The impact of session-introducing mindfulness and relaxation interventions in individual psychotherapy for children and adolescents: a randomized controlled trial (MARS-CA)

Julia Kalmar, Ines Baumann, Elena Gruber, Eva Vonderlin, Hinrich Bents, Andreas B Neubauer, Thomas Heidenreich, Johannes Mander, Julia Kalmar, Ines Baumann, Elena Gruber, Eva Vonderlin, Hinrich Bents, Andreas B Neubauer, Thomas Heidenreich, Johannes Mander

Abstract

Background: The investigation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past years. However, most MBI research with youth focuses on structured, manualized group programs, conducted in school settings. Knowledge about the implementation and effects of MBIs in individual psychotherapy with children and adolescents is scarce. To fill this research gap, the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is designed. It aims to assess the effects of short session-introducing interventions with mindfulness elements on juvenile patients' symptomatic outcome and therapeutic alliance in individual child and adolescent psychotherapy.

Methods: MARS-CA is conducted at a university outpatient training center for cognitive-behavior therapy. Short session-introducing interventions with mindfulness elements will be compared to short session-introducing relaxation interventions and no session-introducing intervention to explore their effects on symptomatic outcome and therapeutic alliance. The session-introducing interventions will take place at the beginning of 24 subsequent therapy sessions. We hypothesize that patients' symptomatic outcome and therapeutic alliance improve more strongly in the mindfulness condition than in the other two conditions and that the mindfulness condition moderates the relationship between therapeutic alliance and symptomatic outcome. Patients and their trainee therapists will be randomized to one of the three treatment arms. Participants aged between 11 and 19 years and having a primary diagnosis of either a depressive disorder, an anxiety disorder, or a hyperkinetic disorder will be included. Therapeutic alliance will be assessed after every therapy session (therapy session 1 to therapy session 24), symptomatic outcome will be assessed before the start of treatment (pre), after the 3rd, the 10th, and the 17th therapy sessions, at the end of treatment (24th therapy session, post), and at a 6-month follow-up. Additionally, mindfulness and mindfulness-related measures as well as demographic data, adherence, allegiance, and therapeutic techniques will be assessed. It is our aim to assess a sample of 135 patients. We will conduct multilevel modeling to address the nested data structure.

Discussion: The study can provide information about how add-on MBIs, conducted by trainee therapists, influence therapeutic alliance and symptomatic outcome in individual psychotherapy in children and adolescents.

Trial registration: ClinicalTrials.gov NCT04034576. Registered on July 17, 2019.

Keywords: Adolescents; Children; Component study; Mindfulness; Randomized controlled trial; Relaxation; Therapeutic alliance.

Conflict of interest statement

TH, HB, and JM receive royalties from mindfulness books they have authored. JM and TH receive stipends from workshops on mindfulness. EG is supported by “Cusanuswerk, Bischöfliche Studienförderung” (Cusanuswerk, episcopal study support).

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
CONSORT flow chart. ADHD, attention-deficit/hyperactivity disorder; CBT, cognitive-behavioral therapy; CEQ, Credibility/Expectancy Questionnaire; CG, control group CG+R, control group: relaxation; CPP, Center for Psychological Psychotherapy; DISYPS-III; SBB-ADHS, Diagnostic System for Mental Disorders; ADHD Self-Rating Scale; DISYPS-III; SBB-ANG, Diagnostic System for Mental Disorders; Anxiety Self-Rating Scale; SBB-DES, Diagnostic System for Mental Disorders; Depression Self-Rating Scale; FTB-KJ, German Version of the Therapeutic Allegiance Scale for Children; HICBI, Heidelberg Inventory of Cognitive-Behavioral Interventions; IG-M, intervention group: mindfulness; Kinder-DIPS – OA, Diagnostic Interview for Mental Disorders in Children and Adolescents – Open Access KIMS, Kentucky Inventory of Mindfulness Skills; SCS, Self-Compassion Scale; TPI, Therapeutic Presence Inventory; YSR, Youth Self-Report
Fig. 2
Fig. 2
Study procedure of MARS-CA. IG-M, intervention group mindfulness; CG-R, control group relaxation; CG, control group; PMR, progressive muscle relaxation; S, therapy session

