety, she proved to be an unreliable subject, even before she eventually changed her mind about being one.  Therefore, in early March, I switched the subject of my evaluation study to myself.

My New Study/Intervention

The behavior I decided to target was the covert one of stress and the element of this “behavior” I decided to monitor is a physical condition I suffer from that appears to have at least largely a psychosomatic component.  I have a condition called “restless legs syndrome.”  It is a syndrome that causes its sufferers legs to feel uncomfortable when they are still.  In my case, I get cramping, originally in one or both of my upper legs and eventually the central ankle area of one leg, right above the foot area.  It began a few years ago, only occurring at night after I got into bed for the evening, usually commencing within the hour before I actually switched off the light to go to sleep.  (I tend to read and/or watch t.v. for a while before actually attempting to go asleep).  Soon after I started having this problem, I went to doctor for the condition and he prescribed a non-addictive drug called Neurontin to be taken as needed before bedtime.  Traditionally, I have taken it anywhere from biweekly, to weekly, to nightly.  Around eight months ago, I decided to stop taking the medication.  I had a bit of discomfort in the beginning, but it soon passed.  In the month precededing my decision to do my evaluation study on myself, I started to need to take it again.  In the first couple of those weeks, I was taking a 300 mg pill approximately every other day.  For the succeeding two weeks after that, I was taking the same dosage nightly. 

Though my doctor never told me that there was a direct correlation between stress and my restless legs syndrome, he did not provide any medical reason for it either and I have seen a pattern where the amount of stress I am under is directly proportional to the amount I suffer from the condition.  The most dramatic example of this is that this past summer was an unusually low-stress period for me, yet in the past two months, I have been under more stress than usual.  Therefore, I have chosen two interventions to deal with my stress.  As a marker to be used of their efficacy, I am using not just the frequency of my restless leg syndrome, but the frequency of my Neurontin-taking.  Eventually, while working on this study, I would learn from the website PubMed Health, a public health consumer website that stress does, indeed, exacerbate restless legs syndrome (n.d.)

Originally, the pair of interventions I was going to work with was a combination of mindfulness meditation and Dialectical Behavior Therapy (DBT).  Yet, it would turn out that latter would be problematic for two reasons.  One was that scholarly literature focused mainly on the therapy’s validity for such conditions borderline personality disorder, and not anxiety that occurred outside of the realm of that illness.  The other is that studies have shown that it has not yet met the criteria of evidence-based therapy except for suicidal gestures and self-injury.  (Ost, 2007; Dr. M. Goldman, personal communication, March, 2011).  Therefore I decided to replace that planned intervention with another one I will later discuss.

    There are many forms of meditation.  One form is called “mindful meditation.”  Interestingly DBT utilizes mindful meditation in its therapy. (Ost, 2007)  Mindfulness meditation involves focusing your mind on the present through specific breathing exercises that require you to be very aware of how your mind and body are experiencing certain prescribed breaths. (I will be mores specific in my next assignment as to what these prescribed breathing exercises are.)  To be “mindful” is to non-judgmentally be aware of your thoughts and actions.   (Wong, 2007).  I chose this form of meditation because I was able to find scholarly journal articles that supported its efficacy for stress reduction.  

A 1997 study examined the effects of an 8-week stress reduction program based on training in mindfulness meditation.  The study used twenty-eight volunteers who were then separated randomly into an experimental group or a non-intervention control group.  Following their participation, experimental subjects, in comparison to those in the control group, experienced greater gains in terms of reducing their overall psychological symptomology, improving their overall sense of feeling they had control in their lives, and scored higher on a measure done within the study of spiritual experiences.  The conclusion of the study was that mindful meditation, due to its emphasis on developing detached observation and awareness of the contents for consciousness, may represent a powerful cognitive behavioral coping strategy for transforming the ways in which we deal with life events and might also might aid preventing those with affective disorders from relapsing.  (Astin, 1997).

In 1990, another study was done on stress reduction through mindful meditation that was performed by a group that included MDs, Ph.Ds, and a doctor of education.  The study’s goal was to assess the efficacy of a mindful mediation-based group stress reduction program for anxiety disorder-sufferers.  The study used 22 people who met the DSM-II-R criteria for generalized anxiety disorder or panic disorder with or without agoraphobia.  Assessments, including self and therapist ratings, were gotten weekly before and after the participants engaged in the stress-reduction group and monthly for a three-month period after they finished it.  It turned out that 20 of the subjects had significant reductions in their scores for depression and anxiety-level tests they took.  This was true both right after their involvement in the group as well as during the follow-up period.  (Kabat-Zinn, Massion, et al., 1992).             

In 2000, a study was done in Canada by a group that included PhDs, an MSW and a PsyD.  Its goal was to discover whether mindfulness meditation could reduce mood disturbances and symptoms of stress in cancer patients.  A randomized-wait-list controlled design was used and a convenience sample of eligible cancer patients enrolled after giving informed consent.  They then were randomly assigned to either an immediate treatment condition or a wait-list control condition.  The subjects subsequently had to complete two assessments: one called the Profile of Mood States, the other called the Symptoms of Stress Inventory.  They then were required to participate in weekly mindfulness meditation group lasting 90 minutes for seven weeks plus home meditation practice.  A group of ninety people averaging 51 years old completed the study.  They were heterogeneous in type and stage of cancer.  After this meditation-based intervention, patients in the treatment group had significantly lower scored on Total Mood Disturbance tests and subscales measuring their anxiety, depression, anger, and confusion than the control subjects.  The group conducting the study concluded that the meditation program has been effective in decreasing mood disturbance and stress symptoms in both male and female patients with a wide variety of cancer diagnoses, illness stages and ages. (Speca, Carlson, et al).

