CONTINUING THE PHILOSOPHY OF REGINALD O. KAPP

9.41 PROPOSED TRIAL OF THE ENHANCED SANDWICH MBCT COURSE

        by John Kapp                                                                 16.11.09

John Kapp, 22, Saxon Rd, Hove BN3 4LE, East Sussex
  johnkapp@btinternet.com   Tel: 01273 417997


1 Why I am proposing this trial
There is an explosion of interest in the Mindfulness Based Cognitive Therapy (MBCT) course because people find it works. Rebecca Crane’s book about the course (2009) quotes a distinguished professor of psychiatry speaking in Jan 2008 about a group of suicidal patients: ‘I have referred hundreds of people for psychological treatments over the years, but I have never seen responses like this….They say that they have found a way of dealing with their difficulties that is completely different from anything else they have ever come across. At first I wondered whether they were becoming manic again; but no; they were saying that something had completely transformed their lives. And it was not just one who said this; many others said the same.’

I had the same experience when I did the MBCT course in April-June 2008 in Brighton. I tried to get onto the teacher training at Bangor but they were massively overbooked. In Jan 09 I finally got the last place on the Oxford centre’s teacher training course from 20-25th Sept 2009. I am now qualified to facilitate the MBCT course, and prefer to start by helping a more experienced facilitator run a course. I have offered to do so and Karen Thirtle asked me to assist her in her next course, but her boss vetoed me because I have not got a degree in psychology. (this requirement is not in the Sussex Partnership Trust (SPT) guidelines)

Inspired by my first MBCT course and the public consultation meeting of the Brighton and Hove Primary Care Trust (PCT) on 2.7.08, when we were asked what we wanted commissioned in the Strategic Commissioning Plan to prevent illness. (Lord Darzi had just reported) I wrote a paper dated 19.8.08 for the commissioners entitled ‘Improving Health by Ending the Prozac Nation’ published on section 9.28 of this website (www.reginaldkapp.org)

In it I proposed that the NHS should commission the MBCT course in sufficient numbers to make it readily available to patients and staff without waiting more than a few weeks. This requires 1,500 courses pa for Brighton and Hove, and a further 2,000 courses pa for West and East Sussex. This would enable 30,000 people to take the course in the city, and a further 40,000 to take is in West and East Sussex, assuming an average class size of 20. This would enable about 12% of the population to take the course. The highest priority is healthcare staff, (who are now required to reduce staff sickness rates since the Boorman report) other public sector staff, unemployed, and patients. Some people might have to repeat the course annually.

I also proposed that the MBCT course be made more accessible and of greater value to participants by converting it into an ‘enhanced sandwich’ MBCT course. The ‘filling’ of the sandwich would be the standard 2 hours per week MBCT course. The ‘bread’ of the sandwich would be one hour Osho dynamic meditation before, and one hour Osho kundalini meditation afterwards, increasing the total time of the course from 2 to 5 hours per week with a 1 hour break. This could still be fitted into a morning (say 730-1230, or 8-1pm)

This proposal is based on my own experience of doing and leading dynamic meditation on a drop in basis in Hove 3 times per week for 7 years (1,000 times) since Nov 2002. To get the enhanced sandwich course accepted as a mainstream course it will have to be tested and found effective in a trial, hence this proposal.

2 Previous trials and clinical outcomes of the MBCT course
a) Trial results

The Mindfulness Based Cognitive Therapy (MBCT) course was developed from Jon Kabat-Zinn’s therapeutic use for the last 30 years of the mindfulness approach in Buddhist practice in Massacheusetts USA. He ran courses for patients for whom conventional medicine could not help, under the name of the Mindfulness Based Stress Reduction (MBSR) course.

The idea was brought to the UK by Dr Mark Williams and others in 1993, and trials resulted in the MBCT course being ‘cited by the National Institute for Clinical Excellence (NICE) as a recommended treatment for people who are “currently well but have experienced three or more previous episodes of depression, because this may significantly reduce the likelihood of future relapse” (NICR 2004 p76) ……

Since 2004 further research findings by Prof Kuyken and others have suggested that MBCT provides an alternative and cost-effective approach to antidepressants in terms of helping people to stay well.’ (Quoted from Rebecca Crane’s book published 2009 titled ‘Mindfulness Based Cognitive Therapy’ p76)

b) Brighton General hospital staff trial 2004
A trial of the MBCT course was conducted from Feb-April 2004 on the staff of the Brighton General hospital to reduce stress under the ‘Better Deal for Staff’ programme. 30 staff signed up for it, who initially collectively scored 11 on the HADs scale in which 0-7 is normal, 8-10 is borderline, and 11-21 is abnormal. The course was extended to 12 classes over 10 weeks. 11 staff completed the course, 10 of whom rated the course ‘extremely helpful’ or ‘excellent’. The 11 had a collective HADs score of 9.4 at the start (borderline abnormal) and 6.1 at the end (normal) It was overseen by Dr Simon Hincks. His executive summary is reproduced in full in appendix 2 of 9.34 of www.reginaldkapp.org. This trial shows that the MBCT course significantly reduced every staff member’s stress levels by 3.3 points from borderline abnormal to normal, which would probably have increased their productivity and reduced their sickness levels.

