CONTINUING THE PHILOSOPHY OF REGINALD O. KAPP

9.54 TRANSFORMING MENTAL HEALTH SERVICES BY THE MASS-PROVISION OF THE MBCT (Mindfulness Based Cognitive Therapy) COURSE


Paper for Geraldine Hoban, Director of Commissioning, NHS Brighton and Hove                                         5.9.10
By John Kapp, MBCT course facilitator and patient representative. Secretary of Mindfulness Interest Network (MIN) Sussex. Local Involvement Network (LINK) member for Sussex on the National Association of LINk Members (NALM) representing Sussex. Secretary of SECTCo (Social Enterprise Complementary Therapy Company, www.sectco.org ).
22, Saxon Rd Hove BN3 4LE,          01273 417997          johnkapp@btinternet.com


Abstract
This paper calls for the removing of health inequalities by mainstreaming the NICE-recommended 8 week MBCT course, so that all GPs can prescribe it for their patients and know that it will be provided free at the point of use within an 18 week wait. Annual Operating and Strategic Commissioning Plans should incorporate the mass-provision of this course, not only for depression, but also for low back pain and IBS, which is the majority of the caseload in primary care. The paper estimates that the inherent annual demand nationally will be for 150,000 courses for 3 million patients, costing £1.2 bn at £400 per course. The outcome will be a halving of the number of persons with long term conditions from 17 to 8 million by 2016, saving the NHS more than ten times the cost of the course.


Contents

1 Conclusion – 3,750 MBCT courses are needed annually in Sussex for 75,000 people. Nationally: 150,000 courses for 3 million people
2 Recommendation to the Health Secretary, Andrew Lansley
3 Recommendations for Sussex commissioners and providers
4 How this paper came to be written
5 The insufficiency of provision of NICE-recommended treatments
6 SPFT’s block contract blocks out other providers
7 The need for outsourcing to the private/voluntary sector
8 The training of facilitators
9 Facilitators should be mediators, not clinicians
10 Why are the NHS commissioners so reluctant to commission the MBCT course?
11 What is the objective of talking therapies?
12 What are the origins of CBT and how does it work?
13 What are the origins of the MBCT course?
14 How does the MBCT course build on CBT theory?
15 How does our breath control our mood and behaviour?
16 Continuing meditation practice during and after the course
17 Why is the MBCT course more cost-effective than CBT? 18 Depressed patients fear of group therapy
19 The enhanced sandwich MBCT course
20 How many MBCT courses were provided in Sussex last year?
21 What is the inherent future demand for the MBCT course in Sussex?
22 How many facilitators are required?
23 What should the tariff be for the MBCT course?
24 SPFT’s standards for facilitators
25 How should the MBCT course be administrated and paid for in future?
26 Should a meeting be held discuss these questions in Sussex?
27 References

Appendix 1 E-mail dated 15.4.10 from Brigitte O’Neill
Appendix 2 Flier
Appendix 3 List of meditation retreat centres


1 Conclusion – 3,750 MBCT courses are needed annually in Sussex for 75,000 people. Nationally: 150,000 courses for 3 million people.
Public money should only be spent on treatments which are evidence-based as safe, effective and giving good patient experience. Antidepressant medications have been recently shown to fail this test, having been scientifically proven to be no better than placebo and with harmful side effects (1) They should therefore be de-commissioned and the public money (£3 bnpa) reinvested in talking therapies, such as Cognitive Behavioural Therapy (CBT) As this is mostly one to one, this tends to have long waiting times, leaving the mental health service without immediate evidence-based treatments to offer to patients, so that the ‘service’ provided is not worthy of the name.

However, over the last 30 years, the 8 week Mindfulness Based Cognitive Therapy (MBCT) course has shown itself to meet these quality standards and dramatically reduce the relapse rate for depression at 10 years and beyond. In clinical trials it has repeatedly been shown to deliver far better outcomes than any drugs, without any side effects, and almost without contra-indications.

Accordingly, 6 years ago, the MBCT course was awarded the gold standard of evidence based medicine by being recommended for depression by the National Institute for Clinical Excellence (NICE) in Clinical Guidelines (CG 23, Dec 2004). Subsequently NICE recommended that the MBCT course should also be considered for the following other conditions after other treatments have been tried and failed: for Irritable Bowel Syndrome (IBS) under CG 61 (Feb 2008) and for low back pain under CG 88 (May 2009).

Depression, IBS and low back pain collectively make up the majority of the workload of general practitioners (GPs), so the MBCT course is clinically appropriate for the majority of patients. Furthermore, patients now have a statutory right to NICE-recommended treatment if their doctor says it is clinically appropriate under the NHS constitution which became law last January (on 21.1.10).

The majority of patients therefore have the statutory right to the MBCT course. Commissioners therefore have no option but to commission it in sufficient quantity for patients to receive it within a 18 week wait. If commissioners refuse, they will be breaking the law, and may be taken to judicial review without a leg to stand on.

The MBCT course could and should be mass-provided to fill the vacuum left by the decommissioning of drug treatments, thereby enabling the NHS to deliver a mental health service worthy of the name. This paper calls for the MBCT course to be commissioned and provided in such quantity that it becomes the treatment of choice for most patients with most conditions.

The paper estimates that the inherent demand for the MBCT course is 1 in 20 of the population. In Sussex with a population of 1.5 million, 3,750 courses pa should be commissioned and provided for 75,000 patients pa, at an average of 20 patients per course. The cost would be £30 mpa at £400 per participant, which is 14% of the present mental health budget. This requires 250 facilitators, each running 15 courses pa.

Nationally, for a population of 60 million, 150,000 courses should be commissioned and provided for 3 million patients pa. This will cost £1.2 bnpa, at £400 per participant. This is less than half the cost of antidepressants, and 1.2% of the health budget The number of facilitators required is 10,000.

We have been here before, in May 2006. This ‘10,000’ is the same number of new CBT therapists that Lord Layard recommended, and Health Secretary, Patricia Hewitt announced in a speech to a mental health conference then. It was billed in the media as ‘The End of the Prozac Nation’, having the aim of replacing antidepressants with talking therapies (CBT). The MBCT course is a descendant version of CBT which is far more cost-effective.

Implementing this proposal could deliver the end of the Prozac nation, and the halving of the number of persons in the UK with long term conditions from 17 to 8 million by 2016. This would yield a saving of at least £12 bnpa to the NHS, which is a tenfold return on the cost of the course.

2 Recommendation to the Health Secretary, Andrew Lansley
The Health Secretary should issue a clear statement to all commissioners rescinding the out-of–date ‘not a penny of public money spent on complementary therapy’ policy, and authorising the commissioning spending of public money on NICE-recommended complementary treatments in sufficient quantity to meet demand within a 18 week wait. This will remove the present blockage to public funding which is preventing the provision of a mental health service worthy of the name, by the enabling the commissioning of the mass-provision of the MBCT course.

