Thesis - Mental Health

Mindfulness and sensory modulation strategies to
regulate levels of arousal and emotional reactivity in

young adults with mental health disorders: A pilot
study
By Deborah Lockeridge
Supervised by Dr Julia Bowman and Amy Wilson
Thesis submitted in fulfilment of the degree:
Bachelor of Applied Science (Honours)
(Occupational Therapy)
University of Western Sydney
October 2012
Mindfulness and Sensory Modulation Group Program
Student Declaration
I, Deborah Lockeridge, declare that this thesis contains no material that has been
accepted for the award of another degree or diploma, and that, to the best of my
knowledge and belief, contains no material previously published or written by another
person, except when due reference material had been made in the text of this thesis.
Name: Deborah Lockeridge
Signature: ________________________
Date: ___________________________
i
Abstract
Individuals with mental health disorders commonly experience problems associated
with regulating arousal and emotional reactivity, resulting in sensory modulation
dysfunction. Sensory modulation is the capacity to regulate and organise the intensity
and nature of responses to sensory input in a graded and adaptive manner. This allows
the individual to achieve and maintain an optimal range of performance. Currently,
the use of sedation and seclusion is standard practice when dealing with highly
agitated individuals in acute mental health facilities. However, the negative impact of
sedation and seclusion on the recovery of individuals with a mental health disorder is
increasingly being reported in research. The aim of this study was to evaluate the
impact of a Mindfulness and Sensory Modulation Group Program on levels of arousal
and emotional reactivity; and to determine whether rates of seclusion and PRN
sedation appear to reduce as a result of participation in the program.
The study was undertaken at Birunji Youth Mental Health Unit, an acute care facility.
The program consisted of ten, one hour group sessions, conducted Monday to Friday
by a multidisciplinary team of occupational therapists, social workers and nurses. The
program was specifically designed to teach participants mindfulness and sensory
modulation skills to regulate their moment-to-moment thoughts, feelings, sensations
and behaviours. A pre-test, post-test design was employed using a convenience
sample (N = 31). Participants were inpatient consumers aged between 16 and 45
years. Upon recruitment to the study a demographic questionnaire and the Sensory
Defensiveness Screen was completed. Participant outcomes on the Philadelphia
Mindfulness Scale (PHMLS) and the Positive and Negative Affect Schedule Short
Form (PANAS - SF) were measured at baseline, after participation in 5 groups, after
ii
10 groups and upon participant discharge. To establish immediate impact of the group
on participants arousal and emotional reactivity, 10 visual analogue scales (VAS)
were completed before and after each group. For the duration of the study, PRN
sedation and seclusion data were also collected. Descriptive and inferential statistics
were used to identify trends in the data.
Of the 31 participants, the most common reason for admission was acute psychosis
(26%) with 58% males and 41% females. The mean age of participants was 24 years.
The greatest proportion of participants had moderate levels of sensory defensiveness.
At completion of the study period, statistically significant results were found on the
awareness subscale of the PHMLS, the negative affect subscale of the PANAS-SF and
on nine of the 10 VAS. Further, of the 407 instances of PRN sedation administered
throughout the study period, 129 (32%) of these were given to study participants. Of
the 7 instances of seclusion, four instances were used for two study participants.
Results reveal the Mindfulness and Sensory Modulation group program has positively
impacted on participants ability to normalise levels of arousal and emotional
reactivity.
iii
Acknowledgements
This research project would not have been possible without the support of many
people. I would firstly like to thank my supervisors, Dr Julia Bowmen and Amy
Wilson. Their amazing contribution in sharing their time, feedback, guidance and
knowledge is deeply appreciated. It has been an honour to have been guided and
mentored by two accomplished professionals, from whom I have learnt a great deal
throughout this journey. Deepest gratitude is also due to Elisabeth Marsland who
offered invaluable help and assistance during the early stages. Thank you to the
facilitators at Birunji Youth Mental Health Unit for their hard work during the research
period.
This thesis would never have been completed without the care, support and patience of
my family and friends. Firstly, my husband, David, whose unending support and love
has helped me through some difficult moments and helped me accomplish this
research project. To my dad, mum, sisters and brothers, thank you for being there to
listen to my complaints and having faith in my ability to reach my maximum potential.
I would like to acknowledge the contribution of Shane, Fiona, Brianna, Shannen and
Caitlin. Thank you for supporting me throughout my university career with your
generosity and support. I really could not have done it without you.
Finally, to the other honours colleagues, Katie, Katrina and Tim. Thank you for the
consistent encouragement and support. I wish you every success in your future career
as occupational therapists.
iv
Table of Contents
Student Declaration .......................................................................................................i
Abstract ..........................................................................................................................ii
Acknowledgements ......................................................................................................iv
Table of Contents .......................................................................................................... v
List of Tables ................................................................................................................. x
List of Figures ...............................................................................................................xi
List of Appendices .......................................................................................................xii
Chapter 1 - Introduction .............................................................................................. 1
1.1 Introduction ...................................................................................................... 1
1.2 Statement of the Problem ................................................................................. 6
1.3 Study Scope ...................................................................................................... 6
1.4 Definition of Terms .......................................................................................... 9
1.5 Structure of the thesis ..................................................................................... 12
Chapter 2 Literature Review .................................................................................. 14
2.1 Introduction ......................................................................................................... 14
2.2 Occupational Therapy in Mental Health ............................................................. 15
2.3 Sensory Modulation ............................................................................................ 18
2.3.1 Sensory Modulation Dysfunction ................................................................ 19
2.3.2 Arousal ......................................................................................................... 19
2.3.3 Emotional Reactivity ................................................................................... 21
v
2.4 Sensory Modulation Dysfunction and Mental Health Disorders ........................ 23
2.5 Impact of the Person on Occupational Performance ........................................ 27
2.6 Sedation and Seclusion ....................................................................................... 28
2.6.1 Sedation........................................................................................................ 28
2.6.2 Seclusion ...................................................................................................... 29
2.7 Impact of the Environment on Occupational Performance .............................. 31
2.8 Recovery ............................................................................................................. 32
2.9 Impact of Occupation on Occupational Performance ...................................... 33
2.10 Mindfulness....................................................................................................... 34
2.11 Sensory Modulation Strategies ......................................................................... 37
2.12 Occupational Therapy Intervention and Occupational Performance ................ 39
2.13 Conclusion ........................................................................................................ 40
2.13.1 Significance of the Study ........................................................................... 40
2.13.2 Research Questions .................................................................................... 41
2.13.3 Research Hypothesis .................................................................................. 41
2.13.4 Expected Outcomes ................................................................................... 42
2.14 Synopsis ............................................................................................................ 42
Chapter 3 Methodology ........................................................................................... 44
3.1 Introduction ......................................................................................................... 44
3.2 Study Design ....................................................................................................... 44
3.3 Sampling and Recruitment .................................................................................. 47
vi
3.3.1 Sampling ...................................................................................................... 47
3.3.2 Recruitment .................................................................................................. 48
3.4 Intervention Mindfulness and Sensory Modulation Group ............................. 49
3.5 Instruments .......................................................................................................... 53
3.5.1 Sensory Defensiveness Screening for Adults .............................................. 54
3.5.2 Philadelphia Mindfulness Scale (PHLMS) .................................................. 55
3.5.3 Positive and Negative Affect Schedule Short Form (PANAS-SF) ........... 55
3.5.4 Visual Analogue Scale Arousal and Emotional Reactivity Scale ............. 57
3.5.5 PRN Sedation and Seclusion Registers........................................................ 58
3.5.6 Feedback ...................................................................................................... 58
3.6 Methods............................................................................................................... 58
Data Collection ..................................................................................................... 58
Data Analysis ........................................................................................................ 59
3.7 Ethical Considerations ........................................................................................ 61
3.8 Synopsis .............................................................................................................. 62
Chapter 4 - Results...................................................................................................... 63
4.1 Introduction ......................................................................................................... 63
4.2 Demographics ..................................................................................................... 63
4.3 Sensory Defensiveness Screening for Adults ..................................................... 66
4.3.1 Sensory Defensiveness................................................................................. 66
4.3.2 Sensory Defensiveness Occupational Dysfunction .................................. 67
vii
4.3.3 Sensory Defensiveness and History of Trauma ........................................... 68
4.4 Philadelphia Mindfulness Scale (PHLMS) ......................................................... 70
4.5 Positive and Negative Affect Schedule Short Form (PANAS-SF) .................. 72
4.6 Arousal and Emotional Reactivity Scale ............................................................ 74
4.7 PRN Sedation Rates ............................................................................................ 76
4.8 Seclusion Rates ................................................................................................... 78
4.9 Consumer Feedback ............................................................................................ 80
4.10 Synopsis ............................................................................................................ 82
Chapter 5 Discussion ............................................................................................... 84
5.1 Introduction ......................................................................................................... 84
5.2 Key Findings ....................................................................................................... 84
5.2.1 Demographics .............................................................................................. 84
5.2.2 Sensory Defensiveness Screening................................................................ 86
5.2.3 Philadelphia Mindfulness Scale (PHLMS) .................................................. 88
5.2.4 Positive and Negative Affect Schedule Short Form (PANAS-SF) ........... 89
5.2.5 Arousal and Emotional Reactivity Scale ..................................................... 90
5.2.6 PRN Sedation ............................................................................................... 92
5.2.7 Seclusion ...................................................................................................... 93
5.2.8 Participant Feedback .................................................................................... 94
5.3 Discussion of Findings in relation to Research Questions .................................. 95
viii
5.3.1 Research Question 1: To investigate if participating in a Mindfulness and
Sensory Modulation group program can have an impact on an individuals levels
of arousal ............................................................................................................... 95
Sensory Modulation group program can have an impact on an individuals levels
of emotional reactivity .......................................................................................... 96
5.3.3 Research Question 3: To assess if participating in a Mindfulness and
Sensory Modulation group program changes the use of PRN sedation ................ 97
5.3.4 Research Question 4: To evaluate if participating in a Mindfulness and
Sensory Modulation group program impacts rates of seclusion ........................... 97
5.4 Limitations .......................................................................................................... 98
5.5 Recommendations ............................................................................................... 99
5.5.1 Practice ......................................................................................................... 99
5.5.2 Education ................................................................................................... 100
5.5.3 Future Research ......................................................................................... 100
5.5.4 Policy ......................................................................................................... 101
5.6 Conclusions ....................................................................................................... 102
References .................................................................................................................. 104
ix
List of Tables
Table 3.1 Mindfulness and Sensory Modulation Group Program Grid 50
Table 4.1 Participant demographics 65
Table 4.2 Sensory defensiveness impact on occupational performance 68
Table 4.3 Sensory defensiveness and trauma history 69
Table 4.4 Mean, standard deviation and range of awareness and acceptance
sub-scales 71
Table 4.5 Z-scores, p-value and effect size of awareness and acceptance
sub-scales 72
Table 4.6 Mean, standard deviation and range of positive and negative affect
sub-scales 73
Table 4.7 Z-scores, p-value and effect size of positive and negative affect
sub-scales 74
Table 4.8 Z-scores, p-value and effect size of arousal and emotional reactivity
scale 75
Table 4.9 Frequency and percentage of PRN sedation rates 77
Table 4.10 Frequency and percentage of seclusion rates 79
x
List of Figures
Figure 2.1 Person, environment, occupation (PEO) model 16
Figure 2.2 Sensory processing framework 22
Figure 2.3 Combination of mindfulness and sensory modulation strategies 40
Figure 3.1 Research design simple pre and post-test design 45
Figure 3.2 Techniques of Mindfulness and Sensory Modulation strategies used in
group program 52
Figure 4.1 Number of participants in sensory defensiveness categories 67
Figure 4.2 Sensory defensiveness and history of trauma correlation 70
Figure 4.3 Scatter plot diagram of group attendance and PRN sedation 78
Figure 4.4 Scatter plot diagram of group attendance and seclusion 80
xi
List of Appendices
Appendix A
Mindfulness and Sensory Modulation group program 104
Appendix B
Participant Demographic Questionnaire 239
Appendix C
Philadelphia Mindfulness Scale 244
Appendix D
Positive and Negative Affect Schedule Short Form 246
Appendix E
Arousal and Emotional Reactivity Scale 247
Appendix F
PRN Sedation Register 248
Appendix G
Seclusion Register 249
Appendix H
Sensory Defensiveness Screening for Adults 250
Appendix I
Feedback Interview Form 251
Appendix J
Participant Information Letter and Consent 254
Appendix K
Medical Clearance Form 258
xii
Chapter 1 - Introduction
1.1 Introduction
The prevalence of young adults with mental health disorders in our population is
increasing (T. Slade et al., 2009). Occupational therapists make a valuable and unique
contribution as part of a multidisciplinary team providing intervention to individuals
with mental health disorders while in acute care (Creek, 2008). Occupational
therapists assist individuals to participate in meaningful occupations to improve their
health and wellbeing (Hocking, 2009; Wilcock, 2006). These meaningful
occupations are completed by a person within a specific environment (American
Occupational Therapy Association, 2008; C. Brown, 2009). The health and wellbeing
of the individual arises from the dynamic interaction between all three components
(American Occupational Therapy Association, 2008). This is known as occupational
performance (C. Brown, 2009; C. Brown & Stoffel, 2011). Individuals with mental
health disorders may experience difficulties in occupational performance (Champagne,
Koomar, & Olson, 2010).