The second type of intervention I have planned for myself is one of exercise.  Normally I exercise four times a week, but in the month preceding the commencement of my study, I had been exercising less, approximately one to two times a week.  I was planning to return to my normal schedule anyway, and soon came to realize it might help my stress levels, which in turn, might help my restless legs syndrome.   Exercise has always had a reputation as a stress reducer, and I found a scholarly article that this reputation is a deserved one.  In 2000, a English study was done that showed that there is a “pattern of evidence [that] suggests the theory that exercise training recruits a process which confers enduring resilience to stress.” (Salmon, 2001, p.1). 

                  Once I chose my interventions, I gave myself the following prescription.  I would begin to work out four times a week and engage in daily five- minute sessions of mindful meditation sessions.  After the first week, I would attempt to raise that number it seven minutes a day.  I know from my past experience with meditation that five minutes would be quite difficult to achieve as it is and feels more like fifteen.  This is why I chose to only commit to small amounts of mediation per day.  I wanted to create a realistic goal regarding the practice.

A Snapshot of My Practice: My First Meditation Session

                  I approached my first meditation session with some trepidation.  In the past, I had tried, to varying degrees, the following three major subsets of eastern meditation: 1. “mantra” meditation, which requires you chant one or several mantras, 2. “yantra” meditation, a silent meditation-type when one focuses on a type of elaborate picture – a yantra, and silent breathing-focused meditation.  The only one I had ever found viable to do was mantra meditation, specifically “chain mantra” meditation, where I chanted a series, a “chain,” of mantras.  The mental effort it took to remember the mantra chain, the oral effort to speak these foreign words for a sustained period, as well as the aural distraction provided by hearing them, occupied my mind and body enough to prevent the feeling of experiencing a mental and physical vacuum.  My past attempts to engage in meditation that required me to just focus of my breath with my eyes open or closed had neutral to agitating results.  This form of meditation simply left my mind too empty, and that emptiness tended to be filled with distraction, boredom and irritability.  All of the articles I found regarding evidence-based studies on the value of meditation on stress were about studies that used mindfulness meditation.  Mindfulness mediation, it turned out, was the very type of meditation I had so much trouble with in the place.  To engage in the practice, you must complete the following steps.

1. Find a quiet, comfortable place and then sit in a chair or on the floor with your head, neck and back straight, but not stiff.

2. Push aside all thoughts of the past and the future and instead remain in the present.

3. Become aware of your breathing, focusing on the feeling of the air moving in and out of your body as you breathe, specifically the sensation of your stomach rising and falling and the air entering your nostrils and leaving your mouth.  You must pay close attention to the way each breath changes and feels different.

4. Notice the coming and going of each thought, merely acknowledging these thoughts non-judgmentally.  Once they enter your mind, however, gently push them aside to return to focusing your thoughts on your breathing.  If there are certain thoughts you cannot push away so easily, observe what they are, once again non-judgmentally, and return to your breathing.

5.  After completing your meditation, remain sitting for a minute or two and then proceed to slowly rise (Kabat-Zinn as cited in Wong, 2007).

The day and time I chose for my first mediation session was around 7:00 a.m. on a Wednesday, approximately an hour before I had to leave for school.  My plan was to do five minutes, which, as I mentioned in my last blog posting, I knew from past meditation experiences was far longer than it might sound.  I knew that, for me at least, five minutes could feel more like fifty.  

         I chose to meditate in my bedroom, on a lightly padded faux-Louis XV chair.  This is a type of chair that one gets for looks, not comfort.  I had a comfortable couch and chair in my living room, but I felt this chair would be just comfortable enough to be appropriate for my meditation.  (You will see why I am mentioning this imminently). 

As I sat down, I considered my concern that I had inferred from the mindfulness meditation instructions I had read that you were supposed to keep your eyes open.  This worried me because I fell it would provide visual distraction, keep me too grounded in my current non-meditative reality and make it harder for me to “turn off” and enter meditation mode. 

I recalled, however, taking a Shambala mediation class years earlier that was basically identical to the mindfulness meditation I was about to begin.  At that class, the instructor had told the students to visually focus on something during our mediation, something naturally within our field of vision.  I decided to do this for my current session and chose as a visual focal point a vase of magenta hyacinths that was directly opposite me.  Its’ location was not the only reason I chose this focal point, however.  Its’ background was an antique gold-edged mirror that partly reflected the flowers, and the wall covered in celery-green faux-more-silk wallpaper.  I found the sight especially pleasing.  I always have flowers in the vase in that exact location, and always color-coordinate the flowers to look good with the green wallpaper because I love the way they look at exactly that spot in my bedroom, where they sit on a faux-Louis XV antique dresser that holds a somewhat ornate collection of perfume bottles on it.  I always make sure there are flowers in the space because it creates a sense of the room being a happy, relaxing, even clean place and this tends to lift my mood and make me feel both more relaxed and energetic.  This is particularly true when I can get hyacinths, the rare flower that actually smells and is perhaps my favorite flower for both this reason and the fact that they smell to me like the start of spring, which is my favorite smell.  