3 Recommendations for Sussex commissioners and providers
a) Adopt in the Strategic Commissioning Plans (SCPs) and Annual Operating Plans (AOPs) for Sussex from April 2011-15 the commissioning of sufficient Mindfulness Based Cognitive Therapy (MBCT) courses so that every patient who wishes to do the course in Sussex can do so within an 18 week wait. I estimate this to be 3,750 courses pa for 75,000 patients pa. If the tariff is £400 per patient, the cost would be £30 mpa. This is 14% of Sussex Partnership Foundation Trust (SPFT) turnover in 2009/10, which was £218 m.

b) Terminate the block contract with SPFT, and make the money follow the patient by moving to GP/Patient Based commissioning (GPPBC) via GP consortia such as Brighton and Hove Integrated Care Service (BICS) GPs will then be able to commission and pay for the MBCT course for their patients like any other NHS treatment.

c) Negotiate new contracts with SPFT, Brighton and Hove Integrated Care Services (BICS) and new providers of NICE-recommended complementary reatments, (such as SECTCo ) in order to provide the MBCT course within a 18 week wait, estimated at 3,750 courses pa.

d) Agree and implement clinical governance arrangements for the training and qualifying of sufficient MBCT course facilitators needed to run these courses in Sussex, estimated at 250. This should be overseen nationally by an accrediting body such as Bangor university, (2) in liason with European bodies such as the European Institute for Applied Buddhism (EIAB) (3)

e) Agree and publish the tariff that commissioners agree to pay to providers for providing the MBCT course, so that they can recruit facilitators and staff to provide sufficient courses. This tariff is estimated at £400 per patient participant for 16 hours (2 hours per week for 8 weeks). However, the course can be made appropriate to more patients, and more effective, if it is run as an enhanced sandwich course between active mediations to music, requiring the whole morning from 8am to 1pm, total 40 hours, and costing £530.

4 How this paper came to be written
The city’s Primary Care Trust (PCT) commissioners, (who are now called NHS Brighton and Hove), have been holding public consultation meetings for the last 4 years, asking the public what treatments should be commissioned. I have attended many of these meetings, and have spoken and followed up what I said with a written response as a paper. I sent them to the commissioners, and published them on my website (4)

I took the MBCT course from March-June 2008 in Brighton, paying £185 for it. It changed my life by giving me ideas and techniques which I still use every day. I learned later that mine is a typical reaction. A distinguished professor of psychiatry in Oxford said in Jan 2008: ‘I have referred hundreds of people for psychological treatments over the years, but I have never seen responses like this.’ This is a quote of from Rebecca Crane’s book (5) The professor was talking about many of his suicidal patients with diagnoses of depression and bipolar disorder who had recently completed the MBCT course. Many of them felt transformed by it, as they had found a way to deal with their difficulties.

Accordingly I wrote a paper for my commissioners entitled ‘Improving Health by Ending the Prozac Nation’, dated 19.8.08 (4) In it I advocated that 3,500 MBCT courses pa should be commissioned and provided in Sussex. On 3.9.08 I attended a meeting to discuss my paper with Amanda Fadero, director of Strategy, and Geraldine Hoban, director of commissioning. On 10.12.09 I attended a public meeting to plan the future mental health services, chaired by Geraldine, and said the same thing, following it up with a letter.

On 11.3.10 I attended a meeting with Geraldine, Max Kammerling, public health consultant, and Penny Kinton, chairman of Social Enterprise Complementary Therapy Company (SECTCo) The purpose of the meeting was to discuss which complementary treatments should be included in the Strategic Commissioning Plan (SCP) and Annual Operating Plan (AOP) for the city of Brighton and Hove 2010/11, commencing 1.4.10. I wrote notes of that meeting which were agreed by Geraldine, and are published. (6)

Under item 8 of those notes, Geraldine asked SECTCo to be involved in the forthcoming review of the mental health access services, which SECTCo are happy to accept. Action NHS to invite SECTCo to a meeting. Nearly 6 months have elapsed since that meeting, and SECTCo has not yet been invited to a meeting or to get involved. However, this may be due to the political environment, which has since changed dramatically.

A new government was elected on 6.5.10, and a new Health Secretary (Andrew Lansley) appointed, who published a white paper on 12.6.10. The Strategic Health Authorities (SHA) are to be abolished, as will be 60% of the commissioning work of the Primary Care Trusts (PCT) including the commissioning of mental health services. This effectively gives Geraldine and her NHS commissioning team notice of the termination of their jobs by 2013.

Commissioning will be given to General Practitioners and their patients jointly, via GP consortia, such as Brighton and Hove Integrated Care Service (BICS) They will all be placed under the political control of Brighton and Hove Council. On 5.8.10, Geraldine and her team moved offices from Prestamex House, Preston Rd, to Lanchester House, Trafalgar Place, Brighton.

While waiting to be invited, I have written this paper setting down how I and SECTCo would like the MBCT course to be included in the future mental health services in Sussex. It is a draft for discussion with commissioners and providers of mental health services with the aim of raising the issues which need to be resolved to create a future mental health service worthy of the name.

5 The insufficiency of provision of NICE-recommended treatments
According to the wording of the NICE directives, NICE-recommended complementary treatments, (including the MBCT course) are advisory, not mandatory, for commissioning, but ‘have to be taken into account when planning services’. On behalf of SECTCo I have been corresponding with Geraldine for over a year to make the point that she has a legal obligation to commission them, particularly since the NHS constitution, (which became law on 21.1.10) gives patients the right to them if their doctor says it is clinically appropriate. Specific to mental health commissioning, the MBCT course was recommended for depression nearly 6 years ago in NICE guidelines CG23, dated Dec 2004.

Geraldine responded that her department complies with this NICE directive, because they have been commissioning the MBCT course for the last 5 years. They employ, through SPFT, a therapist (Robert Marx) to provide it. She can therefore honestly tick the box saying that she complies with NICE guidelines.

However, Robert can offer only 4 MBCT courses pa for up to 20 participants, so can only offer a total of up to 80 patient places pa. This is for the whole of Sussex with a population of 1.5 million people, 150,000 of whom are clinically diagnosed with depression. The average waiting time to see him would therefore be 1,900 years.

SECTCo and I have been saying that although the letter of the NICE guidelines has been complied with, the spirit has not. The spirit of NICE guidelines is that recommended treatments should be freely available within a reasonable wait, such as 18 weeks. The quantity of the treatments that Geraldine commissions is insufficient, and is only token, so the service provided is not worthy of the name.

6 SPFT’s block contract blocks out other providers
SPFT are publicly funded to provide mental health services for the whole of Sussex. They employ a staff of nearly 5,000, including over 1,000 clinicians. These are paid for mostly by the block contract with the 3 NHS commissioners in Sussex (West Sussex PCT, the city of Brighton and Hove, and East Sussex PCT) SPFT’s income from that contract in the financial year 2009/10 was £197 million, and their turnover was £218 million, so they raised £21 million from other sources.

SECTCo and I have been saying that to treat patients within a 18 week wait, Geraldine should commission and pay for a thousand times more MBCT courses than she now does. The private sector already provides about 220 MBCT course places pa (as listed in table 3 below) to those who can afford to pay for them out of their own pocket. They are ready and willing to provide this course immediately to patients referred by their GP if Geraldine will agree to pay for them.

Hitherto, she has refused to do this, perhaps because SPFT has a block contract which excludes the outsourcing of the MBCT course any other potential provider, such as SECTCo. This block contract is adversely affecting patients by blocking the provision of their statutory rights under the NHS constitution to the MBCT course within a 18 week wait. According to government rhetoric in April 2006, (4.5 years ago) block contracts were supposed to go, and the money was supposed to follow the patient via Practice Based Commissioning (PBC)

7 The need for outsourcing to the private/voluntary sector
The SPFT’s are training 8 MBCT course facilitators in 2011, which although welcome, does not go nearly far enough to provide all patients in Sussex with their statutory right to the MBCT course within a 18 week wait. I have been saying for the last 2 years that 70,000 more MBCT courses are needed, which requires a thousandfold increase over SPFT’s present provision.