Occupational performance difficulties may be a result of individuals with mental
health disorders experiencing sensory modulation dysfunction. Sensory modulation
dysfunction occurs when an individual cannot modulate an appropriate response to
sensory stimulus (Abernethy, 2010; James, Miller, Schaaf, Neilsen, & Schoen, 2010;
Lane, Lynn, & Reynolds, 2010; L. Miller, Anzalone, Lane, Cermak, & Osten, 2007).
Individuals with sensory modulation dysfunction misinterpret everyday sensations as
potentially harmful. This eventuates in high levels of arousal and emotional
reactivity in the individual (Champagne, et al., 2010, p. 2). Arousal is the

physiological response of the nervous system to stimuli (Lane, et al., 2010; L. J. Miller
& Hepburn, 2004). High levels of arousal result in a sustained fight or flight response
in the individual (Champagne, et al., 2010; Costanzo, 2010). This means that the
individual experiences increased heart rate, breathing rate, perspiration and blood
pressure (Costanzo, 2010). Emotional reactivity is hypothesised to directly reflect
levels of arousal in an individual (Lane, et al., 2010). This is defined as the ability of
an individual to modulate an appropriate behavioural response to levels of arousal and
external stimuli (Jerome & Liss, 2005; Lane, et al., 2010). Individuals with sensory
modulation dysfunction have difficulty regulating and maintaining a suitable range of
emotions and behaviours (L. Miller, et al., 2007). This results in individuals living in
a constant state of anxiety, stress, disorganisation and agitation due to the over
stimulation of the fight or flight response (S. Brown, Shankar, & Smith, 2009;
Champagne, et al., 2010).
Recent research has identified a co-existence of sensory modulation dysfunction and
mental health disorders (Abernethy, 2010; Moro, 2007). Research has established this
co-existence with schizophrenia (C. Brown, Cromwell, Filion, Dunn, & Tollefson,
2002; Olson, 2010, 2011), depression (May-Benson, 2011), borderline personality
disorder (S. Brown, et al., 2009), obsessive compulsive disorder (Rieke & Anderson,
2009) and anxiety (Engel-Yeger & Dunn, 2011; Pfeiffer & Kinnealey, 2003). Further
to this, individuals with mental health disorders have a high incidence of trauma
(LeBel, Champagne, Stromberg, & Coyle, 2010). Additionally, it is hypothesised that
individuals with a history of trauma experience sensory modulation dysfunction
(LeBel & Champagne, 2010). Therefore, there is an expected link between mental
health disorders, previous experiences of trauma and the presence of sensory
2
modulation dysfunction (Champagne, et al., 2010). All of these aspects can have a
significant impact on the person. Individuals with a coexistence of sensory
modulation dysfunction and mental health disorders may experience functional and
behavioural problems which may result in occupational dysfunction. This may lead to
these individuals presenting at hospitals and being admitted to acute mental health care
units. Individuals admitted to acute care experience significant restrictions in their
environment. While in acute care, if an individuals emotional reactivity is severe,
pro re nata (PRN) sedation and seclusion are commonly used to manage its impact
(Happell & Gaskin, 2011; National Mental Health Working Group, 2005).
Pro re nata (PRN) or as needed medications are used as a first line of treatment to
manage aggressive or distressed individuals to reduce the risk of violence and harm to
themselves, other consumers and staff (Stein-Parbury, Reid, Smith, Mouhanna, &
Lamont, 2008). Seclusion is the locked confinement of a person in a room
(Department of Health, 2011). It is used to treat and protect highly agitated
individuals at risk of aggression (Happell & Gaskin, 2011). Recent research has
reported that the use of PRN sedation and seclusion has a profound negative impact on
the recovery journey of the individual (Happell & Koehn, 2010; Hilton & Whiteford,
2008; Meehan, Bergen, & Fjeldsoe, 2004). These practices also seem to be in direct
contrast to governmental policy in which it states that individuals with mental health
disorders are to receive the best possible care facilitating recovery within a least
restrictive environment framework (Happell & Koehn, 2010; Hilton & Whiteford,
2008; NSW Government, 2007; Ralph, 2000; M. Slade, 2009).
3
Recovery in mental health care is the experience of the individual with the mental
health disorder (Lloyd, Tse, & Bassett, 2004). Mental health settings should facilitate
recovery through services that support personal responsibility and empower the
individual (M. Slade, 2009). These services should be provided to individuals within a
least restrictive environment. Least restrictive environment is the principle of
providing the best possible care to individuals in the least restrictive environment
(NSW Government, 2007). This means, that the individual will receive the least
restrictive intervention in a least restrictive environment. Trauma informed care is
another principle guiding treatment in mental health care. Trauma informed care is an
understanding the psychological, physiological and social implications of the
traumatic event (Champagne, 2011). However, the use of PRN sedation and
seclusion as a first line of treatment seemingly do not support these frameworks. PRN
sedation may be detrimental to the recovery journey of the individual as it replaces
learning therapeutic activities to self-regulate levels of arousal and emotional
reactivity (Hilton & Whiteford, 2008; Stein-Parbury, et al., 2008). The use of
seclusion can be identified as another form of trauma and promotes negative feelings
in the individual (Meehan, Vermeer, & Windsor, 2000; Roberts, Crompton, Milligan,
& Groves, 2009).
However, occupational therapists in acute care provide unique interventions that are
recovery orientated, trauma informed and occur within least restrictive environments
(C. Brown & Stoffel, 2011; Kelly, Lamont, & Brunero, 2010; Lloyd, et al., 2004).
These interventions facilitate participation in occupations and encourage the personal
recovery journey of the individual (C. Brown & Stoffel, 2011; Kelly, et al., 2010).
4
Occupational therapy interventions currently being used in acute mental health care
settings are mindfulness and sensory modulation strategies.
Mindfulness is an emerging intervention in acute mental health settings. Mindfulness
is defined as being aware of the present moment and non-judgementally accepting
thoughts, feelings and behaviours (Bishop et al., 2004; deVibe, Bjorndal, Tipton,
Hammerstrom, & Kowalski, 2012; Siegel, Germer, & Olendzki, 2010). This
technique uses a psychological mechanism in which an individual has a concentrated
awareness of the immediate moment without the habitual concerns of the past or
worries for the future (Melbourne Academic Mindfulness Interest Group, 2006).
Recent research has established that mindfulness techniques have an impact on the
emotional reactivity of individuals with mental health disorders (K. W. Brown &
Ryan, 2003; deVibe, et al., 2012; Kocovski, Segal, & Battista, 2010; Mace, 2008).
Another strategy that fits well with mindfulness is sensory modulation. Both
strategies share a common focus on the use of ones senses to reduce levels of arousal
and emotional reactivity. Sensory modulation strategies aim to develop a person's
skills so they can better cope and adapt to the demands of their sensory environment
(Pfeiffer & Kinnealey, 2003). Individuals with or without sensory modulation
dysfunction can benefit from these strategies. In mental health settings, sensory
modulation strategies include the use of sensory rooms or sensory modulation
activities (Champagne & Sayer, n.d.). Current research suggests that sensory
modulation strategies are effective tools to decrease the rates of PRN sedation and
seclusion used in acute care (Champagne & Stromberg, 2004; Lee, Cox, Whitecross,
Williams, & Hollander, 2010).
5
The mindfulness and sensory modulation strategies appear to be effective in regulating
levels of arousal and emotional reactivity in individuals. Through these strategies, the
occupational therapist educates the person, adapts the environment and modifies
the occupation to optimise levels of arousal and emotional reactivity. This in turn,
improves occupational performance of the individual.
1.2 Statement of the Problem
There is developing evidence of the co-existence of mental health and sensory
modulation disorders. Occupational therapy can provide unique intervention to
individuals with this co-existence. However, there is limited empirical evidence of
occupational therapy interventions used to assist individuals to regulate levels of
arousal and emotional reactivity. Due to the paucity of research, when individuals
with sensory modulation dysfunction have behavioural problems in acute care, PRN
sedation and seclusion are used as a matter of standard practice. Therefore, in order to
inform best practice in the management of individuals with a co-existence of mental
health disorders and sensory modulation dysfunction, research needs to be conducted
to identify other alternate means of intervention. Currently, no research has been
conducted to establish whether a combination of mindfulness and sensory modulation
strategies can impact levels of arousal and emotional reactivity in young adults in
acute care.
1.3 Study Scope
The purpose of this study was to identify the impact of mindfulness and sensory
modulation strategies used with young adults in an acute mental health care facility.
The primary study aim was to evaluate the impact of a Mindfulness and Sensory
6
Modulation group program on levels of arousal and emotional reactivity. The
secondary aim of the study was to determine if the rates of PRN sedations and
seclusions reduced as individuals participated in the program.
This pilot study used a pre and post-test design to examine the impact of the
Mindfulness and Sensory Modulation group program on levels of arousal and
emotional reactivity. The research design involved the study of a single group and
examined the impact of the intervention (Corbetta, 2003; Creswell, 2009; Mertens &
McLaughlin, 1995). Another important aspect of this study was the pragmatic design
of the research. Important elements of this design was the open group policy of the
intervention and no set exclusion criteria for the sample. The intervention, the
Mindfulness and Sensory Modulation group program, ran over a three month period at
Birunji Youth Mental Health Unit. The group sessions occurred every weekday
(Monday to Friday) and for a duration of one hour.
A convenience sample of 31 participants was recruited from Birunji Youth Mental
Health Unit. The inclusion criteria was female and male participants with a diagnosis
of mental health disorders between the ages of 16 to 45 years. There was no set
exclusion criterion. Data was collected using a range of valid and reliable outcome
measures. This information was used to assess the impact of the intervention on levels
of arousal and emotional reactivity.
Upon admission, participants completed a demographic questionnaire and the Sensory
Defensiveness Screening for Adults (Moore, 2005). The Philadelphia Mindfulness
Scale (Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008) and the Positive and
7
Negative Affect Schedule Short Form (Watson, Clark, & Tellegen, 1988) was used to
assess the change over time in levels of awareness and acceptance and positive and
negative affect. Data collection occurred at baseline, after five sessions (midway),
after 10 sessions (follow up data) and upon participant discharge (additional data).
Participants completed a 10 visual analogue scales (Scott & Huskisson, 1976) to
determine the immediate impact of the intervention on levels of arousal and emotional
reactivity - the Arousal and Emotional Reactivity Scale. This outcome measure was
completed before and after each group session to quantify participants levels of
arousal and emotional reactivity. The PRN sedation and seclusion registers were
evaluated to determine whether the rates of PRN sedation and seclusion reduced in
correlation to participants attendance in the Mindfulness and Sensory Modulation
group program.
Participant information generated from the demographic questionnaire and Sensory
Defensiveness Screening for Adults was analysed using descriptive statistics. This
information provided a profile of the participants involved in the study. Descriptive
and inferential statistics were obtained from the pre and post-test outcome measures
and were analysed using the Wilcoxon signed rank test. This data was used to identify
trends to establish the impact of the intervention on arousal and emotional reactivity.
The Spearmans rank order correlation co-efficient was used to determine if there was
a correlation between group attendance and the rates of PRN sedation and seclusion.
Ethical approval was gained from the University of Western Sydney Human Ethical
Review Committee and the South West Sydney Local Health District Human Research
Ethics Committee (HREC).
8
There were few limitations associated with this study. The pre and post-test design did
not contain a control group, small numbers of participants were categorised into
dosage groups and the use of self-report subjective outcome measures introduced bias.
Due to these limitations, results cannot be generalised to the wider population and
were interpreted with caution.
However, the high incidence of mental health disorders with the possible co-existence
of sensory modulation dysfunction highlights the important need for young adults to
self-regulate levels of arousal and emotional reactivity. The combination of using
mindfulness and sensory modulation strategies may provide these individuals with
successful occupations to do this. The knowledge from this study may provide
occupational therapists with interventions that are recovery focused, trauma informed
and fit within a least restrictive environment framework (NSW Government, 2007; M.
Slade, 2009). The Mindfulness and Sensory Modulation strategies may provide an
appropriate alternative intervention to PRN sedation and seclusion.
1.4 Definition of Terms
Acute Care
Intensive treatment provided by a multi-disciplinary team to an individual who is
experiencing extensive mental health symptoms in a locked inpatient psychiatric unit.
Acceptance
One key component of mindfulness. This is the non-judgemental regulation of
recurring thoughts, feelings and behaviours of an individual while practicing the
9
component of awareness (Baer, 2003; Bishop, et al., 2004; K. W. Brown & Ryan,
2003; Mace, 2008; Siegel, et al., 2010).
Awareness
This is the focused and sustained concentration of the individual of the present
moment, monitoring internal and external stimuli (Bishop, et al., 2004; Melbourne
Academic Mindfulness Interest Group, 2006; Siegel, et al., 2010).
Arousal
The physiological reaction of the nervous system to stimuli (L. J. Miller & Hepburn,
2004).
Emotional Reactivity
The emotional reaction of the person to internal and external stimuli (Lane, et al.,
2010).
Least Restrictive Environment
This is an environment in which the best possible care is provided to the individual
with a mental health disorder (NSW Government, 2007).
Mental Health Disorder
A mental health disorder is characterised by the presence of one or more symptoms of
delusions, hallucinations, disorganised thoughts, severe disturbances of mood and
irrational behaviour (NSW Government, 2007).
10
Mindfulness
Mindfulness is a philosophy that practices awareness and acceptance (Bishop, et al.,
2004; K. W. Brown & Ryan, 2003; Germer, 2005).
PRN Sedation
Pro re nata (PRN) or as needed sedation is additional medication given to an
individual to treat or prevent the symptoms of their mental health disorder (Baker,
Lovell, & Harris, 2007).