I started my mediation session at 7:02 a.m..  I started breathing in and out in an exaggerated fashion.  I immediately began to wonder if I was not instead supposed to just breathe naturally.  I considered how the instructions I had read as to how to do this form of meditation had not specifically instructed me to breathe in such a manner.  Was I just supposed to breathe naturally?  I tried breathing naturally, but it was hard “following” my breaths this way and I quickly involuntarily reverted to my previous exaggerated breathing.  After a minute, my eyes wandered over to the nearby digital clock and I realized what I only half-consciously been aware of before: the reason I chosen this particular room and chair for my meditation.  Here, I was almost within eye-line of a digital clock, which would enable me to track how far through the meditation session I was.  I castigated myself for a moment for this.  I also felt frustrated and disappointed that only a minute had passed.  I closed my eyes, only to open them a moment later.  The instructions had read nothing about closing one’s eyes and I wanted to follow them precisely.     

I soon involuntarily began chanting in my head the chanting chain I used to use when I briefly, for about a week or two, began meditating almost daily this summer: tatwan asi – ram nan – ohm.  (I forget specifically what each mantra means.)  I caught myself after a white and my eyes shifted to the clock again.  Only another minute had passed.  I started focusing more intently on my breathing.  I started thinking of what I had to that day in terms of schoolwork, classes and errands, and then what I had to do in those areas for the week.  I was able to stop myself by breathing harder and re-focusing on my breathing. 

A piece of music soon came into my head.  I was not even fully conscious that this was happening at first in the sense that I was not acknowledging it.  It was piece of music I had listened to during relaxation exercises I had done years earlier, one called “The Feeling Begins” by Peter Gabriel, from the soundtrack from the film The Last Temptation of Christ.  A very long purely instrumental piece with a Middle Eastern flavor, I had discovered the soundtrack in high school and both it and particularly this piece of music, was something over the years that I would sporadically listen to when I wanted to relax.  It was not so surprising then when I became fully conscious that it was going through my head while I was meditating.  When I did recognize its presence in my mind, my first instinct was to “turn it off,” but then I decided not to.  I had a sense it would make my meditation easier and it did.  Therefore, there ended up being two “soundtracks” in my head, that of the music and my breathing, and the next time I looked at the clock, it turned out my meditation had already reached, not the five, but the six minute mark.  The music continued to play in my head during the minute I continued to sit in the chair before rising.  I noticed I did feel more relaxed and felt refreshed, almost as if I had just stepped out of the shower.  

The Results of My Study                 

                  The study would end up covering a nine-week period between early February and early April.  The baseline period was five weeks and the intervention period was the succeeding four.  There were several unplanned elements that ended up occurring.  One was that I decided to only meditate for 5 minutes a day throughout the study instead of raising my days to seven-minute daily sessions.  It was hard enough for me to meditate in a proper focused manner for 5 minutes and felt it would be too much of a challenge, perhaps a counterproductive one, to increase the length of the sessions, even by what seems like a small increase, but is not in beginner’s meditation-time.  Also, in the final two weeks of my intervention period, I became concerned about taking Neurontin at all.  My mother, whom I told about some mood issues I was having, told me about an article she had recently read about in the New York Times about a woman who had been taking the drug for multiple sclerosis and had begun to have crying jags soon after and felt the drug was possibly causing it.  Therefore, I was determined not to take the Neurontin even if I did start to feel cramping and on the couple occasions I did, decided to only take it in the event that it became truly uncomfortable for a sustained period.  As my discomfort was only fleeting, I did not take it in those instances. 

                    Some of my baseline period I had to re-construct since it encompassed a period that that preceded my knowing I was going to be doing a study on it.  Therefore, I had to estimate the amount of Neurontin I took during the first two weeks of the baseline period.  I knew that I had been taking a 300-mg capsule approximately every other night, but could only roughly estimate that during this period I took a pill 3 to 4 nights a week.  Therefore, when tabulating the study’s results, I randomly signed one of the weeks in the fortnight as one where I took three pills and the other as one where I took four.  I also had to round off some of my results numerically.  My baseline period followed the pattern listed below.

·       Week 1: exercised 0 times, took a Neurontin pills on 3 nights

·       Week 2: exercised 2 times, took 4 Neurontin pills on 4 nights

·       Week 3: exercised 2 times, took a Neurontin pill on 7 nights

·       Week 4: exercised 1 time, took a Neurontin pill on 7 nights

This means that during this period I exercised 2 times a week (rounded off from 1.5)

and took a 300-milligram Neurontin pill 5 nights a week.

My post-intervention period, in which I meditated for 5 minutes a day and exercised 4 times a week produced the following results:

·       Week 5: exercised 4 times and took a Neurontin pill on 7 nights

·       Week 6: exercised 4 times, and took a Neurontin pill on 5 nights

·       Week 7: exercised 4 times and took a Neurontin pill on 3 nights

·       Week 8: exercised 4 times and took a Neurontin pill on 0 nights

·       Week 9: exercised 4 times and took a Neurontin pill on 0 nights

This means that during this period, in which I did daily 5-minute mindful meditation and roughly doubled my weekly exercise, my Neurontin-taking lowered to an average of three times per week, which is a 40% reduction from the baseline period.  Without judging it within the context of the spurious data that polluted this study, one could say that doubling my exercise and engaging in these daily meditation sessions is what caused this dramatic reduction in my Neurontin-taking.  However, there does exist this spurious data. 

A large reason that the reduction was so great in the post-intervention period was my fear in the last two-week period of taking it for mood-related reasons.  Therefore, without realizing it totally, I may have been loathe to interpret the leg cramping I did experience as bad enough to need a pill. 

However, though I certainly do believe my sudden desire to avoid taking the drug helped the reduction in taking it, I also believe my increased exercise and meditation regimen also played a large part.  I only experienced some cramping on 2 of the nights in the second-to-last week and none in the final week.  There was also a steady week-by-week drop in the pill-taking nights during this period that has not existed during the baseline period where there was a steady increase in the number nights per week that I took a Neurontin pill.  With the exercise, it seems that exercising only once or twice a week had the same affect as not exercising at all judging from the baseline period.  