c) Millview hospital staff and patients’ outcomes
Clinical psychologist Brenda Roberts introduced the MBCT course to the Sussex Partnership Trust and ran courses for both staff and patients in different streams from about 2004-7. About 70 participants gave her written feedback which she wrote up before she retired in a 10 page article entitled ‘Reflections on a Mindfulness-Based Cognitive Therapy (MBCT) course: The Silence that Hides in the Roar’ Her article is reproduced in full in appendix 1 of paper 9.28 of www.reginaldkapp.org. from which I have compiled the following summary of her themes, with the personal experience of participant Rosalind Johnson in italics:
‘Six key themes have emerged from a consideration of the written and verbal comments of approximately 70 students following a Mindfulness-Based Cognitive Therapy programme. These themes appeared common across groups of patients and staff, who were taught in separate streams. These capture the crucial dimension of students’ changing subjective experiences as they develop different ways of understanding themselves and their lives.

Theme 1: An increased sense of compassion towards oneself
One of the first experiences of the MBCT course was this discovery of compassion. I came to the course crushed by circumstance: suffering prolonged physical illness, condemnation, failure and self-judgement. My sense of isolation was so severe that I felt I inhabited an island where I had been washed up after a shipwreck and had found myself unable to escape.
The opening session recognised this without having the emotional wipe-out of one to one compassion or sympathy. Instead, it was as though a window was opened into the compassion of the universe, which allowed light to flood into the heart of the participant. Mysteriously, this hidden treasure of compassion was equally generated from within the self, independent of any other person and therefore readily available. This compassion is not to be confused with self-pity, which is a destructive emotion, but rather a kind of acceptance of reality and hence a firm base from which to start the healing process.


Theme 2: An increased capacity to calm or soothe the self
Compassion leads to the steady diminishing of the negative voices which habitually condemn and plunge the subject into despondency. Mindfulness practice releases a new, true, inner voice which, like the sun on spring shoots, encourages growth and an unfurling towards the light. I have called this voice ‘the Comforter’. Comfort is thus available without recourse to another individual. I found that I carried the Comforter within me to any place or situation. This new ability to calm and soothe myself required no striving, no great thoughts or supreme physical skills, no belief system or outward evaluation. It was utterly liberating. Mindfulness is truly universal in its availability.

Theme 3: An increased ability to resist getting entangled in other people’s emotions
Mindfulness practice fosters a sense of separate wholeness and thus encourages detachment from the destructive emotions of others. For years, it was as though I lived in a runaway carriage, driven by someone else towards a looming precipice. I experienced terror, apprehension and the loss of personal control of my life. The MBCT course furnished me with my own carriage again; far more robust than the one I had in young adulthood. This new carriage is custom-made, light and easy to handle. I am most definitely the driver. This leads to a new-found sense of direction and purpose.

Theme 4: A stronger sense of presence in the here and now
.Mindfulness focuses on the moment; and in so doing has an almost miraculous effect on one’s perception of time. Time ceases to be heavy and restricting; instead of the feeling of being pursued by the weight of the past and confined by the fear of the future to the point of oblivion, the moment becomes tangible. One can taste life and hold it, finding it light and beautiful, full of possibilities, like a boat gliding effortlessly downstream. There is also a sense of connection to the universe created by meditation. One trains oneself to really listen and notice one’s surroundings, to feel an awareness of gravity (a new concept to me!) which instils security and rest. The pinnacle of this awareness resides in the breath, coming as it does from beyond, being totally reliable in its continuation like the waves of the sea, and encompassing as it does the very essence of life.

Theme 5: A stronger sense of embodiment
By teaching acceptance, MBCT brings wholeness. I was introduced to the fact that my essence was active to the tips of my fingers and toes; that every cell of my body was infused with my unique life and was connected to the breath of the universe by my own breath. Far from failing me, my body, just as it is in all its frailty, is able to carry me to the limits of this marvellous ocean.