Recovery
The unique and personal experience of the individual discovering a meaningful life
beyond their mental health disorder (Shepherd, Boardman, & Slade, 2008).
Seclusion
The sole confinement of an individual in a locked room to treat and protect highly
agitated individuals (Department of Health, 2011).
Sensory Modulation Dysfunction
Sensory modulation dysfunction is a pattern of dysfunction in which an individual
cannot modulate an appropriate response to stimuli (Abernethy, 2010; James, et al.,
2010; Lane, 2002).
Sensory Modulation Strategies
Aimed to develop a persons skills so that these individuals can adapt and cope with
the demands of their sensory environment (Pfeiffer & Kinnealey, 2003).
11
Stimuli or Stimulus
A stimulus is defined as something that evokes a specific functional reaction of a sense
which in turn induces activity in the central nervous system (Moore, 2005).
Trauma
An event that is stressful, or emotionally upsetting or an experience that produces
psychological injury (Champagne, 2011). Trauma events may include history of
physical or sexual abuse, self-harming behaviours, eating disorders, torture, multiple
hospitalisations, serious stomach or respiratory problems, serious injury or surgery,
suicide attempts, period of sensory deprivations and a traumatic birth (Moore, 2005).
Trauma Informed Care
Trauma informed care is obtaining an understanding of the holistic effects of trauma
and having an awareness of the prevalence of trauma in individuals with mental health
disorders (Borckardt et al., 2011; Champagne, 2011; LeBel & Champagne, 2010).
1.5 Structure of the thesis
The following provides a brief summary of the thesis structure:
Chapter 2: Literature Review
This chapter describes the occupational therapists role in acute mental health care, the
co-existence of mental health disorders and sensory modulation dysfunction and its
impact on levels of arousal and emotional reactivity in the individual. Chapter 2
outlines the common treatments of PRN sedation and seclusion and how these
negatively impact on the recovery of individuals. This chapter establishes the need for
12
alternative interventions to be utilised in acute care to regulate levels of arousal and
emotional reactivity in individuals, and provide an alternative intervention.
Chapter 3: Methodology
An overview of the methods used to establish the impact of the Mindfulness and
Sensory Modulation group program is given in this chapter. Chapter 3 outlines the
outcome measures, data collection, data analysis and ethics associated with the
research.
Chapter 4: Results
This chapter presents the results of the research project. It examines the results in
terms of statistical significance for each outcome measure.
Chapter 5: Discussion
The research is reviewed in the key findings. The significance of the Mindfulness and
Sensory Modulation group program is established through the discussion of the
research questions and hypothesis. Conclusions and recommendations for further
research, education and policy are given.
13
Chapter 2 Literature Review
2.1 Introduction
One out of four young adults are estimated to experience a mental health disorder
within a twelve month period (Australian Bureau of Statistics, 2007; T. Slade, et al.,
2009). Further to this, 90% of individuals with a mental health disorder have an
experience of trauma (LeBel, et al., 2010). Occupational therapists make a valuable
and unique contribution in the treatment of individuals with mental health disorders in
acute care (C. Brown & Stoffel, 2011; Creek, 2008). In recent times, researchers have
identified a co-existence of sensory modulation dysfunction and mental health
disorders (Abernethy, 2010; May-Benson, 2011; Olson, 2010, 2011). Individuals with
mental health disorders and sensory modulation dysfunction may experience
difficulties in regulating levels of arousal and emotional reactivity (S. Brown, et al.,
2009; Champagne & Sayer, n.d.). This may result in functional and behavioural
problems that are commonly managed medically in an acute care setting through
sedation and seclusion (Champagne & Stromberg, 2004). These practices are
controversial and can have a negative impact on the recovery of the individual
(National Mental Health Working Group, 2005). Therefore, recovery orientated
interventions, such as sensory modulation and mindfulness techniques may provide a
better alternative to promote a positive recovery experience.
The purpose of this chapter is to describe the role of occupational therapy in a mental
health setting, define sensory modulation, identify sensory modulation disorders and
how these influences levels of arousal and emotional reactivity. This chapter will
describe the co-existence of sensory modulation and mental health disorders and how
14
the use of sensory modulation strategies and mindfulness techniques are used to
regulate arousal and emotional reactivity. These will be discussed in detail using the
person, environment and occupation model (Law et al., 1996) utilised by occupational
therapists.
2.2 Occupational Therapy in Mental Health
Occupational therapy has a core belief that participation in meaningful occupations is
central to health and wellbeing (Hocking, 2009; Wilcock, 2006). It is through
participation that individuals engage physical and mental activity and experience
psychosocial effects that promote health and wellbeing (Hocking, 2009).
Occupational therapists believe that a persons health and wellbeing can be affected by
the complex and dynamic relationship of the person completing an occupation in an
environmental context (American Occupational Therapy Association, 2008; C. Brown,
2009). The individuals occupational performance is the result of that interaction (C.
Brown, 2009). Occupational performance is defined as the quality of an individuals
experience of their ability to choose, organise and accomplish occupations (C. Brown
& Stoffel, 2011). Occupational therapists use a person-environment-occupation (PEO)
model (Law, et al., 1996) to identify factors that influence occupational performance.
15
Figure 2.1: Person Environment Occupation (PEO) Model (Law, et al., 1996)
Person Occupation
Occupation
Performance
Environment
An occupational therapist views the person as unique. Each individual has abilities,
values, characteristics, spirituality and life experiences (American Occupational
Therapy Association, 2008; C. Brown, 2009). The person components also include
the affective, cognitive and physical abilities of the individual that may impact
occupational performance (C. Brown & Stoffel, 2011). The environment is another
factor that can create barriers or enhance occupational performance (Brown, 2009).
The environment is the physical, social, cultural and institutional context where
occupation occurs (C. Brown, 2009; C. Brown & Stoffel, 2011). Occupation is the
self-directed tasks and activities that are meaningful to the individual (C. Brown,
2009). Primary occupations include self-care, leisure and productivity (C. Brown &
Stoffel, 2011). Occupational therapists use this model to identify areas that impact
occupational performance and may be detrimental to an individuals health and
wellbeing. The focus of occupational therapy intervention is to improve occupational
performance by adapting one or more of these three components (C. Brown & Stoffel,
2011). Occupational therapy services are provided to individuals at risk of or those
who have an impairment (American Occupational Therapy Association, 2008). An
16
impairment of an individual is defined as any problem with normal psychological or
physiological functioning or bodily structures (World Health Organisation, 2002).
Impairment at this level ultimately influences a persons engagement in activity and
participation in life related occupations (World Health Organisation, 2002).
An impairment in psychological functioning is a mental health disorder (NSW
Government, 2007). A mental health disorder is characterised by the presence of one
or more symptoms of delusions, hallucinations, disorganised thoughts, severe
disturbances of mood and irrational behaviour (NSW Government, 2007). In an acute
mental health care setting, occupational therapists focus on specific person, occupation
and environmental factors that are impacted by a mental health disorder. The person
factors are cognition, motivation, sensation, emotional regulation, communication
skills, and pain management (C. Brown & Stoffel, 2011). Individuals admitted into an
acute care setting may have difficulties in managing the person factors affected by
mental health disorders (Creek, 2008). This may result in an inability to engage in
meaningful occupations. Those admitted to an acute care setting may experience a
drastic change in their physical, institutional, cultural and social environments (C.
Brown & Stoffel, 2011). All of these components may influence the individuals
occupational performance (C. Brown & Stoffel, 2011). Occupational therapy
interventions aim to balance the person, environment and occupation components to
achieve an optimal level of occupational performance (C. Brown & Stoffel, 2011).
This in turn, enhances the health and well-being of the individual (American
Occupational Therapy Association, 2008; Hocking, 2009).
17
Occupational therapists provide a variety of interventions to individuals in acute care.
In recent times, occupational therapists in acute care have identified a need to use
sensory integration interventions (Champagne, et al., 2010). Sensory integration
theory was originally developed by Jane Ayres in 1979. Sensory integration is the
neurological process that organises sensation from ones own body and the
environment. This process makes it possible to use our body effectively in our
environment (Ayres, 1979). Internal sensations from the body include proprioception
or body position, vestibular or body movement, deep pressure touch and oral motor
(Moore, 2005). External or environmental stimuli is interpreted by our sense of touch,
taste, hearing, sight and smell (Moore, 2005). Ayres original theory of sensory
integration provided a framework for occupational therapy assessment and
intervention (C. Brown & Stoffel, 2011). This theory has evolved to include recent
concepts of sensory modulation, sensory discrimination and sensory based motor
disorders (L. Miller, et al., 2007). However, occupational therapists are currently
using sensory modulation strategies in acute mental health care to increase individuals
occupational participation (Champagne & Frederick, 2011; Champagne & Koomar,
2011).
2.3 Sensory Modulation
Sensory modulation is an individuals ability to interpret internal and external stimuli
and respond appropriately to everyday situations (Champagne, 2011; Champagne, et
al., 2010; Lane, et al., 2010). Sensory modulation is defined as an individuals
capacity to regulate and organise the degree, intensity and nature of responses to
sensory input in a graded and adaptive manner (L. Miller, Reisman, McIntosh, &
Simon, 2001, p. 57). Sensory modulation occurs as both a physiological reaction and
18
a behavioural response (Champagne, 2011; L. Miller, et al., 2001). That is, the
reaction of the central nervous system to stimuli and the observed behavioural
responses (L. J. Miller & Hepburn, 2004).
2.3.1 Sensory Modulation Dysfunction
Sensory modulation dysfunction is a term used to describe the pattern of dysfunction
in which a person over or under responds to internal or external stimuli (Abernethy,
2010; James, et al., 2010; Lane, 2002). When an individual has sensory modulation
dysfunction it results in an inability of the nervous system to correctly react to stimuli
(L. Miller, et al., 2007). This incorrect reaction impacts on the individuals
behavioural response (Champagne, et al., 2010). Sensory modulation dysfunction
commonly results in high states of arousal and emotional reactivity (Champagne, et
al., 2010, p. 2).
2.3.2 Arousal
Arousal is the physiological reaction of the nervous system in response to stimuli
(Lane, et al., 2010; L. J. Miller & Hepburn, 2004). This occurs at both a cellular and
systemic level (Lane, 2002). The reaction begins when a sensory receptor is activated
by stimulus and creates a cellular response (Lane, et al., 2010; L. Miller & Lane,
2000). Over time, a neuron has the ability to modulate to stimuli. This modulation
results in an increased or decreased responsiveness. The process of habituation is the
ability of the neuron to decrease its responsiveness to stimuli and adapt to cease its
response (Dunn, 1999; Lane, 2002). A neurons modulation that increases its
responsiveness to stimulus is called sensitisation (Dunn, 1999). If the reaction is not
habituated at a cellular level, it is carried through to the central nervous system (CNS)
creating a systemic reaction (Costanzo, 2010).
19
The systemic reaction of the nervous system occurs after stimuli are interpreted in the
brain (Lane, et al., 2010; L. Miller & Lane, 2000). This interpretation sets a
foundation for appropriate levels of arousal in the CNS (Lane, et al., 2010). An
appropriate level of arousal is achieved through the act of balancing excitatory and
inhibitory outputs of the nervous system (Lane, 2002). This process is known as the
polyvagal theory; first described by Dr Stephen Porges in 1994. Polyvagal theory
explains how the sympathetic and parasympathetic branches of the automatic nervous
system regulate the mechanical process of sensory modulation (Champagne, 2011;
Schaaf, Miller, Seawell, & O'Keefe, 2003). Polyvagal theory proposes that the
physiological state of the nervous system can support or limit the range of behaviours
experienced by an individual (Porges, 2007, 2009). High levels of arousal result from
the incorrect modulation of the nervous system. Individuals with sensory modulation
dysfunction can have an over or under responsivity of their CNS to stimuli.
Over responsivity or sensory defensiveness is the most common form of sensory
modulation dysfunction in which individuals are unable to regulate these high levels of
arousal (S. Brown, et al., 2009; Champagne, 2011). Sensory defensiveness occurs
when normal stimulus, for example touch and sound, is overwhelming to the
individual due to the sensitisation of neurons (Champagne & Sayer, n.d.) and may be
misinterpreted as dangerous (Brown, et al., 2009). When this occurs the sympathetic
nervous system activates the fight or flight response (Champagne, et al., 2010). The
fight or flight response is defined as the reaction of the nervous system in response to
danger (Tortora & Derrickson, 2007). It involves the quick mobilisation of the body
for a rapid response (Costanzo, 2010). The physiological effects of the fight or flight
response includes an increased heart rate, blood pressure, ventilation and perspiration
20
(Costanzo, 2010). Individuals with sensory modulation dysfunction commonly have a
sustained fight or flight response (Champagne, et al., 2010). This sustained response
influences the behavioural responses of individuals (Champagne, 2011). Under
responsivity is the diminished response from the CNS due to the habituation of
neurons (Dunn, 1999; Rieke & Anderson, 2009). Individuals who have under
responsivity require additional or extra sensory input to gain attention or awareness of
the stimuli (Champagne, 2011; Dunn, 1999). It is hypothesised that the behavioural
responses are the observable reaction reflecting the underlying levels of arousal of the
nervous system and a persons interaction with the environment (Lane, et al., 2010).
2.3.3 Emotional Reactivity
Behavioural modulation is the individuals ability to regulate and organise emotional
responses to internal and external stimuli (Lane, et al., 2010). This is also known as
emotional reactivity. Levels of emotional reactivity should match the context of an
activity, and reflect the levels of arousal and the interaction with the environment
(Jerome & Liss, 2005; L. J. Miller & Hepburn, 2004). Individuals with sensory
modulation dysfunction, have emotional responses that are inconsistent with activity
demands and the environment (L. Miller, et al., 2007). These individuals experience
difficulty in achieving and maintaining a suitable range of emotions and behaviours.
The Sensory Processing Framework has identified four behaviours that are observed
within individuals with sensory processing dysfunction (Figure 2.2; Dunn, 1999). The
behaviours displayed act according to, or to counteract the over-responsivity or under-
responsivity levels of arousal in an individual.
21
Figure 2.2 Sensory Processing Framework (Dunn, 1999)
Act According to
Sensitivity Poor
to Sensation Registration
Over-responsivity / Under-responsivity
Low Neurological / High Neurological
Threshold Threshold
Sensation Sensation
Avoiding Seeking
Acting to
Counteract
Behaviours that result due to an individuals under-responsive levels of arousal are
poor registration and sensation seeking. Poor registration behaviours act in
accordance to the high neurological threshold. Behaviours of passively neglecting
sensory information that is often noticed by other individuals characterise this
construct (Dunn, 1999). This results in individuals missing information, appearing
disinterested, having slow responses or being apathetic (C. Brown, et al., 2002).
Sensation seeking behaviours act to counteract the decreased sensitivity of neurons
(Dunn, 1999). This involves individuals constantly seeking pleasure from stimuli and
actively creating more stimuli (Rieke & Anderson, 2009). These behaviours may
involve seeking movement and self-injuring behaviours (Champagne, 2011).
Behaviours that results due to an individuals over-responsive levels of arousal are
termed sensitivity to sensation or sensory avoiding (Dunn, 1999). Sensitivity to
sensation behaviours act in accordance to this low neurological threshold, and
individuals may display a discomfort with stimuli and react accordingly (Rieke &
22
Anderson, 2009). Distractibility, difficulty screening stimuli, appearing overwhelmed,
outbursts and discomfort with sensation characterise this behavioural construct (C.
Brown, Tollefson, Dunn, Cromwell, & Filion, 2001; Schoen, Miller, & Green, 2008).
Sensory avoiding behaviours act to counteract this low neurological threshold (Dunn,
1999). When the stimulus is overwhelming the individual may actively avoid
interacting with sensations (Rieke & Anderson, 2009). Behaviours that characterise
this construct include rigidity with movement, withdrawal or resistance to activities
and the preference to be alone (C. Brown, et al., 2001; Schoen, et al., 2008).
Observed behaviours or emotional reactivity are distinctive to an individuals sensory
processing style (Dunn, 1999). These behaviours can range from mild to severe
(Abernethy, 2010; Champagne, 2011). If the behaviours are severe they can develop
into or be displayed as symptoms of mental health disorders (Abernethy, 2010).
2.4 Sensory Modulation Dysfunction and Mental Health Disorders
The co-existence of mental health disorders and sensory modulation dysfunction has
been established. These mental health disorders include schizophrenia (C. Brown, et
al., 2002; Olson, 2010, 2011), depression (May-Benson, 2011), borderline personality
disorder (S. Brown, et al., 2009), obsessive compulsive disorder (Rieke & Anderson,
2009) and anxiety (Engel-Yeger & Dunn, 2011; Pfeiffer & Kinnealey, 2003).
The sensory processing styles of individuals with schizophrenia have been explored in
a study by Brown, Cromwell, et al. (2002). This study compared the sensory
processing styles of individuals with schizophrenia, bipolar disorder and mentally
healthy individuals using the Adult Sensory Profile. The Adult Sensory Profile is a
23
self-reported 60 item questionnaire that measures the sensory processing styles in the
four quadrants of the sensory processing framework (see Figure 2.2; Brown, et al,
2001). The results indicated that individuals with schizophrenia (n = 27) showed
higher mean scores in the quadrants of sensation avoiding and low registration (x =
40.9, p = 0.001; x = 36.9, p = 0.016 respectively); and lower mean scores in the area of
sensory seeking (x = 45.5, p = 0.001) in comparison to mentally healthy individuals
(n = 29). The researchers identified a preliminary link of sensory processing disorders
in individuals with schizophrenia; however, more conclusive research is required.
A study by Brown, Shankar and Smith (2009) assessed the sensory processing profiles
of people with borderline personality disorders (n = 9) in comparison to participants
with other mental health disorders (n = 11). Using a mixed methods approach, the
researchers collected data from participants using the Adult Sensory Profile and in-
depth interviews. The researchers concluded that individuals with borderline
personality disorder had stronger positive relationships to the sensory sensitive and
sensory avoiding constructs in comparison to other mental health disorders. Statistical
significance were not reported in this study. Results from this study must be viewed
with caution due to the small sample size.
Another study using the Adolescent / Adult Sensory Profile compared the sensory
processing styles of individuals with obsessive-compulsive disorder to the general
population (Rieke & Anderson, 2009). Fifty-one adults (n = 51) were recruited and
the data collected was compared to the statistics of the general population as reported
in the Adolescent / Adult Sensory Profile manual. Researchers used an unequal t-test
variance as sample sizes differed significantly and it provided the best control for type
24
I and type II errors. The results showed statistically significant difference (p = 0.01).
That is, adults with obsessive compulsive disorder had positive correlations with poor
registration (t = 5.26), sensory sensitivity (t = 7.22) and sensation avoiding behaviours
(t = 5.94) and negative correlations with sensation seeking behaviours (t = -3.78). Due
to the limited internal validity of the design of the study, the researchers were unable
to determine why the sample had differences in comparison to the general population
statistics. Another confounding variable that may have influenced the results is the co-
morbidity of obsessive compulsive disorder with depression, attention deficit disorder
and anxiety. The researchers identified a difference within between groups; however,
concluded that more comprehensive research is required.
A pilot study completed by Pfieffer and Kinnealey (2003) examined the relationship
between sensory defensiveness and anxiety in one sample of adults with no known
anxiety disorders. The Adult Sensory Questionnaire, Adult Sensory Interview and the
Becks Anxiety Index were used on fifteen participants (n = 15). The results showed a
significant positive correlation between sensory defensiveness and anxiety (r = 0.61, p
= 0.027). However, limitations of a small sample size and the absence of a control
group restricted the generalizability of the results. The researchers highlighted the
need for further research to be conducted focussing on individuals with clinical
anxiety, depression and sensory defensiveness.
Another study, using a case study design, was completed to examine the relationship
between sensory processing style and anxiety levels in healthy adults (Engel-Yeger &
Dunn, 2011). A case study design is used when the researcher wants to provide
descriptive information about the relationship between two variables (Creswell, 2009;
25
Mertens & McLaughlin, 1995). Israelite participants (n = 135) completed the Adult /
Adolescent Sensory Profile and the State-Trait Anxiety Inventory. A Pearsons
correlation test was used to examine the relationship between the two outcome
measures. The results highlighted a positive correlation between anxiety levels and
low registration (r = 0.19), sensation avoiding (r = 0.38) and the sensory sensitivity (r
= 0.39) quadrants of the sensory processing framework. The strongest correlations
were identified to have low neurological threshold patterns. From this, Engel-Yeger
and Dunn (2011) concluded that sensory processing styles can increase levels of
anxiety and impact on levels of emotional reactivity in individuals. Due to the study
design, data collection was only taken at one point and the timing of this varied
between participants. As such, it is likely bias was introduced into the results.
Researchers identified the need for further research into specific psychiatric
populations.
The majority of research has been conducted to identify the co-existence of mental
health disorders and specific sensory processing patterns or sensory modulation
dysfunction presence. However, it has been suggested that sensory modulation
dysfunction can cause the symptoms of mental health disorders. This suggests that
such individuals have had sensory modulation dysfunction since childhood, left
undiagnosed and untreated causing problems to be confounded in adulthood
(Abernethy, 2010). Researchers suggest that if sensory modulation dysfunction is
severe, the social, emotional and cognitive issues associated can lead to the
development of mental health symptoms (May-Benson, 2009). For example, anxiety
and depression can result from sensory modulation dysfunction (Kinnealey & Smith,
2004).
26
Although recent research appears to support the co-existence of sensory modulation
dysfunction and mental health disorders, this is not observed in all individuals (C.
Brown & Stoffel, 2011). Whether these individuals have a co-existence of both or a
mental health disorder alone, the inability to regulate levels of arousal and emotional
reactivity have significant impact on the person. This in turn affects their occupational
performance.
2.5 Impact of the Person on Occupational Performance
Occupational therapists have identified that levels of arousal and emotional reactivity
are important person components that may influence occupational performance.
Individuals with mental health disorders may experience difficulty with emotional
regulation due to the nature of the mental health disorders (C. Brown & Stoffel, 2011).
Impairment of emotional reactivity is a core symptom in bipolar disorder, borderline
personality disorder and anxiety disorders (C. Brown & Stoffel, 2011; NSW
Government, 2007). Individuals with sensory modulation dysfunction have an
impaired ability to regulate levels of arousal impacting on their emotional reactivity
(May-Benson, 2011). In addition to this, individuals with a co-existence of mental
health disorders and sensory modulation dysfunction experience the impact of all these
symptoms. This may result in the development of behavioural problems (van der
Kolk, 2006). These individuals experience an increase of stress (Champagne, 2011),
irrational thoughts and disorganisation (Watling, Bodison, Henry, & Miller-Kuhaneck,
2006) which in turn may result in agitation and disruptive behaviours (May-Benson,
2011).
27
These individuals have an inability to appropriately interpret their environment and
engage in occupation. This results in occupational dysfunction. Individuals who
experience occupational dysfunction have a decreased level of occupational
performance, health and wellbeing. Behavioural and functional problems may result
from this and lead to their presentation to hospitals, admission to acute care and in
extreme cases interventions of sedation and seclusion (Champagne & Sayer, n.d.).
2.6 Sedation and Seclusion
2.6.1 Sedation
Pro re nata (PRN) or as needed medications are used as a first line of treatment for
individuals in acute care to prevent or treat symptoms of mental health disorders
(Baker, et al., 2007; Dean, McDermott, & Marshall, 2006). PRN medication is used in
conjunction with regular medications and is administered by registered nurses using
clinical rationale (Hilton & Whiteford, 2008; Stein-Parbury, et al., 2008). This clinical
rationale determines that medications need to be administered promptly to aggressive
or distressed individuals to reduce the risk of violence and harm to themselves, other
consumers and staff (Stein-Parbury, et al., 2008). It is estimated that approximately
80% of Australian consumers receive PRN medication while in acute care (Baker, et
al., 2007; Dean, et al., 2006). Some of the reasons for PRN medication use in acute
care is to decrease aggression, agitation, insomnia, worried or anxious behaviours,
pain and at patients request (Baker, et al., 2007; Dean, et al., 2006).
A retrospective medical record audit of four acute mental health settings was
conducted in Australia, to provide a detailed description of the use of PRN
medications (Stein-Parbury, et al., 2008). The study investigated individuals who
28
were admitted to four mental health acute care units in Sydney over a two month
period. These individuals (n = 420) were admitted for a period of time greater than 24
hours. The results of this study identified that eighty four per cent (84%) of
individuals received PRN sedation during their stay in acute care. Of those eighty four
per cent (84%), ninety three per cent (93%) were already on other medications. It was
reported that sixty per cent (60%) of PRN treatments were initiated by nursing staff in
comparison to the ten per cent (10%) of treatments requested by patients and thirty per
cent (30%) was not documented. The researchers identified that the most common
documented reasons for PRN medication prescription was mood disturbances (21.8%),
threatening behaviour (21.6%) and agitation (17.9%). Other documented reasons
included cognitive disturbances (9.9%), insomnia (7.7%), behavioural disturbances
(3.7%), psychotic symptoms (3.3%), and other (14.1%). PRN medication is frequently
used to control disruptive behaviour and may be used in conjunction with seclusion if
required (Hilton & Whiteford, 2008).
2.6.2 Seclusion
Seclusion is used in acute care to treat and protect highly agitated individuals and
those at risk of causing harm to others or themselves (Happell & Gaskin, 2011; Lee, et
al., 2010). Seclusion is defined as the sole confinement of a person at any hour in a
room with windows and doors locked from the outside (Department of Health, 2011).
Three important elements of seclusion are containment, isolation and reduction in
stimuli (Meehan, et al., 2000). It is suggested that seclusion provides a calm,
protected, safe and contained environment by extensively restricting an individuals
freedom (Department of Health, 2011).
29
A cross-sectional research study of eleven mental health inpatient units was conducted
across Australia (Happell & Gaskin, 2011). The aim was to undertake a large scale
study to gain knowledge of the rates of seclusion and associated factors leading to an
instance of seclusion. Throughout the study, 295 (6.8%) individuals were secluded out
of the 4,337 individual episodes of care provided at the mental health units. Of those
295 individuals, fifty five per cent (55.9%) were secluded on one occasion and almost
all (86.4%) had a length of time of 4 hours or less in seclusion. However, these
statistics were lower than national statistics because the acute care settings were
involved in another project aimed at reducing the use of seclusion. National statistics
report that ten per cent (10%) of all patients admitted into acute care are secluded
(Department of Health, 2011). Thirty-one per cent (31%) of those individuals have
two or more episodes of seclusions. The average length of stay in seclusion in
Australian hospitals is 4.82 hours (Roberts, et al., 2009).