It is perhaps interesting to note that in the past week or so since the study has ended, I have only had to take a pill once though I have still suffered from a couple of nights of cramping.  However, I have, perhaps unwisely, retained my intervention-period exercise regimen but stopped meditating.  This may have contributed to the bit of cramping I have had.  I therefore, plan to resume the practice.      

Reference List

Astin, J.A.. (1997).  Stress Reduction through Mindfulness Meditation: Effects on

Psychological Symptomology, Sense of Control, and Spiritual Experiences.

Psychotherapy and Psychosomatics. 66,97-106. (DOI: 10.1159/000289116).

Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K.E., Pbert, L.,

Lenderking, W.R., Santorelli, S.F.. (July, 1992).  Effectiveness of a Meditation-Based Stress Reduction Program in the Treatment of Anxiety Disorders.  Am J Psychiatry.  149, (7), 936-943.

Kabat-Zinn, J..  (1993).   Mindfulness Meditation: Health Benefits of Ancient Buddhist

Practice.  Eds. Goleman, D. and Gurin, R..  Mind/Body Medicine. 259-275.  New York: Consumer Reports Books.

Ost, L-G.. (March, 2008).  Efficacy of third-wave behavioral therapies: A systematic

review and meta-analysis. Behaviour and Therapy.46 (3), 296-321.

PubMedHealth.com (n.d.) Restless Legs Syndrome.  Retrieved on April 20, 2011 from

http://ncbi.nlm.nih.gove/pubmedhealth/PMH0001810/

Salmon, P.  February 2001.  Effects of physical exercise on anxiety, depression, and

sensitivity to stress: A unifying theory.  Clinical Psychology Review. 21(1), 33-61.

Speca, M., Carlson, L.E., Goodey, E, Angen, W.. (2000).  A Randomized, Wait-List

Controlled Clinical Trial: The Effect of a Mindfulness Meditation-Based Stress Reduction Program on Mood and Symptoms of Stress in Cancer Outpatients. Psychosomatic Medicine.  62, 613-622. 

Wong, C.  (0ctober 25, 2007).  Mindfulness Meditation. About.com.  Retrieved on

March 5, 2011 from http://altmedicine.about.com/cs/mindbody.a.meditation.htm.

                                   

Assignment #4: Snapshot of My Practice

            I approached my first meditation session with some trepidation.  In the past, I had tried, to varying degrees, the following three major subsets of eastern meditation: 1. “mantra” meditation, which requires you chant one or several mantras, 2. “yantra” meditation, a silent meditation-type when the meditator focuses on a type of elaborate picture – a yantra, and silent breathing-focused meditation.  The only one I had ever found viable to do was mantra meditation, specifically “chain mantra” meditation, where I chanted a series, a “chain,” of mantras.  The mental effort it took to remember the mantra chain, the oral effort to speak these foreign words for a sustained period, as well as the aural distraction provided by hearing them, occupied my mind and body enough to prevent the feeling of experiencing a mental and physical vacuum.  My past attempts to engage in meditation that required me to just focus of my breath with my eyes open or closed had neutral to agitating results.  This form of meditation simply left my mind too empty, and that emptiness tended to be filled with distraction, boredom and irritability.  All of the articles I found regarding evidence-based studies on the value of meditation on stress were about studies that used mindfulness meditation.  Mindfulness mediation, it turned out, was the very type of meditation I had so much trouble with in the place.  To engage in the practice, you must complete the following steps.

1.     Find a quiet, comfortable place and then sit in a chair or on the floor with your head, neck and back straight, but not stiff.

2.     Push aside all thoughts of the past and the future and instead remain in the present.

3.     Become aware of your breathing, focusing on the feeling of the air moving in and out of your body as you breathe, specifically the sensation of your stomach rising and falling and the air entering your nostrils and leaving your mouth.   You must pay close attention to the way each breath changes and feels different.

4.     Notice the coming and going of each thought, merely acknowledging theses thoughts non-judgmentally.  Once they enter your mind, however, gently push them aside to return to focusing your thoughts on your breathing.  If there are certain thoughts you cannot push away so easily, observe what they are, once again non-judgmentally, and return to your breathing.

5.     After completing your meditation, remain sitting for a minute or two and then proceed to slowly rise (Kabat-Zinn as cited in Wong, 2007).

The day and time I chose for my first mediation session was around 7:00 a.m. on a Wednesday, approximately an hour before I had to leave for school.  My plan was to do five minutes, which, as I mentioned in my last blog posting, I knew from past meditation experiences was far longer than it might sound.  I knew that, for me at least, five minutes could feel more like fifty.  

      I chose to meditate in my bedroom, on a lightly padded faux- Louis XV chair.  This is a type of chair that one gets for looks, not comfort.  I had a comfortable couch and chair in my living room, but I felt this chair would be just comfortable enough to be appropriate for my meditation.  (You will see why I am mentioning this imminently.) 

As I sat down, I considered my concern that I had inferred from the mindfulness meditation instructions I had read that you were supposed to keep your eyes open.  This worried me because I fell it would provide visual distraction, keep me too grounded in my current non-meditative reality and make it harder for me to “turn off” and enter meditation mode. 