The only way that the NHS commissioners can provide the whole inherent demand is by augmenting SPFT’s provision by outsourcing the MBCT course to private/voluntary sector providers. (such as SECTCo) Introducing competition will benefit patients by improving standards, which are presently low according to patients I have met on Improving Access to Psychological Therapy (IAPT) committees, and at LIVE/Gateway meetings. GPs I have met have also complained about low standards of service in SPFT.

Outsourcing is sometimes resisted by political activists as ‘privatising’ the NHS. It is not. It is using public money rightly, by providing evidence based, cost-effective treatments (NICE-recommended) to everyone who needs them, free at the point of use, irrespective of their ability to pay. The blocking of outsourcing hitherto by the aptly named ‘block’ contract, has hitherto deprived patients of the benefits of the MBCT course, because most could not afford to pay for it privately.

This blocking has been the cause of health inequalities which are described in the Marmot report, namely that deprived people suffer long term conditions 18 years earlier, and die 9 years before affluent people. The government has pledged to remove these health inequalities. Opening up the market private /voluntary sector providers (such as SECTCo) will be a big step towards fulfilling that pledge. Geraldine has told me that she is hoping to do this, which I am pleased to hear. SECTCo is ready and willing to negotiate a service level agreement for the provision of NICE-recommended complementary treatments, including the MBCT course.

8 The training of facilitators
The SPFT board and management are well aware of the inadequate publicly funded provision of the MBCT course, and are doing their best to provide more facilitators. As mentioner above, they have resolved to train 8 more MBCT facilitators, and have allocated £16,900 to pay for their training in 2011, presumably with Geraldine’s agereement. Robert Marx, (as lead for the MBCT course) is to arrange this training, which will be by monthly seminars, and the 5 day residential teacher training course with Bangor (2) or Oxford (7) University. When the staff are trained and qualified by 2012 there will be at least an 8 fold increase in SPFT’s provision to patients, and he hopes that this initiative will snowball.

I took the MBCT teacher training with Dr Mark Williams and others near Bath last Sept with 35 other participants, paying £890 for it. However, there are not enough teacher training places to meet the inherent demand. Last year Bangor ran 2 courses, and Oxford ran one, for only about 100 people. My course was fully subscribed 6 months before it started. This report calls for 10,000 facilitators, which to train and qualify will take a century at last year’s rate.

The MBCT teacher training should therefore be expanded a hundred fold by allowing other training establishments to provide teacher training courses. It should be opened up to bodies such as the European Institute for Applied Buddhism, (EIAB) (2) Patients in Europe and America have the same mental health problems, so the solution should be sought by including institutions from those countries as well as UK. The World Health Organisation should also be involved. I have heard of 20 being trained in Italy who have failed to find employment in UK, perhaps due to the problems mentioned above of the blocking of the block contract, and it being a complementary therapy (see paragraph 10 below).

9 Facilitators should be mediators, not clinicians
The most important attribute of a MBCT facilitator is not their clinical knowledge, which can be minimal, because the participants of the publicly funded MBCT courses will be patients who have been prescribed referrals from their GP. The most important attribute is the facilitator’s ability to walk their talk as a meditator. They have to be present with all participants, with empathy and compassion, and without fear. Mental health patients are prone to challenging behaviour, by definition. The facilitator’s meditation practice should have turned their fear and anger into compassion, and removed any ‘buttons’ which participants could press to get a rise out of them.

Being present without buttons is not an attribute required by clinicians in the NHS. A common complaint made by mental health service users is of being treated ‘like dirt’ by clinicians. Although this perception may be a projection, it may also be true, due to the clinician’s unconscious fear of that patient, which comes across in their body language. That complaint should not be able to be truthfully made about MBCT facilitators.

10 Why are the NHS commissioners so reluctant to commission the MBCT course?
I have been asking this question for many years, and have never received an adequate answer. The conclusion that I have come to is as follows. The reason is because the MBCT course is a complementary therapy, and the official NHS policy on commissioning complementary therapy is that not a penny of public money may be spent on it, because it lacks an evidence base.

A document that stated that NHS policy was dated 1997. It is long since out of date. It conflicts with the more recent policy (2003) that NICE-recommended treatments must be taken into account when planning services. The MBCT course received the gold standard of evidence – NICE recommendation - in Dec 2004 in CG23. However, I believe that the out of date ‘not a penny’ 1997 policy has not yet been officially rescinded.

If so, commissioners are between a rock and a hard place. They therefore do their best to honour both policies. They commission a token amount of NICE-recommended complementary treatments, so that they can truthfully say that they comply with NICE guidelines, but only spend a trivial amount of public money on complementary therapy, so that they practically comply with the 1997 policy, which is judged as a peccadillo.

I have written to the Health Secretary via my MP on 6.8.10 asking him to issue a clear statement rescinding the ‘not a penny’ policy on complementary therapy, and authorising the commissioning of NICE-recommended complementary treatments in sufficient quantity to meet a 18 week wait. If he does this, I believe that it will remove the blockage to public funding to the MBCT course, which will allow the provision of a mental health service worthy of the name.

It will also unblock the proper public provision of the 5 other NICE-recommended complementary treatments, which are for low back pain under CG88 (May 09) spinal manipulation by chiropractic, osteopathy, and acupuncture and Alexander Technique, and for IBS under CG61 (Feb 08) hypnotherapy. Under CG23 the MBCT course should be considered for low back pain and IBS after those treatments have failed. These 3 conditions together make up about ¾ of GP’s workload. Physical health depends on mental health. That one ministerial statement could revitalise healthcare.

11 What is the objective of talking therapies?
The purpose of talking therapies, (including CBT and the MBCT course) is to help us to heal, or cure ourselves. The word ‘heal’ is derived from the same roots as ‘whole’ ‘holy’, ‘holistic’, and means that our mind and body are harmonised into one whole. The mind and body are like two sides of the same coin. The ancient greeks knew this, and they called dis-ease ‘psychosomatic’, literally translated ‘mindbody’, (or called ‘bodymind’), to show that the one continually affects the other, and that they cannot be separated. We feel in our body, the way we think in our mind.

We want to drop dysfunctional habits, such as obsessions and addictions, (say smoking) which are causing problems in our body. Ideally, healing would just be a matter of the therapist sitting down with the patient and explaining the benefits of giving up smoking, which the patient would be rational and accept, take the good advice, and drop the habit.

The problem is that the patient is not rational. Relatives and friends have given him the same good advice countless times before, and he himself also wants to drop his habit. He simply can’t do it. It is no good telling him again, because he ‘can’t be told anything,’ in this respect, because he cannot receive (hear) it. He is ‘fact-proof’ and pathologically ‘deaf’ about smoking, because his mind is blocked. What is this blockage? This is the central question in talking therapy.

A Buddhist parable may help to understand this blockage. The therapist is trying giving the patient a cup of tea, (good advice) but the patient’s teacup is full, so that he cannot receive the therapist’s tea. He is ‘too full of himself’ to receive the good advice. Before he can receive the tea, he has to empty his cup, (and himself)

The art of therapy is to empower him to empty his cup, so that he can receive. To do so, we need to understand with what his cup is full. It is full of stress. Stress is the root cause of mental and physical illness. Why can’t he empty it? Because his drain is blocked.