References

    1. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. 4. New York: Delta Trade Paperback/Bantam Dell; 2013.
    1. Davis DM, Hayes JA. What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy. 2011;48(2):198–208.
    1. van Dam NT, van Vugt MK, Vago DR, Schmalzl L, Saron CD, Olendzki A, et al. Mind the hype: a critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspect Psychol Sci J Assoc Psychol Sci. 2018;13(1):36–61.
    1. Klingbeil DA, Renshaw TL, Willenbrink JB, Copek RA, Chan KT, Haddock A, et al. Mindfulness-based interventions with youth: a comprehensive meta-analysis of group-design studies. J Sch Psychol. 2017;63:77–103.
    1. Khoury B, Lecomte T, Fortin G, Masse M, Therien P, Bouchard V, et al. Mindfulness-based therapy: a comprehensive meta-analysis. Clin Psychol Rev. 2013;33(6):763–771.
    1. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78(2):169–183.
    1. Goldberg SB, Tucker RP, Greene PA, Davidson RJ, Wampold BE, Kearney DJ, et al. Mindfulness-based interventions for psychiatric disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52–60.
    1. Dimidjian S, Segal ZV. Prospects for a clinical science of mindfulness-based intervention. Am Psychol. 2015;70(7):593–620.
    1. Michalak J, Steinhaus K, Heidenreich T. (How) do therapists use mindfulness in their clinical work? A study on the implementation of mindfulness interventions. Mindfulness. 2020;11:401–410.
    1. Segal ZV, Williams JM, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York: Guilford Press; 2012.
    1. Shallcross AJ, Gross JJ, Visvanathan PD, Kumar N, Palfrey A, Ford BQ, et al. Relapse prevention in major depressive disorder: mindfulness-based cognitive therapy versus an active control condition. J Consult Clin Psychol. 2015;83(5):964–975.
    1. Williams JMG, Crane C, Barnhofer T, Brennan K, Duggan DS, Fennell MJV, et al. Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: a randomized dismantling trial. J Consult Clin Psychol. 2014;82(2):275–286.
    1. Kuyken W, Watkins E, Holden E, White K, Taylor RS, Byford S, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther. 2010;48(11):1105–1112.
    1. van der Velden AM, Kuyken W, Wattar U, Crane C, Pallesen KJ, Dahlgaard J, et al. A systematic review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of recurrent major depressive disorder. Clin Psychol Rev. 2015;37:26–39.
    1. Mander J, Blanck P, Neubauer AB, Kröger P, Flückiger C, Lutz W, et al. Mindfulness and progressive muscle relaxation as standardized session-introduction in individual therapy: a randomized controlled trial. J Clin Psychol. 2019;75(1):21–45.
    1. Saltzman A. A still quiet place: a mindfulness program for teaching children and adolescents to ease stress and difficult emotions. Oakland: New Harbinger Publications; 2014.
    1. Broderick P. Learning to breathe: a mindfulness curriculum for adolescents to cultivate emotion regulation, attention, and performance. Oakland: New Harbinger Publications; 2013.
    1. Semple R, Lee J. Mindfulness-based cognitive therapy for anxious children: a manual for treating childhood anxiety. Oakland: New Harbinger Publications; 2011.
    1. Semple RJ, Droutman V, Reid BA. Mindfulness goes to school: things learned (so far) from research and real-world experiences. Psychol Sch. 2017;54(1):29–52.
    1. de Bruin EI, Blom R, Smit FM, van Steensel FJ, Bögels SM. MYmind: mindfulness training for youngsters with autism spectrum disorders and their parents. Autism Int J Res Pract. 2015;19(8):906–914.
    1. van der Oord S, Bögels SM, Peijnenburg D. The effectiveness of mindfulness training for children with ADHD and mindful parenting for their parents. J Child Fam Stud. 2012;21(1):139–147.
    1. van de Weijer-Bergsma E, Formsma AR, de Bruin EI, Bögels SM. The effectiveness of mindfulness training on behavioral problems and attentional functioning in adolescents with ADHD. J Child Fam Stud. 2012;21(5):775–787.