I recalled, however, taking a Shambala mediation class years earlier that was basically identical to the mindfulness meditation I was about to begin.  At that class, the instructor had told the students to visually focus on something during our mediation, something naturally within our field of vision.  I decided to do this for my current session and chose as a visual focal point a vase of magenta hyacinths that was directly opposite me.  Its’ location was not the only reason I chose this focal point, however.  Its’ background was an antique gold-edged mirror that partly reflected the flowers, and the wall covered in celery-green faux-more-silk wallpaper.  I found the sight especially pleasing.  I always have flowers in the vase in that exact location, and always color-coordinate the flowers to look good with the green wallpaper because I love the way they look at exactly that spot in my bedroom, where they sit on a faux-Louis XV antique dresser that holds a somewhat ornate collection of perfume bottles on it.  I always make sure there are flowers in the space because it creates a sense of the room being a happy, relaxing, even clean place and this tends to life my mood and make me feel both more relaxed and energetic.  This is particularly true when I can get hyacinths, the rare flower that actually smells and is perhaps my favorite flower for both this reason and the fact that they smell to me like the start of spring, which is my favorite smell.  

I started my mediation session at 7:02 a.m..  I started breathing in and out in an exaggerated fashion.  I immediately began to wonder if I was not instead supposed to just breathe naturally.  I considered how the instructions I had read as to how to do this form of meditation had not specifically instructed me to breathe in such a manner.  Was I just supposed to breathe naturally?  I tried breathing naturally, but it was hard “following” my breaths this way and I quickly involuntarily reverted to my previous exaggerated breathing.  After a minute, my eyes wandered over to the nearby digital clock and I realized what I only half-consciously been aware of before: the reason I chosen this particular room and chair for my meditation.  Here, I was almost within eye-line of a digital clock, which would enable me to track how far through the meditation session I was.  I castigated myself for a moment for this.  I also felt frustrated and disappointed that only a minute had passed.  I closed my eyes, only to open them a moment later.  The instructions had read nothing about closing one’s eyes and I wanted to follow them precisely.     

I soon involuntarily began chanting in my head the chanting chain I used to use when I briefly, for about a week or two, began meditating almost daily this summer: tatwan asi – ram nan – ohm.  (I forget specifically what each mantra means.)  I caught myself after a white and my eyes shifted to the clock again.  Only another minute had passed.  I started focusing more intently on my breathing.  I started thinking of what I had to that day in terms of schoolwork, classes and errands, and then what I had to do in those areas for the week.  I was able to stop myself by breathing harder and re-focusing on my breathing. 

A piece of music soon came into my head.  I was not even fully conscious that this was happening at first in the sense that I was not acknowledging it.  It was piece of music I had listened to during relaxation exercises I had done years earlier, one called “The Feeling Begins” by Peter Gabriel, from the soundtrack from the film The Last Temptation of Christ.  A very long purely instrumental piece with a Middle Eastern flavor, I had discovered the soundtrack in high school and both it and particularly this piece of music, was something over the years that I would sporadically listen to when I wanted to relax.  It was not so surprising then when I became fully conscious that it was going through my head while I was meditating.  When I did recognize its presence in my mind, my first instinct was to “turn it off,” but then I decided not to.  I had a sense it would make my meditation easier and it did.  Therefore, there ended up being two “soundtracks” in my head, that of the music and my breathing, and the next time I looked at the clock, it turned out my meditation had already reached, not the five, but the six minute mark.  The music continued to play in my head during the minute I continued to sit in the chair before rising.  I noticed I did feel more relaxed and felt refreshed, almost as if I had just stepped out of the shower.              

                                                Reference List

Kabat-Zinn, J..  (1993).   Mindfulness Meditation: Health Benefits of Ancient Buddhist

Practice.  Eds. Goleman, D. and Gurin, R..  Mind/Body Medicine. 259-275.  New York: Consumer Reports Books.

Wong, C..  (0ctober 25, 2007).  Mindfulness Meditation. About.com.  Retrieved on

March 5, 2011 from

http://altmedicine.about.com/cs/mindbody.a.meditation.htm.

Assignment #3: My Intervention

                                    Assignment #3: My Intervention

Unfortunately, I have had to change the subject of my study, as my previous subject, Mary, became an unreliable and uninterested participant in it.  Given that she was the only viable fieldwork client I had for this project, I decided to use myself as a subject.  The behavior I would like to target is the covert one of stress and the element of this “behavior” I would like to monitor is a physical condition that appears to have at least largely a psychosomatic component.  I have a condition called “restless legs syndrome.”  It is a syndrome that causes its sufferers legs to feel uncomfortable when they are still.  In my case, I get cramping, originally in one or both of my upper legs and eventually the central ankle area of one leg, right above the foot area.  It began a few years ago, only occurring at night after I got into bed for the evening, usually commencing within the hour before I actually switched off the light to go to sleep.  (I tend to read and/or watch t.v. for a while before actually attempting to go asleep).  Soon after I started having this problem, I went to doctor for the condition and he prescribed a non-addictive drug called Neurontin to be taken as needed before bedtime.  Traditionally, I have taken it anywhere from biweekly, to weekly, to nightly.  Around seven months ago, I decided to stop taking the medication.  I had a bit of discomfort in the beginning, but it soon passed.  In the past month, I have started to need to take it again.  In the first couple of those weeks, and now, in the past two weeks, I am taking it nightly. 

Though my doctor never told me that there is a direct correlation between stress and my restless legs syndrome, he did not provide any medical reason for it either and I have seen a pattern where the amount of stress I am under is directly proportional to the amount I suffer from the condition.  The most dramatic example of this is that this past summer was an unusually low-stress period for me, yet in the past two months, I have been under more stress than usual.  Therefore, I have chosen two interventions to deal with my stress.  As a marker to be used of their efficacy, I am using not just the frequency of my restless leg syndrome, but the frequency of my Neurontin-taking.