Traditional Chinese medicine is based on the theory that sickness is blocked energy (called ‘chi’, lifeforce) and to heal we have to unblock it so that the chi can flow better. The obsessions and addictions which we are trying to unblock by the talking therapy are the blockages of our lifefocce. They are suppressed or repressed emotions (such as anger, anxiety, fear, grief, sadness, frustration) which are memories stored our emotional body. We have 4 bodies, corresponding to the 4 astrological elements, the 3 outer ones being in our aura, as shown in table 1.

TABLE 1 THE BODIES OF OUR AURA SHOWING THE LOCATION OF BLOCKAGES

Body

Astrological element

Corresponding chakra(s)

Blockages

Intuitive

fire

7

Can't hear telepathy

Communication

air

6 third eye

Lack of understanding

Emotion

water

4 heart, 5 throat

Repressed emotions

Physical

earth

1 base, 2 sex,
3 solar plexus

 

Table 1 shows that blockages of repressed and suppressed emotions in our emotional body (water) cause lack of understanding, and dysfunctional thinking in our rational mind body, (air) These are experienced as negative thoughts (such as ‘I’m no good at anything’) Depression is caused by ruminating on these thoughts obsessively, which makes us feel bad in our physical body (earth).

We take drugs addictively (like anaesthetics) to blot out these bad feelings, which temporarily makes us feel a little better. However, they have side effects, so do not make us feel good or healthy. Our bad feelings (mood) leads to our bad behaviour, such as violence towards others and ourselves, and dysfunctional relationships with others at home and at work. To drop (cure) our habit of bad mood and behaviour we need to remove its cause, and eliminate (empty) our cup of our suppressed emotions and misunderstandings which are blocking the flow of our lifeforce to our physical body. This can be done by cartharsis. (7A)

12 What are the origins of CBT and how does it work?
CBT arose out of the behavioural school of psychology, and has a robust evidence base behind it from over half a century of study. In CG23 (Dec 04) NICE recommended the following:
Guided self-help For patients with mild depression, healthcare professionals should consider recommending a guided self-help programme based on cognitive behavioural therapy (CBT) Short term psychological treatment In both mild and moderate depression, psychological treatment specifically focussed on depression, such as problem solving therapy, brief CBT, and counselling of 6 to 8 sessions over 10-12 weeks should be considered.
Initial presentation of severe depression, a combination of antidepressants and individual CBT should be considered, as the combination is more cost effective than either treatment on its own.‘

The aim of CBT is to change our negative thoughts so that our feelings and mood become better and more positive. We are aiming to transform our anger into compassion, our hate and fear into love, our sadness into joy, and our frustration into contentment, irrespective of what happens to us in our lives. That transformation is called ‘healing’, and means that the 4 parts of our aura have become harmonised. Our mood will automatically improve, and our behaviour will become more functional. CBT does this by teaching an understanding of the origin and causes of these negative thoughts, and gives us techniques to transform them into positive feelings.

There are many books about CBT, some in popularised self-help form, such as ’ CBT for Dummies’ (8) CBT has also been computerised into a self-help programme called ‘Computerised CBT’, or CCBT, which is also recommended by NICE. (9)

13 What are the origins of the MBCT course?
Jon Kabat-Zinn pioneered it from 1980 in Massachusetts, USA, calling it Mindfulness Based Stress Reduction (MBSR) He has written many books about it (10) Dr Mark Williams of Bangor University introduced it into UK about 1995. He called it MBCT because it shares the same underlying principle of bodymind as CBT. He wrote several textbooks with others about it (11). He has now moved to Oxford University, (7) where he is training MBCT facilitators and doing research into its application to suicide.

Prof Paul Gilbert, professor of clinical psychology at Derby University has also written many books about mindfulness, the latest of which is: ‘The Compassionate Mind’ (12) Prof William Kuyken of Exeter University has also researched the MBCT course, confirming earlier results. (Dr Jonty Heaversedge) has written a book (13) called ‘The Mindful Manifesto’ whose blurb says ‘encouraging governments to take a mindful approach could make a massive difference to the health and happiness of the whole world’. The essence of the MBCT course is summarised below.

The MBCT course teaches the principles of CBT combined with the practice of meditation. Meditation is practiced and described in the scriptures of many eastern religions, such as Jainism, Hinduism, Buddhism, Taoism, Zen. The essence of meditation practice is watching the breath. This is called ‘pranayama’ in the yoga sutras of Patanjali (written c.5,000 years ago) and ‘vipassana’ in the teachings of the Buddha (written 2,500 years ago) However, the MBCT course does not require or impose any religious belief system on participants.

14 How does the MBCT course build on CBT theory?
The MBCT course accepts the ‘bodymind’ principle of CBT, and its aims of transforming negative thoughts into positive ones, but adds the extra dimension of teaching participants to meditate on those aims in an altered state of consciousness. This enables MBCT participants to go deeper, and to embody the positive thoughts into their cellular memories, so that they become habitual.

In the MBCT course we learn to watch our tendency to ruminate, without judgement, and to keep coming back to watching our breath. This practice automatically changes our mood from negative to positive. This is why early studies found it to halve the rate of relapse in depression. Later studies have found it appropriate for almost every condition, almost without any contra-indications.

‘Mindfulness’ simply means watching everything that is going on both outside and inside us, including sights, sounds, smells, tastes, touch, thoughts, emotions. The practice is basically to continuously watch our breath coming in and going out.

This is done by learning to meditate, first sitting mediation with eyes closed, concentrating on watching our breath, becoming distracted by thoughts, and coming back to our breath every time. We progress to eating meditation, and walking meditation with eyes open, and eventually aim to do everything as a meditation.

15 How does our breath control our mood and behaviour?
Watching the breath is the key to mood, because our breath controls our mood. A fight can be stopped by telling the protagonists to take 3 deep breaths, because it is impossible to remain angry if we breathe deeply. The breath is the bridge between the mind and the body. By controlling our breathing we control our mood, our emotions, our thoughts, and our behaviour.

This is because our breath controls our entire physiology, including our nervous systems, (autonomous, sympathetic, parasympathetic) our HP axis and the release of hormones such as adrenaline, cortisol, (fight and flight) oxytocin (love), and our immune system. Our breath is thus the key to happiness, the ‘peace that passes understanding’, enlightenment, and health.

The mechanism by which this works is the partial pressure of carbon dioxide in the blood, which should be about 40 mm mercury. When we are panic breathing, (such as overbreathing, or hyperventilating) it causes restriction in our bronchae, causing asthma, and hyper tension (high blood pressure) This is described in another paper of mine called ‘The Buteyko method’ (14)

Konstantin Buteyko (1923-2003) discovered that patients can cure themselves of asthma, hypertension and any and every other health condition by learning to control their breathing to be slowly through the nose and into the belly. The method should be studied by MBCT facilitators, integrated into their meditation practice, and taught to their participants.

Core elements of the MBCT course have also been computerised by the Mental Health Foundation (15) see http://www.bemindfulonline.co.uk/ and will be available from 12.9.10, They will be advertising it widely, priced at about £40 on a self-pay basis. Although the online version cannot take the place of the MBCT course, it will be useful in marketing it to GPs, patients, and potential facilitators. It will also help to set the standard of how the course should be run, which will improve clinical governance.

Although the computerized version cannot take the place of the MBCT course, it will be useful in marketing it to GPs, patients, and potential facilitators. It will also help to set the standard of how the course should be run, which will improve clinical governance.