Theme 6: A capacity to be refreshed by silence
This is my favourite. MBCT has transformed my isolation into life-giving solitude. Each silent moment of my day does not have to generate loneliness and regret, but rather a depth of rest which is revelatory. Within the silence is a reality where one is free to grow. Modern life with its necessary bustle means that most people have never encountered the beauty of silence. Meditation trains the mind to stop and see; to part the curtain and find the door into a place where one’s real self can exist unconfined. This is the place at the breath-turn: the place of eternity. It is the antidote to fear, for fear crouches in the dark corners of the mind waiting to spring out and catch the one who hurries past, pursued by thoughts. Those who know how to walk in the light are secure.

3 Clinical trials of Osho dynamic meditation
Dynamic meditation was developed in India in the 1970’s by Indian meditation leader Bagwan Shree Rajneesh, known as Osho (1931-90) It has been made available every day for over 20 years at the meditation centre that he founded in Pune, India. It has been used all over the world to good effect in many institutions (such as prisons, Stockholm’s bus drivers) and corporate health promotion (such as in an Oslo bank) I wrote a paper ‘The Evidence Base for Osho Meditations’ on 17.3.05, published on section 9.3 of this website (www.reginaldkapp.org).

Dynamic meditation was trialled by Avni Vyes PhD in USA in 2007, who wrote up the study in a 19 page report titled: ‘ Effects of Seven-Day Osho Dynamic Study: A Pilot Study’. The article was published in Psychological Science: Research, Theory and Future Directions Edited by Kostas Andrea Fanti ISBN: 978-960-6672-26-2, 347 pages, Hardback First published in 2007 by ATINER. The abstract and conclusions are reproduced below:

a) Abstract
This research was conducted to investigate the clinical and corporate effects of a 7-Day Osho Dynamic Meditation. Clinical variables were measured for psychopathological symptoms or syndromes, self esteem, and anger. Corporate variables were burn out rates and occupational stress. Participants meditated daily for 7 days. Psychological instruments were completed at baseline, Day 7, and Day 12. Results of a mixed-effects model with pair-wise comparisons indicated significant decreases in several psychopathological variables such as anxious-depressive syndrome, somatic complaints, aggressive behaviors, and depression. There was a significant decrease in trait-anger and an increase in defensive self-enhancement scores. In the corporate arena, there was a significant reduction of emotional exhaustion, role overload, psychological strain, physical strain, and a significant increase rational/cognitive coping ability. Thus, this study showed that Osho Dynamic Meditation can be used as a psychotherapeutic intervention for a multitude of clinical and corporate issues.

b) Conclusion
This project demonstrated that Osho Dynamic Meditation had significant effects for many clinical and corporate variables for short term and long term durations. Specifically, in the clinical domain, significant decreases were demonstrated in several psychopathological variables such as anxious-depressive syndrome, somatic complaints, aggressive behaviors, and depression. There was a significant decrease in trait-anger and an increase in defensive self-enhancement scores. In the corporate arena, there was a significant reduction of emotional exhaustion, role overload, psychological strain, physical strain, and a significant increase rational/cognitive coping ability. Therefore, this technique of meditation can be applicable in many psychological settings such as mental health clinics, in or out patient agencies, private practices, as well as professional settings for employees within corporations. The technique itself seems to be very powerful due to the lasting and enduring effects seen not only by the statistical evidence but also by subjective comments of the participants, such as “Feeling more relaxed with myself. I have the overall feeling, that whatever is going to happen, don't be afraid be a witness. I feel like I am living more in the moment. I really dislike several things on my job and last night, I was offered a dream job. I am looking forward to see what happens. I don't feel afraid to take a chance.” or “Very relaxed more than before.” Since this was a pilot project, further research clearly needs to be a true experiment with a control group and/or a placebo in order to establish the reliability of these results. In addition, it appears that this meditation may also have an impact in the medical arena. While Osho Dynamic Meditation takes only an hour the results are impacting along many domains.

4 The benefits of combining the Osho meditations with the MBCT course as a sandwich
The Osho meditation centre in Pune India (see www.osho.com) offers many personal development courses On the programme from which people can choose at any one time there are about 6 different courses running, out of a range of about 100 different courses offered over a whole year. Although the content of each course is different, every course is done in the format of a sandwich course. The bread of the sandwich (meditations) are always the same, but the filling (the courses) are always different. The programme for all sandwich courses is a standard format as follows:

6-7am Dynamic meditation
9.30-4pm Course, with breaks for refreshment and lunch
4.15-5.15pm Kundalini meditation.
6.30-830pm white robe meditation.