    1. Zoogman S, Goldberg SB, Hoyt WT, Miller L. Mindfulness interventions with youth: a meta-analysis. Mindfulness. 2015;6(2):290–302.
    1. Dunning DL, Griffiths K, Kuyken W, Crane C, Foulkes L, Parker J, et al. Research Review: The effects of mindfulness-based interventions on cognition and mental health in children and adolescents - a meta-analysis of randomized controlled trials. J Child Psychol Psychiatry. 2019;60(3):244–258.
    1. Ivanovic M, Swift JK, Callahan JL, Dunn R. A multisite pre/post study of mindfulness training for therapists: the impact on session presence and effectiveness. J Cogn Psychother. 2015;29(4):331–342.
    1. Cigolla F, Brown D. A way of being: bringing mindfulness into individual therapy. Psychother Res. 2011;21(6):709–721.
    1. Horst K, Newsom K, Stith S. Client and therapist initial experience of using mindfulness in therapy. Psychother Res J Soc Psychother Res. 2013;23(4):369–380.
    1. Dunn R, Callahan JL, Swift JK, Ivanovic M. Effects of pre-session centering for therapists on session presence and effectiveness. Psychother Res J Soc Psychother Res. 2013;23(1):78–85.
    1. Schroevers MJ, Tovote KA, Snippe E, Fleer J. Group and individual mindfulness-based cognitive therapy (MBCT) are both effective: a pilot randomized controlled trial in depressed people with a somatic disease. Mindfulness. 2016;7(6):1339–1346.
    1. Mander J, Kröger P, Heidenreich T, Flückiger C, Lutz W, Bents H, et al. The process-outcome mindfulness effects in trainees (PrOMET) study: protocol of a pragmatic randomized controlled trial. BMC Psychol. 2015;3(1):25.
    1. Blanck P, Perleth S, Heidenreich T, Kröger P, Ditzen B, Bents H, et al. Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic review and meta-analysis. Behav Res Ther. 2018;102:25–35.
    1. Karver MS, De Nadai AS, Monahan M, Shirk SR. Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy. 2018;55(4):341–355.
    1. McLeod BD. Relation of the alliance with outcomes in youth psychotherapy: a meta-analysis. Clin Psychol Rev. 2011;31(4):603–616.
    1. Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res. 2011;191(1):36–43.
    1. Kristeller JL, Johnson T. Cultivating loving kindness: a two-stage model of the effects of meditation on empathy, compassion, and altruism. Zygon®. 2005;40(2):391–408.
    1. Speck V. Training progressiver Muskelentspannung für Kinder [Progressive muscle relaxation training for children] Göttingen: Hogrefe; 2013.
    1. Petermann U. Die Kapitän-Nemo-Geschichten: Geschichten gegen Angst und Stress [The tales of Captain Nemo: Stories against anxiety and stress] 19. Göttingen: Hogrefe; 2018.
    1. Schneider S, Pflug V, Margraf J, In-Albon T. Kinder-DIPS: Diagnostisches Interview bei psychischen Störungen im Kindes- und Jugendalter Open Access [Diagnostic interview for mental disorders in children and adolescents - open access]. Ruhr-Univ Boch RUB. 2017; Available at .
    1. World Health Organzation . The ICD-10 classification of mental and behavioural disorders: clinical and diagnostic guidelines. World Health Organization; 1992.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders (DSM) 5. Washington DC: American Psychiatric Association; 2013.
    1. First M, Karg RS, Williams JBW, Spitzer RL. Structured Clinical Interview for DSM-5. Washington DC: American Psychiatric Association; 2015.
    1. Döpfner M, Plück J, Kinnen C. CBCL/6-18 R, TRF 6-18R, YSR/11-18 R Deutsche Schulalter-Formen der Child Behavior Checklist von Thomas M. Achenbach [CBCL/6-18 R, TRF 6-18R, YSR/11-18 R School-age assessment forms of the Child Behavior Checklist by Thomas M. Achenbach] Göttingen: Hogrefe; 2014.
    1. Sedlmeier P, Eberth J, Schwarz M, Zimmermann D, Haarig F, Jaeger S, et al. The psychological effects of meditation: a meta-analysis. Psychol Bull. 2012;138(6):1139–1171.
    1. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–191.