Sedation and seclusion are commonly utilised to reduce or prevent the symptoms of
mental health disorders and to manage behaviours (Baker, et al., 2007; Happell &
Gaskin, 2011; Hilton & Whiteford, 2008). The need for sedation and seclusion use in
acute care arises from the complex interaction between the individual, environment
and staff (Meehan, et al., 2000). Individuals admitted to acute care have a drastic
change in their environments. This environment is restricted and controlled through
the medical management of individuals symptoms using sedation and seclusion (C.
Brown & Stoffel, 2011; Lloyd, Waghorn, & Williams, 2008; Shepherd, et al., 2008).
The use of sedation and seclusion as medical management interventions has been
reported to have a negative impact on the person. It is questionable why these
30
interventions are used as standard treatment, when individuals in acute care are in a
locked, confined environment.
2.7 Impact of the Environment on Occupational Performance
The use of sedation and seclusion has been shown to have a negative impact on an
individuals recovery journey (National Mental Health Working Group, 2005). The
use of PRN medication may ultimately be at the detriment of the person as it replaces
the use of therapeutic occupations in which coping and life skills are learnt (Hilton &
Whiteford, 2008; Stein-Parbury, et al., 2008). This strategy decreases a persons
agency and personal empowerment. The restrictions of the seclusion room
environment have a significant impact on the person. The use of sedation and
seclusion significantly alters the capacities of the person, limits occupations and
restricts their environment (Happell & Koehn, 2010; Hilton & Whiteford, 2008;
Meehan, et al., 2004). This may result in occupational deprivation which has
significant implications on occupational performance. Sedation and seclusion are in
direct contrast to personal recovery and least restrictive environment frameworks that
are established in policy as guidelines for care (Happell & Koehn, 2010; Hilton &
Whiteford, 2008; NSW Government, 2007; Ralph, 2000; M. Slade, 2009).
Researchers have shown the use of seclusion has a direct negative impact on the
emotions of an individual in acute care. A qualitative study was conducted to explore
patients lived experiences and perceptions of seclusion (Matinez, Grimm, &
Adamson, 1999). Data was collected from participants (n = 69) through a written
survey and one focus group discussion. From the results, emotions of neglect,
vulnerability, worthlessness, feeling bad, being punished and a loss of control were
31
experienced by individuals (Meehan, et al., 2000; Roberts, et al., 2009). The isolation
experienced by individuals was the opposite of what patients believed they needed at
the time. Seclusion has been identified as a form of trauma (LeBel & Champagne,
2010; Lee, et al., 2010; Matinez, et al., 1999).
2.8 Recovery
Recovery in mental health is concerned with the personal and unique experience of the
individual with the mental health disorder (Lloyd, et al., 2008; M. Slade, 2009).
Personal recovery is an ongoing process of an individual adjusting attitudes, beliefs
and goals to the challenges of daily living with a mental health disorder (Ralph, 2000;
Shepherd, et al., 2008; Swarbrick, 2009). It is the journey that an individual
undertakes to build a meaningful life for themselves beyond their mental health
disorder (Shepherd, et al., 2008). Four important themes of recovery are finding and
maintaining hope, positive self-identity, building a meaningful life and taking personal
responsibility and control (Ralph, 2000; M. Slade, 2009). Recovery orientated
services should support personal responsibility, positive identity, develop agency,
hope and empower the individual (M. Slade, 2009). The development of these
components is essential to the process of recovery (Ralph, 2000).
Recovery orientated services need to be conducted in a least restrictive environment.
The Mental Health Act (2007) states that a people in mental health care should
receive the best possible care and treatment in the least restrictive environment
enabling care and treatment to be effectively given (p.36). This means that any
alternative, least restrictive intervention that does not require sedation or seclusion of
the individual should be tried in order to manage uncontrolled behaviour (Kozub &
32
Skidmore, 2001). Trauma informed care closely aligns to the recovery and least
restrictive environment frameworks. Trauma informed care is an understanding of the
holistic effects of trauma and obtaining an awareness of the prevalence of trauma in
individuals with mental health disorders (Borckardt, et al., 2011; Champagne, 2011;
LeBel & Champagne, 2010). Trauma informed care is person centred care
(Champagne, 2011).
Occupational therapists provide recovery orientated, trauma informed care, in a least
restrictive care environment in acute mental health care as a part of a multidisciplinary
team (Lloyd, et al., 2004). The core belief of occupational therapy supports the
process of recovery in individuals (C. Brown & Stoffel, 2011). That is, the process of
recovery in an individual can be supported through the engagement in meaningful
occupations (C. Brown & Stoffel, 2011).
2.9 Impact of Occupation on Occupational Performance
The facilitation of participation in occupation is a fundamental component of the
recovery journey of individuals in acute care (Kelly, et al., 2010). Researchers
interviewed five participants to explore the relationship between occupation and
recovery (Kelly, et al., 2010). The researchers identified that engagement in
occupation facilitated the participants journey of recovery. The participants identified
that participation in occupation involved taking personal responsibility, making active
choices, being empowered and searching for hope and meaning. The researchers
concluded that involvement in occupation provided an opportunity for individuals to
re-establish routines, feel meaningful, have purpose, be empowered and provide an
33
environment of social interaction. The use of occupation was fundamental to the
development of recovery in individuals with mental health disorders.
Occupational therapy in acute care can facilitate recovery by providing individuals
with occupational choice. Through the occupational therapy process individuals are
given an opportunity to choose occupations that are meaningful to them (C. Brown &
Stoffel, 2011). Occupational choice is guided by the individuals awareness of their
capacities, their personal interests and goals (Creek, 2008). Further, the occupational
therapist can modify the environment, provide intervention to the person and adapt the
occupation to ensure appropriate levels of occupational performance in the individual
(American Occupational Therapy Association, 2008). Through the engagement in this
process, an individual can accept and learn techniques to help manage their symptoms
while in acute care and begin their process of recovery (C. Brown & Stoffel, 2011;
Shepherd, et al., 2008). Current occupational therapy interventions that provide
occupational choice to individuals wanting to manage their own levels of arousal and
emotional reactivity are mindfulness and sensory modulation strategies.
2.10 Mindfulness
Mindfulness is a philosophy concerning the practices of awareness and acceptance
(Bishop, et al., 2004; K. W. Brown & Ryan, 2003; Germer, 2005). Awareness is the
ability of an individual to be consciously aware of the present moment, monitoring
internal and external stimuli (Bishop, et al., 2004; Harris, 2009; Melbourne Academic
Mindfulness Interest Group, 2006; Siegel, et al., 2010). Acceptance is to non-
judgementally regulate the habitual thoughts, feelings or concerns of the past and
worries of the future (Baer, 2003; Bishop, et al., 2004; K. W. Brown & Ryan, 2003;
34
Mace, 2008; Siegel, et al., 2010). Mindfulness incorporates the use of senses while
practicing awareness and acceptance (Coffey, Hartman, & Fredrickson, 2010;
Didonna, 2010; Melbourne Academic Mindfulness Interest Group, 2006).
Mindfulness is a psychological mechanism that works through the practice of paying
attention in a particular way, on purpose, to the present moment (Melbourne
Academic Mindfulness Interest Group, 2006, p. 288). Through this process,
individuals learn to regulate thoughts, feelings and emotions. The practice of paying
attention in a particular way, involves the regulation of the way in which attention is
held (Coffey, et al., 2010; Teasdale, 1999). This cognitive process of monitoring
attention is a necessary development in understanding that thoughts are transient
entities and are not necessarily a representation of reality (Mace, 2008; Melbourne
Academic Mindfulness Interest Group, 2006). Another form of attention in
mindfulness is the practice of paying attention on purpose (Coffey, et al., 2010). The
maintenance of attention on the present moment increases the ability of individuals to
identify any deviations from this (Melbourne Academic Mindfulness Interest Group,
2006). The benefit of this is that it reduces habitual thought patterns that are evident in
individuals with mental health disorders (Brown & Ryan, 2003).
Constant attention on the present moment requires the acknowledgement of both
negative or positive thoughts and feelings that may appear during this time
(Melbourne Academic Mindfulness Interest Group, 2006). These negative thoughts
should be considered, tolerated and dealt with non-judgementally (Didonna, 2010).
An attitude of openness and receptivity to these thoughts, behaviours and attitude
should be obtained, rather than the habitual maladaptive responses such as judgement
35
(Coffey, et al., 2010). By reducing these maladaptive responses, mindfulness
enhances appropriate cognitive and behavioural responses (Melbourne Academic
Mindfulness Interest Group, 2006).
The practice of mindfulness has an extensive impact on emotional regulation through
the alteration of thoughts and behaviours in individuals with mental health disorders
(K. W. Brown & Ryan, 2003; deVibe, et al., 2012; Mace, 2008; Melbourne Academic
Mindfulness Interest Group, 2006). Mindfulness aims at increasing levels of
acceptance and awareness in the person by engaging in occupations that utilise the
senses (Coffey, et al., 2010; Didonna, 2010). Through this the individual has an
increased ability to tolerate negative emotions, control emotional reactivity and
identify habitual thoughts (Baer, 2003; Coffey, et al., 2010; deVibe, et al., 2012;
Shapiro, Carlson, Astin, & Freedman, 2006). This in turn reduces psychological
distress experienced in individuals with mental health disorders (Coffey, et al., 2010).
A number of preliminary research studies have identified that mindfulness techniques
result in decreased levels of psychological distress and symptoms in individuals with
anxiety (Davis, Strasburger, & Brown, 2007; Greeson & Brantley, 2010); psychosis
(Chadwick, Taylor, & Abba, 2005); depression (Klainin-Yobas, Cho, & Creedy, 2012;
Teasdale et al., 2002) and borderline personality disorder (Mace, 2008). Another
intervention that complements mindfulness and enhances occupational performance is
sensory modulation strategies. Preliminary research of sensory modulation strategies
has highlighted its effectiveness in controlling levels of arousal and emotional
reactivity in individuals with mental health disorders (Champagne, 2011; Champagne
& Sayer, n.d.).
36
2.11 Sensory Modulation Strategies
Sensory modulation strategies aim to develop and enhance a person's skills so they can
better cope and adapt to the demands of their environment (Pfeiffer & Kinnealey,
2003). Interventions based on sensory modulation principles are specifically designed
to stimulate and challenge the senses. Occupational therapists assist the individual to
adapt to their environment or make the best person-environment match to support the
individuals sensory processing style (C. Brown, 2001; Champagne, 2011). That is,
levels of arousal in the individual are challenged or supported by environmental
strategies. Individuals with or without sensory modulation dysfunction can benefit
from this (Champagne, et al., 2010; Dunn, 2009). Sensory modulation strategies
provide opportunities to self-regulate, learn and engage in social interaction while
fostering empowerment, safety and trust in the individual (Champagne, 2011). This
corresponds well with the recovery model by empowering the individual, supporting
the development of self-management skills, fostering personal responsibility and
supporting a positive identity (M. Slade, 2009).
Sensory modulation strategies in mental health include the use of sensory rooms and
the use of sensory activities on an individual or group basis (Champagne & Sayer,
n.d.). Sensory rooms and sensory activities have an increasing use within mental
health care system (Champagne, 2011; Champagne & Stromberg, 2004). Sensory
rooms are specifically designed to address all aspects of the sensory system (touch,
sight, smell, movement and hearing) through environmental and equipment modalities
(Champagne & Stromberg, 2004). Sensory activities are specifically designed to
regulate levels of arousal and emotional reactivity through the modulation of the
senses (May-Benson, 2009). These activities include the development of sensory
37
diets based on sensory preferences with a daily routine and the use of sensory
modalities, for example, weighted vests and weighted blankets (Champagne, et al.,
2010; May-Benson, 2009).
There is limited empirical evidence investigating the effectiveness of sensory
modulation strategies for use within a mental health population. However, preliminary
research is showing positive results. Champagne and Sayer (n.d.) conducted a quality
improvement study examining the possible benefits of the use of a sensory room in
acute mental health care. Overall, eighty nine per cent (89%) of participants (n = 47)
reported positive changes in levels of distress after leaving the sensory room. The
researchers also stated that the rates of seclusion decreased by forty per cent (40%)
throughout the 12 month study duration. However, this study was unable to
demonstrate a direct correlation to the use of sensory modulation strategies due to
other confounding variables.
A pilot study assessing the impact of sensory integration treatment protocol on adults
(n = 15) with sensory defensiveness and anxiety was conducted by Pfeiffer and
Kinnealey (2003). The participants completed an individualised self-treatment
protocol for one month. The results from the Beck Anxiety Inventory and the Adult
Sensory Interview were compared at pre and post-test scores. The researchers
identified that the use of a sensory treatment protocol was successful in decreasing
sensory defensiveness (p = 0.048) and anxiety levels (p = 0.0453). Due to its design,
this research study was able to establish an impact of the sensory integration treatment
protocol. However, further rigorous research with a larger sample size and control
group needs to be completed to establish appropriate effectiveness.
38
Sensory modulation strategies are aimed at managing the person components of
arousal through the adaptation of the environment and occupation for the purpose of
increasing occupational participation (Champagne & Stromberg, 2004; Kocovski, et
al., 2010). Another intervention that complements sensory modulation strategies and
enhances occupational performance is mindfulness techniques. Preliminary research
of mindfulness techniques has highlighted its effectiveness in controlling emotional
reactivity in individuals with mental health disorders (Kocovski, et al., 2010;
Treadway & Lazar, 2010).
