Mindfulness Based Stress Reduction (MBSR)

Core Components

Mindfulness Based Stress Reduction (MBSR) is a standardised intervention that focuses on training in mindfulness approaches, with an emphasis on coping with stress and promoting adaptive health behaviours (including adjusting to chronic conditions). This group-based intervention can be delivered to adults, adolescents and school-aged children to address a range of physical and psychological conditions, including depression, anxiety, substance use, stress and burnout).

MBSR is a group-based therapy, a brief economic analysis of groups delivered in Scotland indicated that three people can be treated with MBSR for the same staff resource as one person in individual therapy, offering the possibility of reduced waiting times(1).

MBSR is usually delivered over 8 weekly in-class sessions, each lasting between 2 to 2.5 hours. It includes weekly homework practices to enhance learning and can include a day-long meditation retreat. The sessions teach mindfulness practices that include mindfulness meditation on the breath, a body scan practice focusing on awareness of body sensations, mindful movement practice (based on gentle yoga or similar practices) and the application of mindful awareness in everyday life.  This is integrated with an understanding of stress from mind-body medicine and psychological understanding of how humans create experiences of distress and build resilience. The intervention aims to enhance awareness of present-moment experience, with increased acceptance and reduced reactivity / judgement. Individuals learn to step out of “automatic pilot” (where we are more likely to react unhelpfully to experience) and to inhabit more a state of “being” in awareness (where we have more choice in how we respond). This leads to reduction in rumination and worry, as well as enhancement in self-esteem, self-regulation, psychological resilience and life satisfaction.

Fidelity

Fidelity is enhanced through a range of competency criteria which includes observation / mentorship (through an apprenticeship model of training). Formal fidelity tools include the Mindfulness Based Intervention – Teaching Assessment Criteria (MBI-TAC) (developed by Bangor Centre for Mindfulness) for observational feedback or self-reflection.

Training should follow an established / validated pathway meeting the Good Practice Guidelines established by BAMBA (British Association of Mindfulness Based Approaches). The NHS Education for Scotland Mindfulness Network has developed a local training pathway to meet the needs of NHS staff / services. It provides a listing of therapists who have completed the expected pathway and encourages an apprenticeship model where training and supervision is offered locally in Health Boards. The Scottish Mindfulness Network is a member of BAMBA and maintains links to this UK based charity to inform training, supervision and professional development of mindfulness therapists.

Modifiable Components

The MBSR protocol can be modified to increase disorder specificity.   MBSR can be delivered in a number of settings (e.g., prisons, schools, community and health-care settings, and corporate environments) for a variety of physical and mental health conditions including stress. In addition to face-to-face delivery, MBSR can be delivered on-line (using a secure platform) with a growing evidence base of its effectiveness. MBSR has also been adapted using a range of structured self-help resources (e.g. via apps, books and audio). These may provide a useful adjunct to other forms of therapy. However, an 8-week face-to-face (or line) course is the “gold standard” in terms of effectiveness.

Support for Organisation / Practice

Implementation Support

Implementation support can be provided primarily by the NHS Scotland Mindfulness Network (supported by NHS Education for Scotland). This is led by two coordinators (Neil Rothwell and Charlotte Procter) who oversee the Scotland wide network and Mindfulness Leads in each Health Board area (Scottish NHS Mindfulness Network), many of whom will be experienced at delivering training and supervision.

In addition, there are national organisations that guide the practice, teaching and development of mindfulness-based approaches and set standards around training and supervision.  These include BAMBA (British Association of Mindfulness Based Approaches) and The Mindfulness Network (UK), who offer supervision, professional development and training. There are a number of additional training organisations (University, private or charity based) that can offer training, supervision and continuing professional development (many of which will be affiliated training organisations within BAMBA).

Implementation support for the delivery of on-line interventions should also include access to a suitable, secure platform which has been approved by the local Health Board. The platform should ideally have the option of break-out rooms.

Start-up Costs

Training in MBSR is provided at no cost if available through local NHS Health Board areas.  This is dependent upon the availability of trainers (mindfulness therapists who have been trained to deliver a training) and their capacity to be made available to conduct training. Health Board areas may share resources / expertise to deliver training jointly.  Staff will be able to complete the 8-week MBSR course at no cost if there are staff places available in patient focussed groups.