Originally, the pair of interventions I was going to work with was a combination of mindfulness meditation and Dialectical Behavior Therapy (DBT).  Yet, it would turn out that latter would be problematic for two reasons.  One was that scholarly literature focused mainly on the therapy’s validity for such conditions borderline personality disorder, and not anxiety that occurred outside of the realm of that illness.  The other is that studies have shown that it has not yet met the criteria of evidence-based therapy except for suicidal gestures and self-injury.  (Ost, 2007; Dr. M. Goldman, personal communication, March, 2011).  Therefore I decided to replace that planned intervention with another one I will later discuss.

    There are many forms of meditation.  One form is called “mindful meditation.”  Interestingly DBT utilizes mindful meditation in its therapy. (Ost, 2007)  Mindfulness meditation involves focusing your mind on the present through specific breathing exercises that require you to be very aware of how your mind and body are experiencing certain prescribed breaths. (I will be mores specific in my next assignment as to what these prescribed breathing exercises are.)  To be “mindful” is to non-judgmentally be aware of your thoughts and actions.   (Wong, 2007).  I chose this form of meditation because I was able to find scholarly journal articles that supported its efficacy for stress reduction.   

A 1997 study examined the effects of an 8-week stress reduction program based on training in mindfulness meditation.  The study used twenty-eight volunteers who were then separated randomly into an experimental group or a non-intervention control group.  Following their participation, experimental subjects, in comparison to those in the control group, experienced greater gains in terms of reducing their overall psychological symptomology, improving their overall sense of feeling they had control in their lives, and scored higher on a measure done within the study of spiritual experiences.  The conclusion of the study was that mindful meditation, due to its emphasis on developing detached observation and awareness of the contents for consciousness, may represent a powerful cognitive behavioral coping strategy for transforming the ways in which we deal with life events and might also might aid preventing those with affective disorders from relapsing.  (Astin, 1997).

In 1990, another study was done on stress reduction through mindful meditation that was performed by a group that included MDs, Ph.Ds, and a doctor of education.  The study’s goal was to assess the efficacy of a mindful mediation-based group stress reduction program for anxiety disorder-sufferers.  The study used 22 people who met the DSM-II-R criteria for generalized anxiety disorder or panic disorder with or without agoraphobia.  Assessments, including self and therapist ratings, were gotten weekly before and after the participants engaged in the stress-reduction group and monthly for a three-month period after they finished it.  It turned out that 20 of the subjects had significant reductions in their scores for depression and anxiety-level tests they took.  This was true both right after their involvement in the group as well as during the follow-up period.  (Kabat-Zinn, Massion, et al., 1992).             

In 2000, a study was done in Canada by a group that included PhDs, an MSW and a PsyD.  Its goal was to discover whether mindfulness meditation could reduce mood disturbances and symptoms of stress in cancer patients.  A randomized-wait-list controlled design was used and a convenience sample of eligible cancer patients enrolled after giving informed consent.  They then were randomly assigned to either an immediate treatment condition or a wait-list control condition.  The subjects subsequently had to complete two assessments: one called the Profile of Mood States, the other called the Symptoms of Stress Inventory.  They then were required to participate in weekly mindfulness meditation group lasting 90 minutes for seven weeks plus home meditation practice.  A group of ninety people averaging 51 years old completed the study.  They were heterogeneous in type and stage of cancer.  After this meditation-based intervention, patients in the treatment group had significantly lower scored on Total Mood Disturbance tests and subscales measuring their anxiety, depression, anger, and confusion than the control subjects.  The group conducting the study concluded that the meditation program has been effective in decreasing mood disturbance and stress symptoms in both male and female patients with a wide variety of cancer diagnoses, illness stages and ages. (Speca, Carlson, et al).

The second type of intervention I have planned for myself is one of exercise.  Normally I exercise four times a week, but in the last month or so, I have been exercising less, approximately one to two times a week.  I was planning to return to my normal schedule anyway, and soon came to realize it might help my stress levels, which in turn, might help my restless legs syndrome.   Exercise has always had a reputation as a stress reducer, and I found a scholarly article that this reputation is a deserved one.  In 2000, a English study was done that showed that there is a “pattern of evidence [that] suggests the theory that exercise training recruits a process which confers enduring resilience to stress.” (Salmon, 2001, p.1). 

            Now that I have chosen my interventions, I am giving myself the following prescription.  I will begin to work out four times a week and engage in daily five- minute sessions of mindful meditation sessions.  After the first week, I will attempt to raise that number it seven minutes a day.  I know from my past experience with meditation that five minutes is quite difficult to achieve as it is and feels more like fifteen.  This is why am I only committing to small amounts of mediation per day.  I want to create a realistic goal regarding the practice.

            I will write about some of my experience with this pair of interventions in my next assignment. 

                                   

Reference List

Astin, J.A.. (1997).  Stress Reduction through Mindfulness Meditation: Effects on

Psychological Symptomology, Sense of Control, and Spiritual Experiences.

Psychotherapy and Psychosomatics. 66,97-106. (DOI: 10.1159/000289116).

Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K.E., Pbert, L.,

Lenderking, W.R., Santorelli, S.F.. (July, 1992).  Effectiveness of a Meditation-Based Stress Reduction Program in the Treatment of Anxiety Disorders.  Am J Psychiatry.  149, (7), 936-943.

Ost, L-G.. (March, 2008).  Efficacy of third-wave behavioral therapies: A systematic

review and meta-analysis. Behaviour and Therapy.46 (3), 296-321.