2.12 Occupational Therapy Intervention and Occupational Performance
Mindfulness and sensory modulation strategies appear to be effective interventions in
regulating levels of arousal and emotional reactivity. Mindfulness aims at increasing
levels of awareness and acceptance of emotional reactivity in the person while using
occupations that engage the senses. Sensory modulation strategies assist the
individual to modulate the person components of arousal using environmental and
occupational strategies. These strategies can create the optimal zone of arousal and
emotional reactivity in individuals. Through combining mindfulness and sensory
modulation strategies, individuals may experience optimal levels of occupational
performance (Figure 2.3).
39
Figure 2.3 An illustrative diagram representing how the combination of mindfulness
and sensory modulation strategies could assist in regulating levels of arousal and
emotional reactivity.
Mindfulness Sensory
Emotional Modulation
Reactivity Arousal
Optimal level of occupational performance
Currently, there is a paucity of research in using the combination of sensory
modulation and mindfulness strategies to regulate levels of arousal and emotional
reactivity in young adults in acute care. Therefore, research needs to be conducted
into these strategies that may provide an alternate means of intervention to sedation
and seclusion; and support the recovery of the individual. This study aims to
contribute to the body of knowledge by identifying the impact of Mindfulness and
Sensory Modulation group program on regulating levels of arousal and emotional
reactivity in young adults within acute care.
2.13 Conclusion
2.13.1 Significance of the Study
The results from this study will potentially identify an alternative means of
intervention to assist individuals in acute care to self-regulate sensory information and
normalise levels of arousal (Pfeiffer & Kinnealey, 2003). The use of mindfulness
40
strategies will potentially reduce anxiety, stress reactivity and increase emotional
stability (Kocovski, et al., 2010; Treadway & Lazar, 2010). These strategies provide a
less invasive intervention in comparison to the standard practice of seclusion and PRN
sedation.
2.13.2 Research Questions
I. To investigate if participating in a Mindfulness and Sensory Modulation group
program can have an impact on an individuals levels of arousal
II. To determine if participating in a Mindfulness and Sensory Modulation group
program can have an impact on an individuals levels of emotional reactivity
III. To assess if participating in a Mindfulness and Sensory Modulation group
program changes the use of PRN sedation
IV. To evaluate if participating in a Mindfulness and Sensory Modulation group
program impacts on rates of seclusion
2.13.3 Research Hypothesis
It is hypothesised that participation in the mindfulness and sensory modulation group
program will reduce the levels of arousal and emotional reactivity of participants. It is
further hypothesised that participants in the program will require fewer episodes of
PRN sedation and seclusion than patients who do not participate in the program.
41
2.13.4 Expected Outcomes
The expected outcomes of this study include:
I. The development and implementation of a Mindfulness and Sensory
Modulation group program in an acute care setting
II. Establish that participation in the Mindfulness and Sensory Modulation group
program will have an impact on an individuals levels of arousal and emotional
reactivity.
III. Determine that those individuals who participated in the Mindfulness and
Sensory Modulation group program will have lower rates of PRN sedations
and seclusions than those who do not participate in the group program.
2.14 Synopsis
The aim of occupational therapy services in acute care is to increase an individuals
occupational performance through participation in meaningful activity. An
occupational therapist achieves this through adapting the occupation, modifying the
environment or providing intervention to the person. The core belief of occupational
therapy supports the process of recovery, in which individuals can be supported
through the engagement in meaningful occupations.
Individuals with sensory modulation dysfunction, mental health disorders or a co-
existence of both, may experience difficulties in managing their levels of arousal and
emotional reactivity. This can result in occupation dysfunction and behavioural
problems in the person. The environmental medical management of these symptoms
in acute care is the use of sedation and seclusion. This has a negative impact on the
individual through occupational deprivation.
42
However, occupational therapists in acute care provide interventions that support the
recovery process of individuals. Through occupational choice and the engagement of
meaningful occupations, the individual has a positive recovery journey. Such
interventions used in acute care are sensory modulation and mindfulness strategies.
This study aims to establish whether the use of sensory modulation and mindfulness
strategies have an impact on levels of arousal and emotional reactivity in young adults
in acute care.
43
Chapter 3 Methodology
3.1 Introduction
The combination of mindfulness and sensory modulation strategies is a unique
approach and may assist individuals in acute care to self-regulate levels of arousal and
emotional reactivity. The expected outcomes of this study was to implement and
evaluate the use of a mindfulness and sensory modulation group in acute care;
establish whether it has an impact on levels of arousal and emotional reactivity of
participants and whether involvement in the group reduces rates of sedation and
seclusion. This chapter will outline and describe the research design, sampling and
recruitment, outcome measures, intervention and data analysis used in the research
process.
3.2 Study Design
A quasi-experimental design was used to examine the impact of the mindfulness and
sensory modulation group on levels of arousal and emotional reactivity in young
adults with mental health disorders. Quasi-experiments are almost true experiments
that contain treatments, outcome measures and experimental units (Corbetta, 2003;
Herzog, 1996; Mertens & McLaughlin, 1995). This research used a single group pre
and post-test design (Figure 3.1) to examine the impact of the independent variable on
dependent variables within a given population (Corbetta, 2003; Creswell, 2009; Mark
& Reichardt, 2009; Mertens & McLaughlin, 1995). Participants in this design are
measured on dependent variables, receive the independent variable or intervention,
and are measured on dependent variables post-test. If a change is noted within the pre
and post-test scores, it is suggested that it is a direct result of the independent variable
44
(Mark & Reichardt, 2009). The independent variable in this research is the
Mindfulness and Sensory Modulation group program (see Appendix A). The
dependent variables are levels of arousal and emotional reactivity and the given
population is young adults with mental health disorders.
Figure 3.1: Research Design Single Group Pre and Post-Test Design
OXO
O = Pre and post-test measurement of dependent variable
X = Independent Variable or Intervention
A quasi-experimental design is also selected when a researcher is expanding the
knowledge of an intervention (Mark & Reichardt, 2009; Mertens & McLaughlin,
1995). As this intervention is the first of its kind, little is known of the impact it will
have on participants. The quasi experimental design was preferred as this research
aimed to increase the knowledge of this intervention and highlight the need for further
rigorous research. Another important aspect was the pragmatic design of the study.
Due to the setting of the study, an acute locked mental health unit, it was important to
be realistic regarding the expectations of staff and participants.
The intervention was a group program consisting of ten, one hour sessions that
contained mindfulness and sensory modulation strategies. Participants were recruited
from Birunji Youth Mental Health Unit in Campbelltown, New South Wales.
Demographic information (see Appendix B) including age, gender, mental health
diagnosis, social environment, and education / employment status was collected.
45
Three outcome measures were used to evaluate the primary aim of the study, the
impact on levels of arousal and emotional reactivity. The Philadelphia Mindfulness
Scale (see Appendix C) and the Positive and Negative Affect Schedule Short Form
(see Appendix D) were used to provide information of the change over time in
participants. These outcome measures were taken at baseline, midway at the
completion of 5 sessions, follow up at the completion of 10 sessions and additional
data on participants at discharge. A visual analogue scale, the Arousal and Emotional
Reactivity Scale (see Appendix E), was developed and used to evaluate the immediate
impact of the intervention. The secondary aim of reduced PRN sedation and seclusion
rates were analysed through the clinical staff registers (see Appendix F and G). In
addition to this, feedback was sought from participants regarding their experience of
the group.
This pre and post-test design was used to address the following research questions:
I. To investigate if participating in a Mindfulness and Sensory Modulation group
program can have an impact on an individuals levels of arousal
II. To determine if participating in a Mindfulness and Sensory Modulation group
program can have an impact on an individuals levels of emotional reactivity
III. To assess if participating in a Mindfulness and Sensory Modulation group
program changes the use of PRN sedation
IV. To evaluate if participating in a Mindfulness and Sensory Modulation group
program impacts on rates of seclusion
46
3.3 Sampling and Recruitment
3.3.1 Sampling
Participants from Birunji Youth Mental Health Unit were recruited for this study.
Birunji Youth Mental Health Unit located in South Western Sydney and is a 20 bed
mental health unit that provides clinical care for young adults with acute mental health
disorders (Sydney South West Area Health Service, 2010). Birunji Youth Mental
Health Unit is staffed with medical officers, clinical staff, social workers and an
occupational therapist, psychologist and diversional therapist (Sydney South West
Area Health Service, 2009). A wide range of services are provided by this
multidisciplinary team. The occupational therapist provides individual and group
interventions including self-care and other instrumental activities of daily living
contributing to health and wellbeing. Birunji Youth Mental Health unit provides
support and care for individuals diagnosed with schizophrenia, schizoaffective
disorder, psychosis, depression, bipolar disorder and other mental health disorders.
This research process used a convenience sample. A convenience sample is when
participants are recruited to a study due to their ease of data for researchers (Battaglia,
2008; Henry, 2009). This sampling technique matched the pragmatic research design
(Battaglia, 2008; McMurray, Pace, & Scott, 2004). However, a convenience sample is
not representative of the general population (Battaglia, 2008).
Researchers conducted a sample size power calculation to ensure that the study had
enough power to conclude correct results. The power of a research study is the
probability of correctly identifying that the results are statistically significant (Aron,
2008; E. Whitley & J. Ball, 2002). This is, the act of balancing type I and type II error
47
in the study design (McMurray, et al., 2004). Type I error is accepting the results as
statistically significant when this is not the case (Aron, 2008; McMurray, et al., 2004).
Type II error is concluding the results are not statistically significant, when in fact, the
results are (McMurray, et al., 2004). The power of a study should be set at 0.8 or
above (Aron, 2008). One technique of increasing the power of the study is to increase
the sample size (Aron, 2008; E Whitley & J. Ball, 2002a). It was calculated, with an
alpha set at 5%, an effect size of 0.8 and power of 0.95, that a total of 20 participants
would be necessary to detect a clinically worthwhile effect.
3.3.2 Recruitment
All consumers admitted to the Birunji Youth Mental Health Unit were invited to
participate in the research study. The inclusion criteria for this study were female and
male participants with a diagnosis of a mental health disorder, between the ages of 16-
45 years and receiving treatment at Birunji Youth Mental Health Unit. Due to the
pragmatic design of the study, there was no set exclusion criteria. Participants did
require medical clearance from their treating physician to participate.
All researchers were responsible for the recruitment process. Recruitment involved
posting flyers advertising the times of the group in the main meeting area, living area
and dining room. Interested participants were directed to contact the research
associates and read the participant information letter for more information. During
initial contact with associate researcher, participants completed the participant consent,
demographic data, sensory screening and baseline data collection. At each morning
meeting, the group was advertised to recruit new people and to serve as a reminder for
48
participants. Before each session, the researchers invited all consumers on the ward to
attend the Mindfulness and Sensory Modulation group.
3.4 Intervention Mindfulness and Sensory Modulation Group
The intervention, the Mindfulness and Sensory Modulation group program, was
evaluated over a three month period at Birunji Youth Mental Health Unit. The
program consisted of 10 groups on a fortnightly cycle. That is, one to five sessions
running in the first week, followed by sessions six to ten in the second week (Monday
to Friday). Each group ran for the duration of one hour (Table 3.1).
49
Table 3.1: Mindfulness and Sensory Modulation Group Program Grid
PHASE 1: PHASE 2: PHASE 3: PHASE 4: PHASE 5:

CENTERING MINDFUL SENSORY MINDFUL REPLACING
AWARENESS AWARENESS ACCEPTANCE MAL-
ADAPTIVE
BEHAVIOU
RS WITH
MINDFUL
AND
SENSORY
STRATEGIE
Session 1 Mindful Mindful Bean Bag Discussion Exploring sensory
Stretches Tea/Hot Tapping diets
Deep Chocolate
Breathing
Session 2 Mindful Mindful Resistance Discussion Write Your Worry
movements Looking Band Exercises Away
Session 3 Mindful Mindful Medicine ball Discussion What would you

Stretches Walking exercises do if?
Deep
Breathing
Session 4 Mindful Mindful Deep Pressure Discussion Goals for
movements Listening Hand Massage Discharge
Session 5 Mindful Mindfulness of Wall Exercises Discussion Exploring

Stretches Sound Emotions
Deep Meditation
Breathing
Session 6 Mindful Mindful Tasting Sun Salutations Discussion Explore Sensory
movements Kits
Session 7 Mindful Mindfulness of Exercise Discussion Social Skills

Stretches Breath Circuit
Meditation
Session 8 Mindful Mindful Balance Discussion Exploring our
movements Smelling Routine Senses
Session 9 Mindful Mindfully Self-Foot Discussion Getting Ready for

Stretches Eating Massage Discharge
Deep Chocolate
Breathing
Session 10 Mindful Mindful Touch Dumbbell Discussion Assertiveness
movements Weights
50
Each session was facilitated by a mental health professional (occupational therapist,
registered nurse, social worker or a diversional therapist) employed at Birunji Mental
Health Unit who had undergone training in the Mindfulness and Sensory Modulation
Group Program. The training consisted of a one day workshop in which facilitators
were provided with theoretical and practical education on mindfulness and sensory
modulation strategies, practiced components of the program and received training and
feedback on the use of the outcome measurements.
The group program aimed to provide mindfulness and sensory modulation activities
that participants could use to self-regulate their levels of arousal and emotional
reactivity. The program was developed using evidence and expert clinical knowledge
provided by senior occupational therapists. To date, majority of the research on
sensory modulation techniques has had a paediatric focus (May-Benson, 2009). This
has resulted in the use of age inappropriate sensory activities used in adult mental
health settings (May-Benson, 2009). For example, the use of weighted stuffed toy
dogs, ribbon waving, parachute exercises and pinwheels (Champagne, 2011; Moore,
2005). It was important that activities selected for the Mindfulness and Sensory
Modulation group program would be age appropriate and normalised to increase
acceptability and participation (May-Benson, 2009). Sensory modulation strategies
selected consisted of alerting and calming occupations. The mindfulness techniques of
awareness and acceptance were incorporated into each of the sensory modulation
strategies.