I have done hundreds of days of normal personal development courses without meditation. I have also done about 200 days of sandwich courses with meditation before and after to the above programme. I got more out of the sandwich courses because the meditation made me more receptive to the content of the course. Other participants reported the same. Dynamic meditation at the start of the day ‘clears the decks’ by ‘emptying the garbage can’, so that participants are more able to receive the course content. The kundalini meditation afterwards ‘shakes down’ the course content, and ‘files it for future reference’.

The problem with the MBCT course (and any meditation method that requires passive sitting, such as vipassana and Brahma Kumaris) is that the people who need it most are too disturbed and restless to be able to fully receive the content. Their body is uncomfortable, and their mind keeps wandering off onto thoughts such as: ’why am I wasting my time on this course when I have so much else that I have to do…..’

Dynamic meditation was designed for disturbed and restless people to release their pent-up energy. The first half hour co-operates with their restless mind, saying: ‘you want to be active so I will give you half and hour of arousing music to be hyper-active and exhaust yourself totally, so that when I say ‘stop’ your mind will be glad of a rest.’ This is like hyper-active children at school letting off steam running around in the playground, so that when the bell goes they can sit quietly and attentively and receive the teacher’s lesson.

Osho says that personal and spiritual development, healing and wellness requires ‘learning to fly with two wings’. One wing is the Buddhist ‘path of awareness’, (watching the breath and mind as taught in the MBCT course) The other wing is the Hindu/Sufi ‘path of love’, which releases repressed emotions (as dynamic meditation does).which block the life force energy and make you feel stuck in a rut.

The MBCT course is an excellent teaching of the path of awareness, but it is only one of these two wings. I noticed that some participants in the MBCT course and the teacher training course that I did were disturbed and restless, and would have benefited from doing dynamic beforehand. So would patients, who by definition are disturbed and restless. The sandwich course combines both paths and teaches the two wings needed to fly, so makes the enhanced course more accessible and beneficial.

5 The proposed enhanced MBCT course trial protocol
As this proposed course has not been tried before, the participants will be guinea pigs, so it would therefore not be ethical to charge them for attending it. The going rate for the 8 week MBCT course (16 hours of tuition) is about £180 for waged participants and about £80 for concessions. The enhanced course is double the number of tuition hours (32) so it should be about double the price, £360/160. I propose to make this a free trial, but with the following condition. A deposit of £160 will be required on booking which will be returned in full at the end of the course if you have attended all 8 sessions and filled in all 9 questionnaires, which will be the raw data of the trial. This will give participants incentive to complete the trial and take it seriously.

The questionnaire will be the HADs test or equivalent. The control will be the participants’ assessment of their previous lives without this intervention. Participants will be asked to stop anti-depressant medication from the time of booking until the end of the course, and to log all medication that they take during that time.

The baseline for the staff trial will be the trial in 2004 at the Brighton General hospital staff trial, in which the 11 staff who completed the course reduced their collective HAD score from 9.4 to 6.1. I will offer the course to healthcare and public sector staff on 8 successive Saturdays (say for example, from 9th Jan -27th Feb) Due to the deposit I hope to get a smaller drop-out rate than the 19 out of 30 or 63% that the Brighton General hospital trial got. The trial will measure whether the introduction of dynamic and kundalini results in a higher reduction in stress than the 3.3 points on the HAD scale, from 9.4 to 6.1.

As I have been campaigning for the NHS to provide this course for patients, I will also offer the same course as a trial for patients on 8 successive Thurdays say, for example, from 7th Jan to 25th Feb. The venue for both courses will be Revitalise, 86 Church Rd Hove BN3 2EB. The maximum number of participants will be 20, due to the size of the room. I will facilitate the course, donating my time for nothing, and I will pay for the room hire out of my own pocket as part of a deal that I have with the management of Revitalise. (I am the freeholder of the building who rents a group room for 5.5 hours per week as a discount on the rent.)

6 Draft Fliers for the trial courses
The draft fliers for the trial courses are shown below. Those for working staff are held on Saturday mornings. Those for patients and unemployed people are held on Thursday mornings.

The first flier is designed for healthcare staff (such as GPs and managers) to distribute to staff and patients. The second flier is designed for potential participants who show interest in the trial and want more detail about the trial before they book and pay the deposit.



8 WEEK MBCT COURSE - SATURDAY

Saturday Course Flier

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8 WEEK MBCT COURSE - THURSDAY

Thursday Course Flier

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7 Supervision of the trial
I am looking for a supervisor who will authenticate the protocol, provide the questionnaires and write up and publish the results. Please forward this proposal to anyone who might be interested.

8 Conclusion
Please send comments and suggestions to John Kapp, 22, Saxon Rd, Hove BN£ 4LE 01273 417997, johnkapp@btinternet.com.

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