Costs will apply for training by private providers, if there is no availability of local training within the NHS Boards, and if a Health Board / service area is starting or restarting a mindfulness service.

Start-up costs include costs of basic training, optional membership of BAMBA (this is not a requirement of mindfulness therapists in Scotland as there is use of an alternative listing procedure) and supervision fees. Additional costs apply including books / training materials / ongoing CPD events including mindfulness-based retreats / intensive training.

1. Staff attendance at an 8-week mindfulness-based course (free if locally provided) or available at a number of locations (locally, on-line, staff-based course run by NES). Costs outwith NHS provision is typically £200 - £300 (may be less if delivered on-line).
2. Therapist training course (free if locally provided) or available through a variety of training organisations (University, private or charity organisations), usually in the form of a 12-month programme of training at costs ranging from £1, 350 - £1, 500 from private organisations to £4000 to £5000 (University based). The courses differ in that some provide therapist training alone, some are competency assessed and others offer a Masters qualification.
3. Supervision costs (free if offered locally with supervisors who have attended NES generic supervision training plus the “bolt on” training for mindfulness supervision) or privately at a variable cost (around £60 / hour). Expectation is for three half hour sessions of supervision (minimum for the delivery of a 8 week course) as a newly qualified therapist (over at least two 8 week courses) and ongoing monthly supervision (which can often be provided in a peer group setting).
4. Fee for joining the BAMBA register of mindfulness therapists (optional for NHS Scotland therapists, but recommended if delivering privately), £90 for initial application and £37.50 for annual renewal.
5. CPD costs (recommended two to seven days of annual training which may include CPD training days and intensive training in the form of practice “retreats”). £60 - £150 per day (costs vary). The NHS Scotland Mindfulness Network offers two CPD days per year (which are free to mindfulness therapists).
6. Additional costs in the form of key texts / course books (around £25 - £100).

Building Staff Competency

Qualifications Required

MBSR is delivered in the NHS by professionals with a variety of backgrounds in health and social care (e.g., clinical psychology, psychiatry, occupational health, nursing, physiotherapy, OT, social work), who have training and experience in working with the population (in physical and/or mental health) to whom the intervention will be offered.

Personal interest in mindfulness / meditation practice and a willingness to develop and sustain a personal practice is vital, as the intervention is delivered from the in-depth experience and embodiment of the practice. Those who already have a personal mindfulness practice (including a mindful movement practice such as yoga, T’ai Chi) will probably have a shorter training journey as they already have an established practice.

Training Requirements

Training comprises a 1-2 year-long journey starting with the staff member attending an 8-week MBSR course as a participant and developing a stable, regular practice of mindfulness meditation / mindful movement. There are often opportunities for staff to take part in a patient-based course as a “staff participant” in their local health board areas.  There is an expectation that personal practice is established for about one year prior to engaging in a therapist training course. Professionals who have a pre-existing and ongoing mindfulness practice might be particularly interested in training in mindfulness-based approaches and could proceed more quickly to the therapist training level. The therapist training component comprises up to 7 training days (but may be shorter in health board areas if the apprenticeship model can be applied). Training is often “generic” for the range of different mindfulness-based approaches or curriculums and will cover core features in common with MBSR and MBCT (Mindfulness Based Cognitive Therapy). 

It is expected that trainees will deliver their first two courses under supervision / and as part of an apprenticeship model with a more experienced therapist prior to delivering courses independently. 

There is no formal accreditation as part of the training courses, but local Mindfulness Leads (Scottish NHS Mindfulness Network)) in Health Board areas will approve trained staff as suitable for joining the NHS listing of therapists once they have completed training / apprenticeship and these will be listed on the NHS Mindfulness website.

Therapists may choose to join the UK based register of mindfulness teachers with the British Association for Mindfulness-Based Approaches (BAMBA) who use a formal registration and re-registration process for an annual fee.  This is not a formal requirement for professionals who are trained to deliver mindfulness interventions in NHS Scotland. Ongoing mindfulness practice and CPD is a requirement for the delivery of MBSR. 