Salmon, P.  February 2001.  Effects of physical exercise on anxiety, depression, and

sensitivity to stress: A unifying theory.  Clinical Psychology Review. 21(1), 33-61.

Speca, M., Carlson, L.E., Goodey, E, Angen, W.. (2000).  A Randomized, Wait-List

Controlled Clinical Trial: The Effect of a Mindfulness Meditation-Based Stress Reduction Program on Mood and Symptoms of Stress in Cancer Outpatients. Psychosomatic Medicine.  62, 613-622. 

Wong, C.  (0ctober 25, 2007).  Mindfulness Meditation. About.com.  Retrieved on

March 5, 2011 from http://altmedicine.about.com/cs/mindbody.a.meditation.htm.

Note: A computer glitch has created a spacing problem on the last line above.

My Client

                                      Assignment #2: My Client

The client I have chosen for this evaluation study, Mary, is a 72 year-old single white female.  She suffers from both mental and physical health problems.  Her mental problems include psychosis, an anxiety disorder, and depression.  As mentioned in my prior blog post, she also is a hoarder and this problem appears to have had something to do with her having been legally declared an “Incompetent Person” or in the terminology of my agency, an “IP.”  As I also earlier mentioned, the staff at her nursing home has found a way to get this problem under control but only through constant monitoring and involvement.  A chronic pain sufferer, Mary has been diagnosed with a set of physical disorders that include but are not limited to the following: fibromyalgia, pulmonary embolism, spinal stenosis, and cataracts.  She became an IP in 2009 and became a resident of the nursing home where she currently lives despite the fact that, at least in the view of my agency, it is an inappropriately restrictive setting for her due to how relatively mentally and physically high-functioning she is.  She is eligible to transfer to an adult home and loathes, or at least claims to loathe, living in a nursing home, but there are obstacles toward her achieving this goal that, for reasons I will imminently discuss, are partly self-created.

Mary is considered a particularly difficult resident by her nursing home’s staff.  She is frequently rude and even abusive to the nursing staff on her floor and refuses to leave her room, even for out-of-home medical appointments and staff-recommended in-house physical therapy.  She refuses to do anything involving socializing or even doing activities with her fellow residents because she feels that she is nothing “like” them.  By law, someone from the home, an activities coordinator whom I’ll call Fawn, comes into her room once a day to socialize with her and Mary accepts this service.  (Assume all names I use in the future of individuals and agencies are pseudonyms.)  These sessions usually go one for a duration of about 45 minutes.  She also sometimes refuses medication – though not to my knowledge psychiatric medication – and constantly demands that the staff give her “prn” pain medication that is prescribed to be taken only when in a level of pain that they do not believe she is in.  (They do, however, give it to her.)

Though there are few adult homes willing to take geriatrics with Medicaid, and even fewer with spaces open, there was one that was at least willing to wait-list her.  The home required she attend an interview that her social worker, Ms. C., at the nursing home made.  However, she refused to leave the home on the day of the interview.  Ms. C rescheduled three times, and each time Mary refused to go on the day of the interview until eventually the home was no longer interested in meeting with her.  (She would later claim to me that she had stomach problems that prevented her from attending these appointments).  Her situation is further complicated by her Latino boyfriend of twenty years, Fernando, whom she sometimes refers to as her husband.  She often changes her mind about whether she would like to move to an adult home or Fernando’s home, though my agency would only allow her to move to the former.  (Plus, she has not wanted to move in with Fernando since the beginning of our relationship anyway.)  According to Ms. C, he has financially “sucked her dry.”  When I told my field instructor at my agency about this, she told me that that “we” were “still investigating” whether this was the case and at this point it was only alleged.  Based on this as well as other discussions I have had about him with Ms. C and Mary, I have inferred that he is most likely a problematic figure in Mary’s life with whom she has a codependent relationship.

Using the assigned reading from our textbook, Evaluating Practice: Guidelines for the Accountable Professional, after a period of conceptualization I developed a theory about what I believe is at least largely the source of Mary’s maladaptive pattern of behavior.  It is my belief that Mary is making a bad situation worse because she simply cannot face and accept that fact that she is legally an IP with a guardian who has very little power over her life.  What she ideally needs to do, to make the most of a terrible situation, is to accept and acknowledge what she cannot control and what she can, and then proceed to fully exploit what little power she does have, such as the power to potentially get transferred into a less restrictive adult home where she would be living amongst her peers in a place designed for people with her set of problems and level of functioning if she wishes.  (My field instructor, however, believes she really does not want to go into an adult home, and though I partly agree with her, this is an issue too complex for this posting.)  I do not, however, believe she is both fully willing and able to confront such a bitter truth about her extremely limited power in the limited amount of time I will have to work with her.  I do believe though that I can help her become less maladaptive by helping her somewhat with her anxiety with a therapy I will discuss in my next posting.

One major source of her anxiety is what I have come to think of as the “Agency X/money/possessions issue.”  From here on out, I will call it the X/money issue for brevity’s sake.  It is her overt expressions of anxiety to me regarding this issue (which are often intertwined with anger),that I have chosen to target and measure.  I will later discuss why I have limited my measuring of the behavior to her covert expression of it with me.  First let me explain what the X/money issue is.