16 Continuing meditation practice during and after the course
The MBCT course teaches participants how to meditate, but to heal their sickness they will need to practice daily both as homework during the 8 week duration of the course, and afterwards. If not, they are likely to relapse into their old habits. Meditation is easier in a group, and there are many meditation centres which offer drop-in meditation for donations. Participants are advised to take advantage of these centres both during and after the course. A flier listing centres in Brighton and Hove is shown in appendix 2.

There are also many organisations which offer residential meditation retreats for days or weeks to anyone who books them in the company of others with the same objective. These retreats support participants to meditate for most of every day. Meditation is cumulative, and this intensity helps us to incorporate meditation into our way of life, so that it becomes habitual. Participants are advised to take advantage of these centres as often as they can afford them. A flier listing centres in UK and abroad is shown in appendix 3.

17 Why is the MBCT course more cost-effective than CBT?
There are many reasons:

i) One facilitator can teach a class of say 20 participants, making it 20 times more cost effective than one to one treatment.
ii) Participants teach each other, while the facilitator holds the space.
iii) Meditation is infectious, so one person meditating in an altered state of consciousness (say in alpha rhythm at 10 Hz, rather than the usual beta rhythm at 20 Hz) pulls others' brain waves into alpha coherence. Studies have wired meditators up to EEG machines, and shown 97% coherence between their brain waves.
iv) The CBT course thinks about the bodymind principle, whereas the MBCT course embodies it in the altered state of consciousness known as mediation. Healing requires a change of programming in our mind, like a download of new software. We cannot change the programming of our computer without acquiring new software from outside our system. Similarly, we cannot reprogramme our mind just by thinking with our existing thinking programme. If we try, it goes ‘in one ear and out of the other’ and does not get embodied in our neurons. Quantum physics shows that by thinking alone we cannot collapse the waves of new attitude required for healing into thoughts. (16) To heal we have to go beyond our mind in an altered state of consciousness (meditation), when we can download the new programme. It feels like a revelation when the ‘penny drops’ and it is then embodied permanently into our neurons, so we never revert to the old attitude.

18 Depressed patients fear of group therapy
The biggest problem with group therapy is that the depressed patients who need it most are the least able to attend groups. Their depression tends to make them scared of other people, so they tend to go into isolation. It is hard to get them to come to one to one therapy sessions, such as CBT. The proportion of mental health patients who ‘Did Not Attend’ (DNA) their appointments is often as high as 50% with one to one. It tends to be even higher with groups, which is why not many CBT groups are run.

Mental health patients need much support to get them to come to a group. They need to be reassured that they will be able to cope with the others that they might meet, and resist their tendency to run away, which is their normal coping mechanism. The administration of the MBCT course should recognise this difficulty and take measures to make it as easy as possible for patients to attend.

One or more open taster sessions should be held in the same venue and at the same time as the course, one and/ or two weeks before it starts. The patients can then see the environment that they will be in, and meet the facilitator, assistant(s) and some of the other participants before they commit to attend the course.

There should be standing instructions that they have full permission to drop out of the course at any time that they need to, (perhaps because they have a panic attack) and come back in again as and when they are ready. Few will actually run out in the middle of a session, but in case they do there should be a helper ready to run after them and give them support through their episode, without disrupting the rest of the group.

Those who do not show without sending apologies should be telephoned and asked why in a supportive way, which does not tell them off as if they are truanting. Every reasonable means should be taken to encourage them to come in late, and the attitude of the facilitator should be that he is glad to see them, and not chastise them for being late. They may have hated school and be in the habit of disfunctional behaviour, which needs to be broken.

19 The enhanced sandwich MBCT course
The best time to meditate is first thing in the morning, when the bodymind is freshest following sleep. All traditional meditation is done then. Accordingly, the best time to hold the MBCT course would be from say 8-10 am. However, having spent the effort in getting them together, why not keep them a little longer? 2 hours is the time required to transmit the core curriculum, but that is not much therapeutic time for depressed and burnt out patients.

I have proposed in an earlier paper (4) that the 2 hour core curriculum should be enhanced by being sandwiched between an hour’s pre meditation, and followed by an hour’s post meditation. These are called ‘active’ because they are moving to music, without words. The pre-meditation (Osho dynamic meditation) helps participants to empty their cups (I call it their ‘garbage can’ ) of repressed emotions. This releases their pent-up tensions in the body with cartharsis, and prepares them to sit and receive the content of the course. The post meditation (Osho kundalini meditation) helps what they have learned to become embodied, and so remain permanently.

The enhanced sandwich course would be more suitable for patients who find it difficult to sit still with their eyes closed for the half hour required at a time. It would take the whole morning of about 5 hours, including refreshment breaks. I could be timed from 730-1230, or 8-1pm. It would be further enhanced if the group could eat lunch together before departure.

20 How many MBCT courses were provided in Sussex last year?
In planning the future, we should start from the knowledge of what was provided last year. I have been asking this question since I became secretary of the Mindfulness Interest Network (MIN) for Sussex at the end of 2007. MIN database contains about 65 persons who are interested in mindfulness. They are mostly clinical psychologists working for SPFT or privately, or meditation leaders working in the voluntary or private sector.

I have compiled the following tables 2 and 3, estimating the number of MBCT courses run in Sussex in the last year 2009/10 from what I have come to know. However although I have asked for statistics repeatedly, information has been hard to get, as facilitators seem cagey about telling me how many courses they have run for commercial/political reasons. The figures are therefore guestimated from heresay evidence, which may be inaccurate and incomplete.

The results show that in the private/voluntary sector for paying clients, about 10 facilitators ran about 22 courses for about 220 participants. In the public sector run by SPFT, free at the point of use to patients, officially only 4 MBCT courses were run by one facilitator (Robert Marx). However, mindfulness techniques were used in other similar courses for stress reduction and pain relief etc by about 10 facilitators. The total of participants might be similar to that of the private sector, namely 22 courses run for 220 patients. This would make the total number of participants trained in mindfulness techniques in Sussex in 2009/10 about 440.

TABLE 2 MBCT COURSE FACILITATORS LIST

PRIVATE AND VOLUNTARY SECTOR

No

Name

Organisation

Venue

Cost to patients/clients

No of courses run
financial year 09/10

1

Taravajra

Evolution

2 Sillwood Terrace

£130/85

4?

2

Karuavira

 

 

 

4?

3

Rory Singer
Rosie Roberts
Meg Griffiths +2

Centre for Mindfulness Based Education (CMBE)

28, New Rd
Brighton

£190

6

45

Judy Lewis

Elton John Foundatation

Beacon Centre, Bevendean, Brighton

 

2?

5

Kate Charlton

Newhaven Community Development

Newhaven

 

2?

 

 

Partnership

 

 

 

6

Richard Gilpin

Priory Clinic, Hove

 

£370

4

7

Jiva Masheder

 

Anahata Clini

£140/100

0?

8

John Kapp

Social Enterprise Comlementary Therapy Company

Revitalise
86 Church Rd Hove

£400 for enhanced 40 hour course

0

9

 

 

 

 

 

10

 

 

 

 

 

 

Total

 

 

 

22

TABLE 3 MBCT COURSE FACILITATORS LIST

PUBLIC SECTOR (SUSSEX PARTNERSHIP FOUNDATION TRUST) SPFT

No

Name

Organisation

Venue

Cost to patients/clients

No of courses run
financial year 09/10

1

Robert Marx

St Peters Place,
Brighton

 

0

4

2

Brigitte O'Neill

Highmore recovery, Eastbourne

 

0

2?

3

Fergal Jones

 

 

0

 

4

Catherine Cameron

 

Pain management

0

 

5

Brenda Davies

 

 

0

 

6

Karen Thirtle

Hastings

Old people

0

 

7

Graham Tooth

Worthing
01903 839464

 

0

 

8

Phillipa Meek

07961 794121

 

0

 

9

Heather Ball

E. Brighton

 

0

2?

10

Stephen Ashby

Allen Centre Autogenic relaxation 8 week course similar to the MBCT course

 

0

2?

11

Judy Lewis and Jane

MBSR courses for staff

 

 

 

 

Total

 

 

0

10?

The following facilitators in training, or meditation leaders in the city have told me that they wish to become facilitators when teacher training becomes available: Carolyn Pollack, Rakendra, Suki, Anne Pether, Lotus Nguyen, Anne O’Keife.

21 What is the inherent future demand for the MBCT course in Sussex?
a) Those patients with long term conditions

The MBCT course is the only NICE-recommended cost-effective course for dealing with stress, which is the main cause of sickness. In UK, 17 million adults (about 1 in 3) have been diagnosed with long term conditions whose cause is excessive stress. They are made up of about 9 million with arthritis and bad backs, 6 million with depression, 2 million with Irritable Bowel Syndrome (IBS) and 2 million with diabetes. (There is some double counting here as some people have more than 1 condition) The population of Sussex (1.5m) is about 1/40th of the total (60m) in the country. Accordingly, Sussex probably has about 450,000 adults with long term conditions, 225,000 with arthritis and bad backs, 150,000 with depression, 50,000 with IBS and 50,000 with diabetes.

The MBCT course is indicated and recommended by NICE not only for depression, but also for nearly all of these people with long term conditions, as follows. NICE guideline CG 88 (May 09) recommend the MBCT course for low back pain after spinal manipulation and acupuncture have failed to work. CG 61 recommends psychological interventions (such as the MBCT course) for Irritable Bowel Syndrome (IBS) after hypnotherapy has failed. The term ‘long term condition’ implies that the medical profession expect them to have it for the rest of their lives, because there is no known conventional cure for it. The free availability of the MBCT course will give patients fresh hope that they might be able to cure themselves with the techniques that they learn on the course.

b) NHS staff and others
The 1.3 million NHS staff have a staff sickness rate of about 5% (1 in 20, or 65,000), which is 50% higher than the national average (3.3% or 1 in 30) The NHS is required to meet the Boorman target of reducing their staff sickness rate by 3.5 million staff days lost pa, namely reducing it by 1%, to 4%.

The only way that NHS human resource managers can do this is to send their long-term sick staff on a MBCT course. There are about 40,000 NHS staff in Sussex, of whom 2,000 are off sick. 100 MBCT courses per year should therefore be run just for these sick NHS staff. This provision should be the highest priority, as if the NHS cannot keep its staff healthy, what chance have the rest of us patients got of staying healthy?

There are at lease a further 100,000 public sector workers in Sussex, over and above the 40,000 NHS staff. They too have high staff sickness rates, assumed 5% or 5,000, and who could benefit from the MBCT course. They are the next highest priority, and would need 250 courses pa.

The government are trying to get the 2.5 million people on disability benefit back to work. The MBCT course is the best way for them to help them to get themselves fit to work. Proportionally, some 60,000 of them are in Sussex, needing 3,000 courses pa.

They are probably among the 150,000 who are depressed. If all the depressed people did a MBCT course each year, they would need 7,500 courses to be provided each year. Those who are most sick would probably need to repeat the course each year for several years until they are cured.

c) The total numbers
The above figures are summarised in table 1 below, which shows that 157,000 could benefit from doing a MBCT course, requiring 7,850 courses pa. We have taken half that number as a practicable number for which to plan future course provision. We estimate that the outcome would be a halving of the numbers with long term conditions by 2016, which would save the NHS at least ten times the cost of the courses.

TABLE 4 NUMBER OF MBCT COURSES REQUIRED ANNUALLY IN SUSSEX

Category

Condition

Number affected

No of courses required

1

NHS staff off sick

2,000

100

2

Other public sector staff off sick

5,000

250

3

Off work on disability benefit

60,000

3,000

4

Other depressed patients

90,000

4.500

Total

Inherent demand at start

157,000

7,850

 

Practical number 50% for planning

75,000

3.750

22 How many facilitators are required?
a) How many courses can a facilitator run in a year?

The above figures of 75,000 places on 3,750 MBCT courses are the planning target on which commissioning, and the provision of facilitators should be based. This number of courses could theoretically be run by 125 full time facilitators each running 30 courses per year. (5 days per week, 6 times per year) However, they would probably burn out within a few years if they ran so many, so for planning purposes we assume that we need twice as many facilitators (250) running 15 courses pa each.

The course time teaching totals 8X2=16 hours. However, course preparation and travelling should at least equal that at 16 hours, and aftercare support should be budgeted at least 16 hours, bringing the total to 48 hours per course. Running 15 courses pa for 300 mental health patients, the hours would be 720, which is about a third of a working year of 2,000 hours. It is expected that facilitators will need to do other less emotionally demanding work for the other 2/3rd of their time, to stay sane.

b) When and for how many hours per week?
As mentioned above, all courses should be held in the morning. Accordingly, the best time to hold the standard 2 hour course would be from say 8-10 am, or 9-11 am. However, having got the participants together, there would be added benefit if extra time can be given to do an hours pre-meditation before the course, and an hour’s post meditation after the course. I have proposed (4) the enhanced sandwich course, taking a total of 5 hours, say from 8-1pm, including refreshment breaks, and if possible the group should eat lunch together before departure.

23 What should the tariff be for the MBCT course?
a) What is the going rate for the MBCT course in the private sector?

As shown in table 3 above, the public sector provider, SPFT, employ Robert Marx, and 10 other clinicians who are already incorporating mindfulness into their interventions. They are planning to train 30 new facilitators, bringing the total up to 40. While this is welcome news, it will only meet a sixth of the inherent demand. The remaining 5/6ths (210 facilitators) should be planned to be employed by the private/ voluntary sector.

We estimate from the tables above that about 22 courses are run each year in the private sector, for about 10 participants per course. This totals 220 people pa, who have to pay for their course out of their own pocket at the going rate. At present this varies from £370 at the Priory Clinic, New Church Rd, Hove, to about £85 as the concessionary rate at Evolution Arts, 2, Sillwood St, Brighton. The standards vary, as these courses are not regulated.

b) What should the clinical governance standards be?
A tariff rate should be agreed with commissioners which enables high and sustainable clinical governance standards. The first requirement is to set these standards. As mentioned above, there should be an assistant facilitator for each 10 participants, (2 assistants for up to 20, 3 for up to 30) so that those who need personal assistance can be given it without stopping the class. The facilitator and assistants should make themselves available for a free session one / two weeks before the class, and at least one follow up session 1-2 months after the class. They should also make themselves available on the phone for support whenever the participants need it. They should budget for spending at least as much time in extra-mural activities as they spend teaching the course. The venue should be easy of access, with a good energy, and well equipped with meditation cushions.

