Mindfulness-Based Cognitive Approach for Seniors (MBCAS): Program Development and Implementation

The MBCAS program is based on the MBSR, Mindfulness-Based Cognitive Therapy (MBCT; Segal et al. 2002) and Mindfulness-Based Relapse Prevention (MBRP; Bowen et al. 2011) programs. It is designed for seniors, defined as people 65 years or older, who are healthy or mostly healthy. Its main objectives are to teach them to (a) observe current experiences with nonjudgmental awareness, (b) identify automatic behaviors or reactions to current experiences that are potentially nonadaptive, and (c) enhance and reinforce positive coping with typical difficulties that they face in their daily lives. An experienced mindfulness instructor teaches the MBCAS program.

The mindfulness training was conceived as a group process, where participants and instructors meet regularly to learn and practice. The core of any mindfulness program takes place during these practice sessions, where each participant exercises the connection to his or her inner world at the same time as others practicing in the same room, and sharing with others, moment-by-moment. Thus, each participant could report on his or her unique inner experience, which has been knitted with the shared common moment (e.g., the bird song that some have heard and appreciated, while some have not, or a participant's cough). Moreover, people are generally seated in a circle, which enables subtle and inherent information to pass within the group: “When one sits in a circle with others, everyone is equal and linked… Because everyone is interrelated and derives meaning through the relationship of the circle, each person's vision is transformed as the circle takes form” (Murdock 1990, pp. 180–181). The communication process turns from one to another, with the instructor becoming no more important than any other participant.

This group process provides a unique way of learning about “inter-being,” a major pillar of any mindfulness-based program (Hanh 2009). The concept of inter-being is a concise formulation of the doctrine of dependent co-arising—that there is no independent self and all things arise in dependence upon multiple causes and conditions—as explicated in the paticcasamuppada-vibhanga Sutta (Dalai Lama 1992). This linking process—the inter-being—stimulates relationships with others and goes beyond the duality of “I” and “others.” This non-dual exploration is fundamental in any mindfulness-based intervention.

To develop the participant's mindfulness, two kinds of exercises were used: (a) focusing on something specific during meditation, an excellent training to reduce distraction and loss of focus and to increase concentration, and (b) simply “being,” that is, without selecting or avoiding anything that could emerge during a meditation session, which is standard training for cultivating presence and openness moment-by-moment. The progression of the exercises starts with the very tangible bodily sensations and moves toward the less tangible inner experiences (i.e., the observation of one's thoughts and emotions). The meditation and cognitive exercises in MBCAS are similar to those used in other programs but adapted to the needs of the seniors. At the end of each session, the participants receive audio CDs, written material, and home practice exercises.

The basis of mindfulness practice is to cultivate disidentification from one's experience of internal events. For example, the participants are taught, “I am not what I feel or think,” in order to understand that feeling anxious or having negative ideas at one moment does not mean that they are that inner feeling or thought. They learn to observe their thoughts, feelings, and emotions as transient events that pass through their mind but to not hold on to them as being true or descriptive of them (Allen et al. 2009). To reinforce this decentering process (i.e., not believing all of our thoughts), MBCAS enables the participants to learn to establish new relationships with their thoughts, feelings, and emotions, through various exercises. In order to foster the learning of the decentering process, the MBCAS program includes experimenting with the feeling of losing control. Thus, seniors explore their automatic reactions during short experimental situations, where they meet the fear of losing control. For seniors who have tried to master their moods for years and who worry about aging and loss of autonomy, the perspective of developing a new relationship with themselves is deeply touching and hopeful.

As in the other mindfulness-based programs that stimulate body consciousness, MBCAS incorporates mindful movements in various postures and walking exercises. This component is particularly important in the context of aging and often aching bodies, where movements may be affected by arthritic pains or other physical limitations. Participants learn eight adapted movements, in both sitting and standing positions. The objective is to awaken the consciousness of the upper body by gently mobilizing the joints. These movements may stimulate and possibly strengthen muscle tone as well as balance when in a standing position (upper body mobility, motor coordination of hands, and balance on each foot). The MBCAS program provides the opportunity to be more mindful of upper body tensions and movements, allowing better understanding of one's bodily sensations. The participants are invited to practice all eight movements every day.

The walking exercise permits rediscovering a certain quality of openness to and acceptance of the present moment. Participants are encouraged to explore walking at various speeds in order to rediscover their safe balance. They may also try the walking exercise with a small rice bag on top of their head, to practice the feeling of having or losing control, and cultivate their kinesthetic sense of verticality. Even though it is not an objective per se, in time, practicing conscious verticality stimulates deep musculature and frees the head. This results in an enhanced physical presence that inspires dignity.

Six months prior to implementing the program, a free introductory session was announced in the local newspaper. During this 2-h session, the mindfulness approach and the MBCAS program with the title of each of the eight sessions were presented, along with two typical exercises. At the end of the session, people could complete a form to preregister for the program or they could think about it and contact the instructor later, within a specified deadline. Writing the title and dates of each of the eight sessions on the flyers was a key point for many participants in deciding to enroll in the program, with many commenting, “This program is written for me.”

One month before the program began, all potential participants were individually interviewed and invited to set private goals for the particular aspects of themselves they wanted to be more aware of. These personal goals often give clues about how the participants perceive themselves. During the interview, some informal questions were asked regarding health, aches and pains, and important psychosocial events that the participant might have encountered. The French versions of the following assessment instruments were administered: the Geriatric Depression Scale (Brink et al. 1982), the WHO-5 Well-Being Index (Psychiatric Research Unit 1999), and the Rosenberg Self-Esteem scale (Vallieres and Vallerand 1990). Following the interview, those with suspected psychiatric issues were referred for psychiatric services before deciding about their participation in the program. Each participant was then invited to express his or her commitment to following the 8-month program, including home practice.

To date, four groups of participants have completed the MBCAS program (N = 43). On average, participants attended 12.6 of the 15 meetings. The percentage of participants who dropped out was low (i.e., 7 %), and 10 % of enrolled participants had to postpone their training for personal reasons to the next time the MBCAS program was run. Periodically, we monitored the frequency and duration of home practice through a random poll. We found that, on average, participants practiced for about 27 min every 1 to 2 days. This is a level of practice that is slightly higher than the usual 15 to 20 min reported in the literature (Kristeller 2007). Former participants, who attended the 1-h monthly practice sessions in the following year, reported meditating at home more than three times a week, for a mean duration of 20 min. This is also slightly higher than the usual 15 min reported by Kabat-Zinn et al. (1987). While we did not undertake a rigorous evaluation of the MBCAS program, a quasi-experimental single-group, pre- and post-training evaluations using the three assessment instruments, indicated significant positive changes in depression, well-being, and self-esteem.

Participants in the four groups were asked to rate on a 10-point scale how meaningful and useful they considered the program. Most rated the program as very meaningful and useful in their life (mean = 8). Most also reported an improved quality of life and also specific personal outcomes such as joy and satisfaction during the 8 months, traversing periods of low motivation without giving up, feeling of release at the realization that thoughts are just thoughts, better insight into one's automatic pilot, enhanced linking to the present moment, self-dignity, better connection to self, and better acceptance of the process (i.e., understanding that acceptance is not resignation). Some also reported that, during the training period, they acquired new behaviors that they considered to be efficient. These included, “I recover faster from emotional events,” “When I lock the door, I no longer need to check it again,” “I try to do less, but try to complete what I start,” and “I have discovered a way of exploring who I am and I am eager to continue this exploration.”