This year my agency took over guardianship from agency X.  Mary has displayed to me much anxiety and anger regarding the subject of money, her possessions, and Agency X.  She is currently nearly 100% broke.  The nursing home has no money in her account and my agency, according to its “finance person” assigned to her, has only “a little money” in the account we have for her.  She, however, correctly or incorrectly, believes that she possesses “thousands of dollars,” which our agency should have for her.  There is a chance, it is unclear at this point, that our agency might acquire more money for her, but that this point it seems unlikely.  She also, either rightly or wrongly, believes that X stole a lot of her money and that they are trying to sue her for $15,000 for back-rent for an apartment she claims to have never lived in.  She also believes that they have a storage locker of all her possessions from the apartment she lived in before she became an IP that they are withholding from her.  This issue seems to obsess her and clearly causes her much anxiety and anger.

 Ultimately, for the purpose of this project, I have no concern as to what is true and what is not regarding the X/money issue.  As her caseworker, I have limited power to fully find out the truth regarding it.  Even if I did, I am almost positive I would not have any power to help fix the situation if there was anything that needed fixing.  I do however, believe that all of her anxiety and anger regarding this issue is only serving to inflame her mental distress and worsen her behavior with others at the home.  I do not know if thinking about the X/money issue makes her agitated or if agitation provokes her to think about the X/money issue but clearly there is a causal relationship between the two things. (Bloom, Fischer, Orme, 2006).  I believe that, ultimately, if she could “let go” of this issue, her mental state and behavior would probably improve significantly, perhaps even greatly.    

            Though she talks about the issue constantly with me and frequently with Fawn and could theoretically keep a diary and do some sort of self-anchoring scale on her covert distress regarding the issue, there is a very specific reason that I chose to only measure her anxiety about the issue in her conversations with me.  Fawn is someone I do not feel is someone who would be both willing and able to cooperate in such a study.  Staff is rarely helpful except in the most marginal way in the homes I go to for my internship and she was someone who, though polite, seemed uninterested in even engaging in a detailed conversation about the subject of Mary.  Generally the nature of my internship is one where it would be very difficult and unreliable to rely on anyone but myself for any type evaluation study.  Mary also would never both agree to cooperate and then actually cooperate with doing anything when I’m not there to aid the study.  She has agreed to the evaluation study, but barely.  She seems to feel neutrally about being a subject for such a study. The problem is she does not see herself as being in any way the source of her problems.  Her problems, in her estimation, are every one else’s fault.  She also does not like the idea, though she has agreed, to do anything that might involve having to work in any way to help herself.  She refuses to take any responsibility for her own problems.  Therefore, it makes sense perhaps that she also does not like the idea of doing anything that inherently takes the responsibility for lessening them into her own hands.     

            My fieldwork supervisor thinks Mary is an excellent subject for this evaluation study.  She, as I do, believes that though she will also be a difficult subject, she is the only really viable one for the study because my caseload, like everyone’s at the agency, is full of people who are generally so low-functioning.  She did not however, think I should have asked her for her consent to be a part of an evaluation study.  She felt that she herself would have refused if asked.  This, of course, was before she was informed that such consent and disclosure was mandatory.   

            In our first meeting, which took place before the commencement of this course, we spoke for a long time, perhaps 45 minutes to an hour.  Perhaps half of that time was spent talking about the X/money issue.  Interestingly, though she spent much of the remainder of the time talking about other distressing topics such as her history of as a hoarder, a foster care youth and the daughter of an alcoholic mother, this would turn out to be of all our meetings, the one where she seemed warmest toward me and the one where she seemed the least agitated.  Soon after that, once again, before this course started, after that in which she made a request for clothing which was quite long and elaborate that I presumed was in response to my in-meeting asking of her if she needed any clothing.  (This was before I was unaware of her dire financial situation).  As I recall, she either made no mention of the X/money issue or a brief one, but I do remember that she seemed relatively non-agitated.     We did have another phone call, one that occurred between our last two meetings, in which I called her to update her about the fact that I still had not found out anything regarding her financial situation.  She did not spend any time talking about the X/money issue in response except to say that she was getting “very angry.”  It appeared that this anger was directed less at me than at my agency as a whole.

            At our next two meetings, both which lasted probably 20 minutes or so, 90% of the conversation was focused on the X/money issue.  I at first attempted to count the number of times she spoke of the issue and their duration, but I found this distracting in a manner that was counterproductive to our work together.  I felt it was more important to truly focus of making her feel that I was truly listening to her in an empathetic manner and that I genuinely was empathizing with and listening to her.  

            It was after our last meeting I could arrange before this posting that I found out that I could have asked her to do a self-anchoring scale.  However, even had I known this information earlier it would not have been a good idea to give her one.  She is in a very fragile state and having to directly confront how much distress she is under and explore it in detail at this stage, at least in the context our relationship, would likely just cause her further distress and likely feelings of resentment and even outright anger toward me. 

I was able to construct, however, a retroactive self-anchoring scale of my own design in relationship with these meetings and phone calls.  The formation of the scale is largely based on my observation that the more anxious she seems about the X/money issue, the more anger is likely to be interlaced with her anxiety.   Therefore, I created the following 5-point anchoring scale: 1 – displaying no anxiety or anger, 2 – displaying anxiety but not anger, 3 – displaying anxiety with anger, but nothing beyond a harsh tone of voice, 4 – displaying anxiety with anger extending to a raised voice, even cursing, and 5 – agitation displaying itself in the form of a panic attack or physical aggression.   In our first meeting, I would her agitation was at a 2 regarding the target issue.  During our first phone call, it was at a 1.  At our second and third meeting it was at a 2.  During our second phone call, it was at a 3.     

In my next post, I will write about my intervention plans for this behavior.

Reference List   

 

Bloom, M., Fischer, J, Orme, J.G. (2006.)  Evaluation Practice: Guidelines For The

Accountable Professional.  Boston: Pearson.