We believe that the tariff should be set at around £400 per participant so that well qualified and motivated facilitators, assistants and staff can be attracted and kept. The basis of this estimate is as follows per course:

Income

 

20 participants per course each paying £400

£8000

Expenditure

 

Marketing and course handouts

  £200

Room hire for 3 hours per week @£30 per hr

  £720

Wages of course administrator 50hrs @ £30per hr

£1500

Wages of 2 assistant facilitators 50 hrs @£30 per hr

£3000

Wages for facilitator 50 hrs @ £50 per hr

£2500

Surplus

    £80

Total expenditure equals total income

£8000

If the enhanced sandwich course is provided at 5 hours per week for 8 weeks, total 40 hours, the tariff should include payment of 40-16=24 more hours for the facilitatorm, assistants, and room hire, total £3,360. This increases the price by 42% to £11,380, or £570 per participant, who gets more than double the benefit.

24 SPFT’s standards for facilitators
These were developed from Bangor University’s good practice guidelines (2) and are as follows:
‘In order to offer MBCT of an appropriate standard within the Trust it is expected that clinicians shall;

1) Have an established personal Mindfulness/Meditation practice. (This is usually interpreted as 2 years or more)
2) Have attended an introductory 2 days training in MBCT.
3) Have attended at least one 8 week MBCT course as participant.
4) Co run at least one MBCT group with a more experienced teacher.
5) Have regular supervision of their Mindfulness teaching from experienced practitioners.
6) Have undertaken further training in Mindfulness approaches such as the teacher development training offered at University of Bangor (or equivalent)

Continuing development;
Teachers of Mindfulness will be expected to undertake ongoing development that will include a mix of the following elements

7) Peer or other supervision arrangements to reflect on their practice
8) Personal Mindfulness development via structured or unstructured retreat or similar meditation experience.
9) Maintain knowledge of developments in the field by formal training, reading and peer exchange.’

25 How should the MBCT course be administrated and paid for in future?
We concluded above that in Sussex in 2009/10, about 440 people had MBCT courses or mindfulness training, roughly equal numbers (220) getting it free on the NHS, and 220 paying about £150 for it in the private sector. This is one 170th part of the estimated inherent demand of 75,000. The planned provision should therefore be about 170 times greater.

a) Venue for the MBCT courses
The government has long been trying to locate treatment in the community, rather than in hospitals or clinics. The MBCT course lends itself to being provided where-ever there is a suitable public room big enough to hold about 20 people. Complementary therapy centres, and community halls may be suitable for this, and are well spread around, so that they are easily accessible to all.

SPFT have many suitable buildings for this. They have community Mental Health Centres in the city at 79, Buckingham Rd, Brighton, BN1 3RJ, tel 01273 749500, near Brighton station, open 9.30-5pm Mon to Friday, and the Allen Centre, 60, Sackville Gardens, Hove BN3 4GH, off New Church Rd, tel 01273 265626. These would be suitable venues to hold the MBCT course.

The above named therapists are employed by the NHS, so they are paid to provide the courses as part of their salary. At present there is no means of paying facilitators who are not employed by the NHS for running courses. This means that the MBCT course provision cannot be outsourced at present.

This is a weakness in the system resulting in health inequalities. The rich, who can afford complementary therapy, have long term conditions 18 years later than the poor who cannot. This weakness can be remedied by creating a means by which commissioners can pay any suitably qualified facilitator for running the course. There are several ways in which this could be done, as follows.

b) Voucher scheme
A voucher scheme has already been created by SECTCo, (www.sectco.org) which is ready to start providing courses for patients immediately. One GP (Dr Susie Rockwell) has registered with SECTCo to prescribe the vouchers, and 2 MBCT facilitators (Jiva Masheder and John Kapp) have registered to provide the course. However, the funding arrangement for paying the facilitators for the used vouchers has not yet been worked out. Patients should not be denied treatment for which they have a statutory right, so the facilitators have agreed to run MBCT courses on credit until the means of paying them has been arranged.

c) Through BICS
Brighton and Hove Integrated Care Service (BICS) already handles 47,000 referrals each year from GPs in the city, and is keen to handle more, including the MBCT course. BICS arranges the appointments for patients with hospitals and other treatment centres. They have a contract called ‘Specialist Provider of Medical Services’ (SPMS) by which they manage the payment of clinicians for dermatological and other referrals. They presumably do this by bulk invoicing the commissioners. BICS could also refer patients to MBCT course providers and pay the facilitators as they do the dermatologists and others.

26 Should a meeting be held discuss these questions in Sussex?
The government require the NHS to consult the public when designing new services, particularly through the Local Involvement Networks (LINKs)s, which are set up and funded by the Local Authorities for that purpose. This paper calls for the transformation of the mental health services by the mass-provision of the MBCT course, so that GPs can prescribe it to their patients knowing that it will be provided free at the point of use within a 18 week wait.

This raises the following questions about the future provision of mental health services in Sussex, which if agreed should be incorporated in the Annual Operating Plan and Strategic Commissioning Plan of NHS Brighton and Hove, and SPFT:

a) Should the MBCT course be mass-commissioned and provided in Sussex?
b) Should 3,750 courses pa for 75,000 participants be planned to be provided at an estimated cost of £30 mpa, (which is 14% of the mental health budget)?
c) Should 250 facilitators be trained and qualified to provide it, of which 30 should be SPFT employees, and 220 private/voluntary sector?
d) Should private/voluntary sector providers be allowed to contract with commissioners to provide MBCT courses at agreed clinical governance standards and tariff?
e) If so, how? Through BICS, or through a voucher scheme, such as SECTCo’s?

These issues should be seriously considered by all the stakeholders, including:
• NHS Brighton and Hove (Geraldine Hoban director of commissioning, and her lead mental health commissioners, Claire Newman and Margaret Cooney).
• SPFT, (Kay McDonald, clinical director, and her MBCT course lead clinician, Robert Marx)
• Centre for Mindfulness Based Education (Rory Singer)
• BICS (Zoe Nicholson, director)
• A representative of GPs (such as Dr Susie Rockwell, Portslade)
• A representative of the Health Overview and Scrutiny Committee (s) (HOSC)
• A representative (s) of LINks from W & E Sussex and Brighton and Hove.
• A representative of the Mental Health Foundation

It would be helpful if Geraldine could call a meeting to discuss these questions, and invite the above named people to it.

27 References
1 Book ‘The Emperor’s New Drugs’ by Inving Kisch, Feb 2010, reviewed in Newsweek, 8.2.10 ‘The depressing news about antidepressants – studies suggest that popular drugs are no more effective than placebo, in fact they may be worse’ by Sharon Begley, and New York Times, 1.3.10 .
2 Centre for Mindfulness Based Research and Practice, Gwynedd, Bangor, LL57 1UT, 01248 382939, bangor.ac.uk
3 European Institute for Applied Buddhism, EIAB, Schaumburgweg 3, D- 51545, Waldbrol, Germany, eiab.eu
4 Paper ‘Improving Health by Ending the Prozac Nation’ by John Kapp dated 19.8.08, paper 9.28 www.reginaldkapp.org.
5 Book ‘Mindfulness Based Cognitive Therapy’ by Rebecca Crane, 2009 p xiii
6 Paper ‘Meeting with NHS commissioners 11.3.10, 9.48 of www.reginaldkapp.org.
7 Oxford Cognitive Therapy Centre, octc@ombh.nhs.uk 01865 223986
7A Paper ‘Cathartic Meditation as Prevention and Therapy’ 9.27.www.reginaldkapp.org
8 Book ‘Cognitive Behaviour Therapy for Dummies – commonsense techniques for improving your mind and mood.’ by Rob Willson and Rhena Branch John Wiley 2006.
9 Computerised CBT CCBT see nice.org/ccbt
10 Book ‘Coming to Our Senses’ by Jon Kabat-Zinn, 2005
11 Book ‘The Mindful Way through Depression – Freeing Yourself from Chronic Unhappiness’ by Mark Williams, John Teasdale, Zindel Segal, and Jon Kabat-Zinn, 2007.
12 Book ‘The Compassionate Mind’ by Prof Paul Gilbert 2010. Prof of Clinical Psychology at University of Derby. See compassionatemind
13 Book by GP Dr Jonty Heaversedge and Ed Halliwell ‘The Mindful Manifesto – How doing less and noticing more can help us thrive in a stressed-out world’’, 2010
14 Paper ‘Buteyko method of slow breathing’ by John Kapp, 9.53 www.reginaldkapp.org
15 Mental Health Foundation www.mhf.org.uk
www.bemindful.co.uk, http://www.bemindfulonline.co.uk/
16 Book ‘Creative Evolution’ by Prof Amit Goswami, 2009