The Mindfulness and Sensory Modulation group program aimed to promote
mindfulness in aspects of everyday life using occupations that engage the senses
51
(Didonna, 2010; Melbourne Academic Mindfulness Interest Group, 2006; Nhat Hanh,
2009). These everyday sensory occupations included the use of walking, eating,
breathing and movements (Nhat Hanh, 2008, 2009). Researchers have cautioned
against using certain meditation techniques of mindfulness with vulnerable people and
those at risk of or experiencing active psychosis (Chadwick, et al., 2005). It was
important that the mindfulness components used in the program were grounded in
reality by using the sensory occupations (Mace, 2008). Figure 3.2 pictorially
highlights the unique contribution of each technique used in the program to create the
optimal level of occupational performance in participants.
Figure 3.2 Techniques of Mindfulness and Sensory Modulation used in the program
Mindfulness Sensory
Modulation
Awareness
Alerting /
Acceptance Calming
Occupations
Optimal level of occupational performance
An open group policy was designed for the mindfulness and sensory modulation
group. That is, participants had the option of attending the group when it was
convenient. This was used to account for the demands of working within the context
of a mental health unit, and the vulnerability of this participant group. Participants
were encouraged to attend each session, however, working within this setting, it was
expected that due to fluctuating mental state participants would not be available to
attend all sessions. The open group policy accounted for the vulnerability of
52
participants. That is, if participants were too unwell for a session, they were free not
to attend that session and re-join when feeling well.
An additional aspect of the intervention was a sensory kit being kept on the ward in
the nurses station. The purpose of this kit was to provide individuals with an option
of a least restrictive care intervention before PRN sedation and or seclusion was used.
The kit was located at the nurses station and contained instructional cards and
equipment. Training was provided to clinical staff to suggest to participants a
mindfulness and sensory modulation strategy in the first instance, prior to resorting to
PRN sedation.
3.5 Instruments
A variety of outcome measures and a screening tool was used. The Sensory
Defensiveness Screening (see Appendix H) was used as a screening tool to ascertain if
participants were identified to have sensory defensiveness (Moore, 2005). The
Philadelphia Mindfulness Scale (PHMLS) and the Positive and Negative Affect
Schedule Short Form (PANAS-SF) were used to evaluate the change over time in
levels of emotional reactivity. Visual analogue scales were used to assess the
immediate impact of the intervention on levels of arousal and emotional reactivity.
All outcome measures were chosen because of to their short administration timing and
user friendly language which reduced participant burden. Baseline data collection
took approximately 30 minutes to complete. All participants were asked to provide
verbal feedback interview (see Appendix I) on their experiences of participating in the
Mindfulness and Sensory Modulation group program.
53
3.5.1 Sensory Defensiveness Screening for Adults
The Sensory Defensiveness Screening (see Appendix H; Moore, 2005) is a two part
measure used to identify the presence of sensory defensiveness and occupational
implications for participants. This screening tool also identifies any trauma that the
participant might have experienced in their past. Part one contains 50 items which
participants circle either yes or no, indicating their initial response to the listed sensory
behaviours. The score is the addition of the number of yes responses out of 50. The
higher number of yes responses indicates an increase of sensory defensiveness in
participants.
Part two, has two sections. The first section consists of nine statements indicating the
functional implications of sensory defensiveness and identifies a history of trauma in
participants. Participants circle a yes and no response to the identified occupations
that are impacted by their sensory defensiveness. These occupations include hygiene,
independence in the community, relationships with others, ability to care for family
and home and safety. The second section lists possible trauma experiences.
Participants are required to identify their history of trauma experiences. These include
a history of physical and sexual abuse, torture, serious injury or surgery, stomach or
respiratory problems, suicide attempts and a period of sensory deprivation. This
screening tool was used in the study to identify any sensory defensiveness that may
impact a participants involvement, its occupational implications and the correlation of
sensory defensiveness and a history of trauma. This allowed facilitators to implement
trauma informed care and modify the group program to suit individual sensory needs.
54
3.5.2 Philadelphia Mindfulness Scale (PHLMS)
The Philadelphia Mindfulness Scale (see Appendix C; Cardaciotto, et al., 2008) is a
20 item measure that evaluates participants experiences of the core elements of
mindfulness. The core elements are awareness and acceptance. Each item is rated on
a 5 point Likert Scale (1 = never to 5 = very often) where participants self-report their
experience of each item within the last week. This outcome measure has two sub-
scales, awareness and acceptance, each containing 10 items. The Awareness sub-scale
consists of the odd numbered items and is scored through the addition of each point for
the item. The Acceptance sub-scale consists of the even numbered items and is
reversed scored. That is, items rated 5 (very often) on the Likert scale are scored as
one point, and items rated 1 (never) on the scale are scored as five points.
Each subscale on the PHLMS yields a possible sub-score of 50. A higher score on the
sub-scale of the PHMLS indicates greater acceptance and awareness. Through the
development of the PHMLS, researchers established content validity, internal
reliability (awareness subscale Cronbach alpha = 0.75, acceptance subscale Cronbach
alpha = 0.82) and discriminant validity (Cardaciotto, et al., 2008). This outcome
measure was used at baseline, the completion of five sessions, at follow up data at the
completion of 10 sessions and at patient discharge. It was hypothesised that
participants would achieve greater scores of awareness and acceptance through
involvement in the mindfulness and sensory modulation group.
3.5.3 Positive and Negative Affect Schedule Short Form (PANAS-SF)
The Positive and Negative Affect Schedule (see Appendix D; Watson, et al., 1988) is
an outcome measure that evaluates positive and negative affect. Positive affect is the
55
extent to which a person feels enthusiastic, active and alert (Watson, et al., 1988).
Negative affect is the dimension of distress and aversive mood states (Watson, et al.,
1988). The PANAS-SF is a 10 item measure, on which participants rate on a 5 point
Likert scale (1 = not at all to 5 = very much) the duration that they have experienced
an emotion over the past week. This outcome measure has two five item subscales,
positive and negative affect, which are scored individually. A higher positive affect
score indicates an increase of positive affect. A lower negative affect score indicates a
lower negative affect in the participant. The PANAS-SF yields a possible score of 25
for each subscale.
The PANAS-SF was developed directly from the 20 item PANAS (Kercher, 1992).
The 20 item PANAS measure has established a low relationship between the subscales
(ranging from -.12 to -.23), test retest reliability and high construct validity (Watson, et
al., 1988). The 10 items selected for inclusion to the PANAS-SF had the highest
factor loading from the exploratory factor analysis conducted by Watson, et al (1988).
The information collected from the PANAS-SF was used to analyse changes in levels
emotional reactivity over time. It was hypothesised that the negative affect scores of
participants would decrease and the positive affect scores would increase as a direct
result of participating in the Mindfulness and Sensory Modulation group program.
This outcome measure was used at baseline, midway (completion of 5 sessions),
follow up obtained at the completion of 10 sessions and additional data upon patient
discharge.
56
3.5.4 Visual Analogue Scale Arousal and Emotional Reactivity Scale
Ten visual analogue scales (Finch, Brooks, Stratford, & Mayo, 2002; Scott &
Huskisson, 1976) were used to evaluate the immediate impact of the intervention on
levels of arousal and emotional reactivity. A visual analogue scale is a 10 centimetre
line containing extreme limits at each end of the line. A visual analogue scale can be
modified to quantify any subjective experiences of participants (Scott & Huskisson,
1976). For this study, the visual analogue scale was designed to measure levels of
arousal and emotional reactivity (see Appendix E). Three subscale items measured the
physiological effects of high levels of arousal in participants (Champagne, et al., 2010;
Costanzo, 2010). These include heart rate, breathing rate and perspiration. The six
subscale items measuring emotional reactivity were formulated from the circumplex
model of affect (Posner, Russell, & Peterson, 2005). The circumplex model of affect
suggests that emotions are an activation of the neurophysiological systems by stimuli
(Posner, et al., 2005). The emotions selected from the circumplex model of affect
were angry, annoyed, upset, happy, depressed, confident or anxious.
Participants self-administered this measure, placing a single mark on the line to
quantifying their subjective experiences of arousal and emotional reactivity. This
outcome measure was completed before and after each group session to measure the
immediate effects of the program. It was hypothesised that majority of participants
would report a before session scale containing higher scores than their after session
scale. This would indicate an improvement in levels of arousal and emotional
reactivity.
57
3.5.5 PRN Sedation and Seclusion Registers
The PRN sedation and seclusion registers (see Appendix F and G) were used to
establish whether participation in the mindfulness and sensory modulation group
impacted rates of seclusion and PRN sedation. Clinical staff completed the adapted
registers at each incidence of PRN sedation and each episode of sedation. The adapted
PRN sedation register included additional sections where clinical staff documented if a
participant used a mindfulness and sensory modulation technique; whether this
intervention was successful or if PRN sedation was still required. Training was
provided to clinical staff to ensure consistency when completing the registers. The
information collected was analysed to evaluate whether the rates of seclusion and PRN
sedation have reduced throughout the study duration.
3.5.6 Feedback
The feedback was sought with participants. Participants targeted were those who had
attended a minimum of five sessions. Feedback was prompted by seven questions
asked conducted with the honours student (see Appendix I). Participants were
encouraged to report on the important skills they learnt from the intervention, what
strategies they could use and their overall experience. The purpose of the feedback
interview was to improve components of the Mindfulness and Sensory Modulation
group program.
3.6 Methods
Data Collection
Data collection occurred at varied times to evaluate the change over time and the
immediate impact of the intervention on the dependent variables. The data collection
58
occurred with the researcher and one participant at a time in a separate room. Baseline
measurements of the PHLMS and PANAS-SF were taken during initial contact. This
occurred either before the participant attended their first session or immediately
following. After participants had attended five or ten sessions of the group, the
associate researcher collected the midway and follow up data of the PHLMS and the
PANAS-SF. Additional data of the PHLMS and the PANAS-SF was collected at
participant discharge with the researchers.
Due to the pragmatic research design and the flexibility required within the mental
health setting, some participants did not complete five sessions on five consecutive
days. Therefore, data was collected when the participant completed the number of
sessions required or at participant discharge. Before and after each session,
participants completed the Arousal and Emotional Reactivity Scale. Feedback was
sought from participants at convenient times.
Data Analysis
After data collection, participants were categorised into three dosage groups according
to their attendance rates. These dosage groups were 5 sessions, 6-10 sessions and
11 sessions. If participants did not have discharge data available, the midway or
follow up data was utilised.
The PHLMS, PANAS-SF and Arousal and Emotional Reactivity scales were analysed
using the Wilcoxon Signed Rank Test to investigate the potential impact of the
intervention. A comparison was then made to establish if there was a difference in
results between the dosage groups. That is, participants with higher rates of
59
attendance exhibit a greater impact on their levels of arousal and emotional reactivity.
Descriptive statistics provided a profile of the participants involved in the intervention.
These descriptive statistics were reported in terms of mean and range of ages,
percentages of gender, diagnosis and presence of sensory defensiveness (Creswell,
2009). The data will be analysed using an intention to treat analysis (Aron, 2008).
That is, missing data will be estimated from other information collected.
The Wilcoxon Signed Rank Test was selected because it is a non-parametric test used
to examine the difference in signed ranks within matched participants (Jackson, 2010;
E Whitley & J. Ball, 2002b). A non-parametric test is used when the underlying
distribution is not normal due to a small sample size (Aron, 2008). In the Wilcoxon
signed rank test, each participant is represented by a single score that is the difference
between their pre and post-test measurements (Edwards, 2008; Jackson, 2010). This
score is then ranked and summed to have a positive, negative or tied rank. A positive
rank indicates that the post-test measurements were higher than pre-test measurements.
A negative rank reveals that the post-test measurement is less than the pre-test
measurement. A tied rank signifies no change in the pre and post-test measurements.
Statistically significant results are revealed when there is a substantial difference
between the positive and negative ranks (Aron, 2008; Jackson, 2010; E Whitley & J.
Ball, 2002b).
A one-tailed Wilcoxon Signed Rank test was used for the PHLMS and PANAS-SF
with a significance level set at p = 0.05. This was used to determine if there was a
positive difference of the PHLMS and the PANAS-SF positive affect subscale. That
is, the midway or discharge total will be greater than the baseline total, indicating a
60
positive rank. It is expected that a negative difference will be displayed in the
negative affect subscale of the PANAS-SF. That is, the baseline score will be greater
than the midway or discharge data scores, indicating a negative rank. A two tailed test
with a significance level set at p = 0.05 was used for the arousal and emotional
reactivity scale. This predicts that individuals can obtain either a positive or negative
rank. The data analysis was conducted using SPSS statistical software package.
Effect size was reported to determine the impact of the intervention.
The Spearmans rank correlation co-efficient was used to determine if there was a
correlation between sensory defensiveness and history of trauma, group attendance
and the use of PRN sedation and seclusion. The Spearmans rank correlation co-
efficient is a non-parametric measure of correlation between two variables (Aron,
2008; Jackson, 2010). This was used because it was estimated that the distribution of
rates of group attendance, PRN sedation and seclusion were not normally distributed.
Rates of PRN sedation and seclusion of the participants first five days of study
involvement was utilised for this correlation test. This time frame ensured that all
participants had equal opportunity to attend the Mindfulness and Sensory Modulation
group sessions, and control the rates of PRN sedation and seclusion.