    1. Baldwin SA, Imel ZE, Braithwaite SR, Atkins DC. Analyzing multiple outcomes in clinical research using multivariate multilevel models. J Consult Clin Psychol. 2014;82(5):920–930.
    1. Quené H, van den Bergh H. On multi-level modeling of data from repeated measures designs: a tutorial. Speech Comm. 2004;43(1):103–121.
    1. Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134(8):663–694.
    1. Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B, et al. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ. 2008;337:a2390.
    1. Leiner DJ. SoSci Survey (Version 3.2.42) 2019.
    1. Gomez R, Vance A, Gomez RM. Analysis of the convergent and discriminant validity of the CBCL, TRF, and YSR in a clinic-referred Sample. J Abnorm Child Psychol. 2014;42(8):1413–1425.
    1. Kronmüller KT, Hartmann M, Reck C, Victor D, Horn H, Winkelmann K. Die therapeutische Beziehung in der Kinder- und Jugendlichen-Psychotherapie: Evaluation einer deutschen Version der Therapeutic Alliance Scales for Children [Therapeutic alliance in child and adolescent psychotherapy: Evaluation of a German version of the Therapeutic Alliance Scales for Children] Z Für Klin Psychol Psychother. 2003;32(1):14–23.
    1. Ströhle G, Nachtigall C, Michalak J, Heidenreich T. Die Erfassung von Achtsamkeit als mehrdimensionales Konstrukt: Die deutsche Version des Kentucky Inventory of Mindfulness Skills (KIMS-D) [Measuring mindfulness as a multidimensional construct: A German version of the Kentucky Inventory of Mindfulness Skills (KIMS-D)] Z Für Klin Psychol Psychother. 2010;39(1):1–12.
    1. Greco LA, Baer RA, Smith GT. Assessing mindfulness in children and adolescents: development and validation of the Child and Adolescent Mindfulness Measure (CAMM) Psychol Assess. 2011;23(3):606–614.
    1. Baer RA, Smith GT, Allen KB. Assessment of mindfulness by self-report: the Kentucky inventory of mindfulness skills. Assessment. 2004;11(3):191–206.
    1. Hupfeld J, Ruffieux N. Validierung einer deutschen Version der Self-Compassion Scale (SCS-D) [Validation of a German version of the Self-Compassion Scale (SCS-D)] Z Für Klin Psychol Psychother. 2011;40(2):115–123.
    1. Stolow D, Zuroff DC, Young JF, Karlin RA, Abela JRZ. A prospective examination of self-compassion as a predictor of depressive symptoms in children and adolescents. J Soc Clin Psychol. 2015;35(1):1–20.
    1. King S, Holosko MJ. The development and initial validation of the Empathy Scale for Social Workers. Res Soc Work Pract. 2012;22(2):174–185.
    1. Döpfner M, Görtz-Dorten A. DISYPS-III Diagnostik-System für psychische Störungen nach ICD-10 und DSM-5 für Kinder und Jugendliche - III [Diagnostic system for mental disorders in childhood and adolescence] Göttingen: Hogrefe; 2017.
    1. Del Re AC, Flückiger C, Goldberg SB, Hoyt WT. Monitoring mindfulness practice quality: an important consideration in mindfulness practice. Psychother Res J Soc Psychother Res. 2013;23(1):54–66.
    1. Devilly GJ, Borkovec TD. Psychometric properties of the credibility/expectancy questionnaire. J Behav Ther Exp Psychiatry. 2000;31(2):73–86.
    1. D’Errico L, Call M, Vogel E, Bents H, Mander J. Spezifische Techniken in kognitiv-verhaltenstherapeutischen Ausbildungstherapien [Specific techniques in cognitive-behavioral training therapy: development and validation of a questionnaire]. Z Für Klin. Psychol Psychother. 2018:1–12.
    1. Geller SM, Greenberg LS, Watson JC. Therapist and client perceptions of therapeutic presence: the development of a measure. Psychother Res J Soc Psychother Res. 2010;20(5):599–610.
    1. Carsley D, Khoury B, Heath NL. Effectiveness of mindfulness interventions for mental health in schools: a comprehensive meta-analysis. Mindfulness. 2018;9(3):693–707.
    1. Michalak J, Crane C, Germer CK, Gold E, Heidenreich T, Mander J, et al. Principles for a responsible integration of mindfulness in individual therapy. Mindfulness. 2019;10(5):799–811.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj