Soles of the Feet: a mindfulness-based self-control intervention for aggression by an individual with mild mental retardation and mental illness

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Abstract

Uncontrolled low frequency, high intensity aggressive behavior is often a barrier to community living for individuals with developmental disabilities. Aggressive behaviors are typically treated with psychotropic medication, behavioral interventions or their combination; but often the behaviors persist at a level that is problematic for the individual as well as care providers. We developed a mindfulness-based, self-control strategy for an adult with mental retardation and mental illness whose aggression had precluded successful community placement. He was taught a simple meditation technique that required him to shift his attention and awareness from the anger-producing situation to a neutral point on his body, the soles of his feet. After practice he applied this technique fairly consistently in situations that would normally have elicited an aggressive response from him. The data show that he increased self-control over his aggressive behaviors, met the community provider’s requirement for 6 months of aggression-free behavior in the inpatient facility before being transitioned to the community, and then successfully lived in the community without readmission to a facility. No aggressive behavior was seen during the 1-year follow-up after his community placement. Mindfulness-based intervention may offer a viable alternative to traditional interventions currently being used to treat behavioral challenges in children and adults with mild mental retardation.

Introduction

Uncontrolled aggression jeopardizes the community placement of individuals with developmental disabilities, especially if they also have a concomitant psychiatric illness. Community care providers find it difficult to manage such individuals because often they exhibit low frequency but high intensity aggressive behaviors targeted at staff and peers. Unlike facilities for people with developmental disabilities where trained and experienced staff are typically available to manage aggressive outbursts of such individuals, care providers in the community are often less qualified and experienced in dealing with these behaviors.

Aggression can be managed in a number of ways (Matson & Duncan, 1997). In institutions for individuals with developmental disabilities or inpatient psychiatric hospitals, it is managed through functionally-derived behavioral contingencies, psychotropic medication, or their combination. Typically, these methods work well and many individuals are successfully transitioned to community settings. However, a small number of individuals are repeatedly readmitted to facilities because their aggression cannot be managed in community residences. Typically, community settings either lack staff experienced in developing function-based behavioral interventions, or they are so few in number, highly labor-intensive behavioral programs cannot be maintained with any degree of fidelity. Each readmission to an institution reduces the chances of an individual returning to the community and eventually community providers become highly resistant to accepting that individual into their homes.

Given that the majority of interventions for aggression used with individuals with mental retardation are externally controlled by either a physician or behavioral therapist, and these interventions are purportedly not successful with those individuals who are repeatedly readmitted to institutions, we reasoned that perhaps more cognitively oriented self-control strategies may provide possible alternative treatment options. In addition, we suspected that individuals with mild mental retardation have difficulty controlling their aggression because the traditional techniques did not teach them how to deal with anger under different contextual conditions. Further, the small literature on the use of cognitive behavioral therapies to control anger in individuals with mild mental retardation appeared quite promising (e.g., Benson, Johnson-Rice, & Miranti, 1986; Black & Novaco, 1997; Moore, Adams, Elsworth, & Lewis, 1997; Rose, 1996; Rose, West, & Clifford, 2000). This literature suggested that these individuals are not only able to accurately report their own emotional states, including anger, but also can learn ways to appropriately respond to them (Rose & West, 1999; Stenfert-Kroese, Dagnan, & Loumidis, 1997).

Cognitive behavior therapy approaches to anger management with individuals with mental retardation have typically involved a combination of procedures that include, among others, relaxation training, self-instructional training and problem solving (e.g., Benson, 1992, Benson, 1994, Benson et al., 1986, Moore et al., 1997, Rose et al., 2000). While these multi-component interventions show definite promise, we wondered if a similar outcome could be achieved with a single intervention; specifically, could we teach an individual a simple method of internalized control of his or her aggressive behavior that they could use in known and novel contexts?

Mindfulness-based therapies provide one option. Being mindful can be described as having a clear, calm mind that is focused on the present moment. This state of mindfulness allows an individual to be aware not only of external conditions but also of internal ones, especially physiological arousal states. Thus, we hypothesized that an individual who was mindful would be aware not only of what was unfolding in the external environment, but also what was occurring in his or her internal environment, that is, any changes in emotional state due to the external contingencies. Research by Kabat-Zinn (1990) on the use of mindfulness with pain and other emotional arousal states indicated that this was a tenable hypothesis. Further, our research on mindfulness as a therapeutic and training tool (Singh et al., 2002a, Singh et al., 2002b; Singh, Singh, Sabaawi, Myers, & Wahler, in press; Singh, Wahler, Winton, & Adkins, in press) suggested that individuals can enhance their mindfulness through guided meditation techniques. Thus, the aim of this case study was to explore the possibility of teaching a man with mild mental retardation to use a simple mindfulness-based technique to effectively self-regulate his verbal and physical aggression in multiple contexts.

Section snippets

Participant

James was a 27-year-old man who, because of uncontrolled aggression, had been institutionalized several times in a facility for developmental disabilities beginning at the age of 7. At the age of 15 years, he was placed in foster care but was admitted a year later to an adolescent psychiatric hospital to control his aggression. He was given an Axis I diagnosis of Conduct Disorder and an Axis II diagnosis of mild mental retardation. He was discharged after 4 months on a combined behavioral and

Results

Fig. 1 presents history, baseline, treatment and follow-up data on staff- and self-reported incidents, verbal and physical aggression, and staff- and self-reported self-control. Fig. 2 presents history, baseline, treatment and follow-up data on PRN medication, physical restraints, staff and resident injuries, and physically and socially integrated activities in the community. Phase means for each of these measures are presented in Table 2. In general, when compared to history and baseline

Discussion

Individuals, like James, with mild mental retardation and mental illness, often have a history of admissions to inpatient psychiatric hospitals for their uncontrolled aggressive behavior. Typically, they present with low frequency but high intensity aggressive behaviors that are treated in psychiatric hospitals with psychotropic medication, behavior therapy or their combination. Upon discharge to the community, these individuals sometimes become medication non-compliant or their behavioral

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Primary members of the Mindfulness Research Group are Nirbhay N. Singh of ONE Research Institute, Robert G. Wahler of University of Tennessee at Knoxville, Alan S.W. Winton of Massey University in New Zealand, Paul S. Strand of Washington State University, Oliver W. Hill and Judy Singh of ONE Research Institute, Jack W. Barber of Western State Hospital, Mohamed Sabaawi of Northern Virginia Mental Health Institute, and Jean Dumas of Purdue University.

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