Appendix 1 E mail from Brigitte O’Neill
E mail from Brigitte ONeill, MBCT facilitator with SPFT, to John Kapp, dated 15.4.10, on behalf of Robert Marx, Fergal Jones, Cath Cameron, and Brenda Davis, setting out the present provision of the MBCT course, with intent to expand it.

‘I agree that currently there is limited access to mindfulness based interventions within the Trust; however, this is slowly changing. There have been MBCT groups available in secondary care (recovery) services in East Sussex since 2002. Recently primary care services in East Sussex have also begun offering MBCT groups within their IAPT programme. In Brighton and Hove, there is a rolling programme of MBCT groups in the Access Service (primary care and less complex secondary care) and a pilot MBSR course is about to be offered for the Brighton and Hove secondary care (recovery) services. Individually tailored mindfulness approaches are also offered individually to adolescents within the Child and Adolescent Mental Health Services in Brighton and Hove. In West Sussex, an introduction to mindfulness course is available in acute and recovery services and several practitioners draw on mindfulness in their individual work. MBSR groups are also available within pain management services in both East Sussex and Brighton and Hove.

Our Trust also offers person based cognitive therapy groups for people who hear voices, based on the work of Paul Chadwick. This approach has a large mindfulness component but also requires people to have separate training from the MBSR/ MBCT training. In addition, mindfulness groups have been offered to older people as a pilot project in Brighton and Hove and I understand that this may be developed further as part of a large research project linking with practitioners in other Trusts.

Recently a proposal was approved for offering MBCT groups within IAPT services in Brighton and Hove, although the practitioner who was going to do this has now left the Trust. I think this does indicate that there is interest and support from management for developing mindfulness approaches within the Trust. However, the development of new services does require planning and co-ordination so that it makes sense within the context of the broader service and so that services remain well governanced (safe for service users). This is the point we are at. In addition, there is an element of awareness raising needed in relation to our stake holders. The recent Mental Health Foundation report regarding mindfulness indicated that from their research only 1 in 20 GPs regularly suggested MBCT as an intervention for depression.’


Appendix 2 Flier
PLACES TO MEDITATE IN BRIGHTON AND HOVE
Learning and practicing meditation is easier in a group


Bodhi Garden Brighton
7a Ship St Gardens Brighton BN1 1AJ
(near Media Centre in Middle St in lane to Ship St)
Buddhist tradition, Most weekday evenings for Donations, www.bodhigarden.org, info@bodhigarden.org
Queries to 07531 556616

Bodhisattva Centre Hove
3, Lansdowne Rd Hove BN3 1DN
(N of Western Rd, opp Cambridge Rd)
Buddhist tradition for donations Programme - see website
www.meditateinbrighton.com
e mail: info@meditateinbrighton.com
Queries to 01273 732917

Brighton Buddhist Centre
17, Tichborne St, Brighton BN1 1UR,
(near the station, east of Queens Rd,)
Triratna Buddhist tradition
01273 772090
Most days of the week for donations
www.brightonbuddhistcentre.co.uk. info@brightonbuddhistcentre.co.uk

Aum at Coral Stadium Hove
off Neville Rd Hove BN3 7BG
Osho/Veresh Aum meditation from path of love tradition,£15/£10 concs
Normally second Sat of each month 3.30-7pm
optional meal together afterwards
See www.brightonaum.co.uk
Queries to info@brightonaum.co.uk or 01273 724899, 07872 643317

Revitalise Hove via back door
86, Church Rd Hove BN3 2EB
(opposite Hove town hall)
Osho Dynamic active meditation, from path of love tradition, £4
or month’s season ticket £20
Every Tues morning 7.30-8.30am
Every Thurs morning 7.30-8.30am
Every Sat morning 8-9am.
Queries to John Kapp see below

Yogahaven, Hove
Donkey Mews, Brunswick St, Hove BN3 1AW
(off Western Rd, near Old Market, opposite Juggler pub)
Buddhist tradition, donations 557610
Every Monday evening 745-930pm
www.brighton.shambhala.info/calendar e mail brighton@shambhala-europe.org

22, Saxon Rd Hove BN3 4LE near lagoon
Osho kundalini meditation every Tues, 6-7pm
Osho/Hellinger family constellation day
Normally every 4th Sunday 10-5pm for donations.
Queries to John Kapp see below

Pebbles Sangha
Patcham Community Centre, Ladies Mile Rd, Patcham, BN1 6BP
Zen meditation in the tradition of Thich Nhat Hanh
Donations up to £4,
www.pebblessangha.com 0333 044 2435 Vivien and Barry info@pebblessangha.com
Normally first and third Sat mornings 0945-1230.

Lotus Sangha
31 Hanover St, Brighton BN2 9ST
01273 571806, 07947 070598
Zen in tradition of Thich Naht Hanh for donations
lotus@lotusnguyen.com www.lotusnguyen.com.
Normally first and third Weds of month 715-930pm.

Published by John Kapp, 01273 417997 22 Saxon Rd, Hove, BN3 4LE johnkapp@btinternet,com 29.8.10


Appendix 3 List of meditation retreat centres UK
Sussex
Tilton House, Firle, www.tiltonhouse.co.uk

London
Janki Foundation for Global Healthcare, Moran House, 449/451 High Rd, Willesden, London NW10 2JJ, 020 8459 1400 www.jankifoundation.org

Rest of UK
Thich Nhat Hanh, zen master from Vietnam, does frequent retreats in UK, see www.mindfulnessretreats.org.uk

Samye Ling Monastry, Eskdalemuir, Langholm, Dumfrieshire, Scotland, DG13 0QL, 01387 373232, www.samyeling.org, Scotland@samyeling.org

Holy Island of Lindisfarne, Northumberland, TD15 2SE, www.holyisland.org.uk.

Osho Leela, Thorngrove House, (Osho centre and commune) Common Mead Lane, Gillingham, Dorset, SP8 4RE, 01747 821221, www.osholeela.co.uk, info@osholeela.co.uk

Croydon Hall, (Osho centre and commune) Rodhuish, Nr Minehead, Somerset, 01984 642200. www.croydonhall.co.uk, admin@croydonhall.co.uk,

Abroad
European Institute for Applied Buddhism, EIAB, Schaumburgweg 3, D- 51545, Waldbrol, Germany, www.eiab.eu This is part of the Zen monastry of Thich Nhat Hanh, zen master from Vietnam. Also Plum Village, France.

Osho Risk Meditation Centre and commune, Bogballevej3, 8740 Braedstrup, Denmark, 0045 75752500, oshorisk@oshorisk.dk
Osho Meditation Resort, 17, Koregon Park, Pune, India, www.osho.com

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