Supervision Requirements

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in MBSR / mindfulness based approaches, the clinical area in which it is being delivered  and has completed training in supervision of psychological therapies and interventions (further information: Supervision of psychological therapies and intervention | NHS Ed (scot.nhs.uk) including the Mindfulness specialist supervision training component.

One to one supervision is particularly helpful for newly qualified therapists and MBSR group supervision is useful (as an alternative to ongoing one to one supervision) for more experienced MBSR therapists.

Theory of Change

MBSR aims to increase mindfulness via enhanced present-moment awareness and nonreactivity. In anxiety conditions, enhanced levels of mindfulness are expected to reduce focus on past and future oriented ruminations and worry. It is also expected to increase decentering, translating to reductions in anxiety symptoms. In chronic pain conditions, increased mindfulness is expected to translate to increased pain acceptance, healthier responses to pain, and reduced pain associated distress.

Values

MBSR focuses on training in mindfulness meditation techniques, with emphasis on coping with stress and promoting adaptive health behaviours. It aims to promote mindfulness via enhanced present-moment awareness and nonreactivity.

• Does the mindfulness-based approach of this intervention align with the requirements of your organisation?

Priorities

MBSR aims to reduce focus on past and future oriented ruminations and worry, and to enable the acknowledgement and acceptance of objective present experiences without reacting to negative experiences. It can be delivered to adults, adolescents and school-aged children to address a range of physical (chronic pain, diabetes, asthma) and psychological conditions (including depression and anxiety disorders).

• What population does your organisation serve?
• What physical and/ or mental health conditions will your service prioritise?

Existing Initiatives

• Does your service currently deliver interventions that address anxiety disorders and chronic pain conditions?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

MBSR can be delivered by professionals with backgrounds in health (physical and/ or mental) and social care. Practitioners are required to attend an 8-week MBSR course, a 12-month MBSR therapist training course, and teach two supervised 8-week MBSR courses. MBSR is delivered over 8 weekly in-class sessions, each lasting about 2 hours, or can be delivered as an on-line course.

• Does your service have practitioners who are available and interested in learning and delivering MBSR?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?

Technology Support

Practitioner teacher training and supervision can be accessed remotely. MBSR can be delivered as an online course.

• Can your practitioners access technology for training and supervision?
• Will your organisation deliver MBSR as an online course? Can your service provide the technology that facilitates this?

Administrative Support

MBSR is delivered over 8 weekly sessions in a number of settings (e.g. prisons, schools, community settings, and corporate environments). MBSR can also include a one-day meditation retreat. Administrative support will be needed for organising the course.

• In what setting will MBSR be delivered?
• Does your service have a venue to deliver sessions?
• Can administrative supports needed to deliver MBSR be provided?

Financial Support

In Scotland, training is overseen by the Scottish NHS Mindfulness Network supported by NHS Education for Scotland.  Therapist training and supervision can often be run within health boards by experienced trainers. The only cost for this is allocating time for trainee therapists and supervisor / trainer(s).  However, this training route currently has a limited capacity.

External training is also available.  The Mindfulness-Based Stress Reduction (MBSR) course costs around £200 for the 8-week course (may be less if delivered online).  The 12 month therapist training course costs around £1,500 per practitioner (if delivered by a private organisation or up to £4, 000 - £5,000 (if delivered by a University). Additional costs for MBSR resources and activities should be considered.

• How many practitioners will your service train to deliver MBSR?
• Can your service financially support practitioner training and purchase of MBSR resources?

Comparable Population

MBSR is delivered to adults, adolescents and school-aged children to address a range of physical (chronic pain, diabetes, asthma) and psychological conditions (including depression and anxiety disorders). Evidence of effectiveness has been demonstrated in people (including Veterans) with panic disorder with or without agoraphobia (PD/AG),  generalized anxiety disorder (GAD), and chronic pain.

• Is this comparable to the population your service would like to serve?

Desired Outcome

MBSR is associated with significant improvement across several outcomes including anxiety, depression, physical functioning, and stress markers. Some effects have been observed at 3- and 6-months follow-up.

• Is delivering a mindfulness-based intervention for mental health disorders and chronic pain a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?