3.7 Ethical Considerations
Ethical approval was obtained from the University of Wester Sydney Human Ethical
Review Committee and the South West Sydney Local Health District Human Research
Ethics Committee. It was a requirement that before participants commenced in the
study, the participant information letter was understood and written consent (see
Appendix J) was obtained. Medical clearance (see Appendix K) was required by their
61
treating medical officer. All participant data was stored in paper format in a locked
filing cabinet at Birunji Youth Mental Health unit. Access was provided to primary
and associate researchers. Once data collection was completed, the information was
securely transferred to the University of Western Sydney for data analysis. All
participant information was de-identified using a numeric code. The participant name
and assigned numeric code were stored separately to outcome measurement data.
3.8 Synopsis
A quasi-experimental research design was utilised for this pilot study to establish the
impact of the mindfulness and sensory modulation group on participants levels of
arousal and emotional reactivity. A convenience sample was recruited from Birunji
Youth Mental Health Unit. These participants were involved in a Mindfulness and
Sensory Modulation group program that ran for three month duration. Participants
were involved for the duration of their admission. Data was collected through a
variety valid and reliable outcome measures. These were the Philadelphia
Mindfulness Scale, the Positive and Negative Affect Schedule Short Form and the
Visual Analogue Scale. Data was collected to obtain information on the immediate
impact and change over time in participants. The data was analysed using the
nonparametric test Wilcoxon signed rank test. Results were reported in statistical
significance and effect size to determine the impact of the intervention.
62
Chapter 4 - Results
4.1 Introduction
Data from thirty-four (n = 34) participants was gathered during the study period. Two
participants dropped out of the study reporting personal reasons and one participant
was excluded from the sample being medically unfit. The final sample size for the
study was 31 participants. Group attendance ranged from two to 16 sessions with a
mean of 6.97. Participants were categorised into dosage groups according to their
attendance rates. Thirty-one participants were categorised to the 5 dosage group (n
= 31), the dosage group six to ten sessions had fourteen participants (n = 14). Five
participants were categorised to the 11 sessions dosage group. It was hypothesised
that participants with a higher level attendance at the Mindfulness and Sensory
Modulation group program will show greater improvement in levels of arousal and
emotional reactivity. Participant demographic information and sensory defensiveness
screening results will be presented using descriptive statistics. Results of the
Philadelphia Mindfulness Scale (PHLMS), the Positive and Negative Affect Scale
(PANAS-SF) and the Arousal and Emotional Reactivity Scale will be presented using
a Wilcoxon Signed Rank Test. The Spearmans rank correlation co-efficient was used
to determine if there was a relationship between sensory defensiveness and trauma;
and group attendance and the rates of PRN sedation and seclusion.
4.2 Demographics
Of the 31 participants, 18 were male (58.1%) and 13 were female (41.9%). The mean
age of the sample was 24.71 years and twenty participants (67.7%) reported to be
single. Forty-two percent of participants reported their highest education level as a
63
Certificate I to IV. Fifty-eight percent of participants were unemployed. Cultural
background of participants was predominately Australian (n = 18, 58.1%). Of the 31
participants, three identified to be of Aboriginal / Torres Strait Islander descent (9.7%)
and three participants were born overseas (9.7%). Twenty-two percent (22.6%) of
participants reported that they did not know their mental health diagnosis, and an
additional 16 percent (16.1%) reported that they did not have a mental health
diagnosis. The highest proportion of participants were admitted by medical staff with
acute psychosis (25.8%) followed by major depression (22.6%). Family was
identified as the major social support network for participants (77.4%). The majority
of participants reported to have no previous history with mindfulness techniques (n =
24, 77.4%) or sensory strategies (n = 25, 80.6%). A detailed breakdown of participant
demographics is shown in Table 4.1.
64
Table 4.1 Participant Demographics
Mean (SD) Frequency (%)

Age (yr) 24.71 (6.06)
Gender
Male 18 (58.1)
Female 13 (41.9)
Marital Status
Single, never married 21 (67.7)
Unmarried Partner 3 (9.7)
Married 3 (9.7)
Divorced 2 (6.5)
Separated 2 (6.5)
Education Status
Certificate I to IV 13 (41.9)
Year 9 or 10, no School Certificate 7 (22.6)
Higher School Certificate 5 (16.1)
Diploma / Advanced Diploma 3 (9.7)
School Certificate 2 (6.5)
Year 11 or 12, no Higher School 1 (3.2)
Certificate
Employment Status
Unemployed 18 (58.1)
Employed Casual / Part Time 6 (19.4)
Student 4 (12.9)
Employed Full Time 3 (9.7)
Cultural Background
Australian 18 (58.1)
Aboriginal Decent 2 (6.5)
Lebanese 1 (3.2)
Tonga 1 (3.2)
Maori 1 (3.2)
Serbian 1 (3.2)
Torres Strait Islander 1 (3.2)
Macedonian 1 (3.2)
Vietnamese 1 (3.2)
Italian 1 (3.2)
Pilipino 1 (3.2)
New Zealand 1 (3.2)
Born in Australia
Yes 28 (90.3)
No, overseas 3 (9.7)
Patient Reported Diagnosis
Dont Know 7 (22.6)
Dont have a mental health disorder 5 (16.1)
Major Depression 5 (16.1)
Dual Diagnosis 4 (12.9)
Bipolar Disorder 3 (9.7)
Psychosis 3 (9.7)
Schizophrenia 2 (6.5)
Schizoaffective Disorder 2 (6.5)
65
Mental Health Diagnosis

Psychosis 8 (25.8)
Major Depression 7 (22.6)
Dual Diagnosis 6 (19.4)
Schizoaffective Disorder 4 (12.9)
Schizophrenia 2 (6.5)
Drug Induced Psychosis 2 (6.5)
Bipolar Disorder 2 (6.5)
Social Support Network
Family 24 (77.4)
Extended Family 2 (6.5)
Friends 2 (6.5)
None Identified 2 (6.5)
Husband / Wife / Partner 1 (3.2)
History of using mindfulness Strategies
No 24 (77.4)
Yes, at Birunji previously 2 (6.5)
Yes, practiced meditation 2 (6.5)
Yes, at another health facility 1 (3.2)
Yes, participated in DBT 1 (3.2)
No Response 1 (3.2)
History of using sensory strategies
No 25 (80.6)
Yes, at Birunji previously 5 (16.1)
No Response 1 (3.2)
4.3 Sensory Defensiveness Screening for Adults
4.3.1 Sensory Defensiveness
The majority of participants were categorised as having moderate sensory
defensiveness (n = 11, 35.5%). The second highest group of participants were
categorised as having mild sensory defensiveness (n = 10, 32.3%). Figure 4.1 presents
the number of participants in each of the sensory defensiveness categories.
66
Figure 4.1: Number of Participants in Sensory Defensiveness Categories

12
11
10
10
Number of Participants
6
6
4
4
0
0
Normal (0-10) Mild (11-20) Moderate (21-30) Severe (31-40) Extreme (41-50)
Sensory Defensiveness Categories (Number of Yes Responses out of 50)
4.3.2 Sensory Defensiveness Occupational Dysfunction
Over half the participants reported occupational dysfunction in areas of interfering
with relationships (n = 18, 58.1%), intimate relationships (n = 17, 54.8%) and their
ability to socialise (n = 17, 54.8%). Table 4.2 presents the areas of occupational
dysfunction identified as a result of their sensory defensiveness.
67
Table 4.2 Sensory Defensiveness Impact on Occupational Performance
Frequency (%)
Hygiene
Yes 2 (6.5)
No 28 (90.5)
No response 1 (3.2)
Independent in the Community
Yes 6 (19.4)
No 25 (80.6)
Impact on Relationships
Yes 18 (58.1)
No 13 (41.9)
Impact on Intimate Relationships
Yes 17 (54.8)
No 13 (41.9)
No Response 1 (3.2)
Impact on ability to socialise
Yes 17 (54.8)
No 14 (45.2)
Impact ability to care for home or family
Yes 11 (35.5)
No 20 (64.5)
School or Employment Functioning
Yes 12 (38.7)
No 19 (61.3)
Leisure Activities
Yes 10 (32.3)
No 21 (67.7)
Safety
Yes 9 (29.0)
No 22 (71.0)
4.3.3 Sensory Defensiveness and History of Trauma
Over half the participants reported experiences of trauma as multiple hospitalisations
(n = 18, 58.1%) and a history physical abuse (n = 18, 58.1%). Following this, was
suicide attempts (n = 17, 54.8%). A summary of trauma experiences reported by
participants is in Table 4.3.
68
Table 4.3 Sensory Defensiveness and Trauma History
Frequency (%)
History of Sexual Abuse
Yes 10 (32.3)
No 21 (67.7)
History of Physical Abuse
Yes 18 (58.1)
No 13 (41.9)
Self-Harming Behaviour
Yes 12 (38.7)
No 19 (61.3)
Eating Disorder
Yes 6 (19.4)
No 25 (80.6)
Respiratory Problems
Yes 14 (45.2)
No 17 (54.8)
Multiple Hospitalisations
Yes 18 (58.1)
No 13 (41.9)
Torture
Yes 8 (25.8)
No 23 (74.2)
Serious Stomach Problems
Yes 10 (32.3)
No 21 (67.7)
Serious Injury / Surgery
Yes 13 (41.9)
No 18 (58.1)
Traumatic Birth
Yes 2 (6.5)
No 29 (93.5)
Suicide Attempts
Yes 17 (54.8)
No 14 (45.2)
Sensory Deprivation
Yes 8 (29.0)
No 22 (71.0)
The Spearmans rank correlation co-efficient was used to identify if participants with
past experiences of trauma had high levels of sensory defensiveness. There was a
statistically significant positive correlation (r = 0.773, p = <0.001). This revealed that
participants with high sensory defensiveness had high incidences of past trauma.
Figure 4.2 represents the positive correlation.
69
Figure 4.2 Sensory defensiveness and history of trauma correlation
4.4 Philadelphia Mindfulness Scale (PHLMS)
Participants awareness increased as their dosage of group sessions advanced. Levels
of acceptance increased in participants categorised into dosage group 5 and group
six to ten sessions. However, participants in the dosage group 11 sessions did not
display any changes. Table 4.4 highlights the mean, standard deviation and range of
scores for the awareness and acceptance sub-scales of the PHMS across the dosage
groups.
70
Table 4.4 Mean, Standard Deviation and Range of Awareness and Acceptance Sub-
scales
Awareness Sub-scale Acceptance Sub-scale

M (SD) Range M (SD) Range
Baseline (n=31) 36.19 (6.93) 35.00 26.70 (9.78) 36.00
Dosage 5 sessions (n=31) 36.90 (6.67) 28.00 27.42 (8.37) 33.00
Dosage 6-10 sessions (n=14) 39.28 (6.44) 22.00 28.64 (10.50) 34.00
The statistical results of the Wilcoxon Signed Rank Test for the Awareness and
Acceptance subscales are presented in Table 4.5. Participants who had attended 5 (n
= 31) indicated that there was no significant change in acceptance and awareness
levels. Thirteen participants demonstrated a decrease in awareness levels, 12
participants increased their levels of awareness and six participants reported no
change. The awareness subscale did not indicate statistically significant results, z = -
0.337, p = 0.373, r = -0.06. Data collected on the acceptance subscale revealed that 12
participants decreased their levels of awareness and 16 participants increased their
levels of awareness. Three participants demonstrated no change in awareness levels.
No statistically significant results were revealed for the acceptance subscale, z = -
0.627, p = 0.270, r = -0.11.
The 14 participants who attended six to ten sessions demonstrated no statistically
significant results for both subscales. The awareness subscale data revealed that six
participants had a decrease in levels of awareness, seven participants had an increase
in awareness levels and one participant had no change. Overall however, this
indicated that there was no statistically significant difference between the baseline and
follow up data, z = -1.120, p = 0.140, r = -0.30. Of the 14 participants, five
participants demonstrated decreased levels of acceptance, eight had an increase in their
71
acceptance levels and one participant had no change. The acceptance subscale did not
demonstrate statistically significant results, z = -0.490, p = 0.324, r = 0.13.
Participants completing 11 sessions (n = 5) revealed a statistically significant score
in the awareness subscale. The awareness data revealed all five participants
experienced an increase of awareness levels. This increase of awareness was highly
significant, z = -2.023, p = 0.031, r = -.91. This result showed a large effect size (r = -
0.91) as identified by Cohens effect size conventions (Aron, 2008). The acceptance
subscale did not show statistically significant results, z = -0.813, p = 0.250, r = -0.36.
Of the acceptance data, three participants decreased in levels of acceptance and two
participants increased their levels of acceptance. All results should be viewed with
caution due to the small sample size.
Table 4.5 Z-score, p-value and effect size of Awareness and Acceptance Sub-scale
Awareness Sub-scale Acceptance Sub-scale

z (p-value) ES z (p-value) ES
Dosage 5 sessions (n=31) -0.337 (0.373) -0.06 -0.627 (0.270) -0.11
Dosage 6-10 sessions (n=14) -1.120 (0.140) -0.30 -0.490 (0.324) -0.13
Dosage 11 sessions (n=5) -2.023 (0.031*) -0.90 -0.813 (0.250) -0.36
*Statistically significant results
4.5 Positive and Negative Affect Schedule Short Form (PANAS-SF)
As hypothesised, participants demonstrated an increase of positive affect as their
attendance to groups progressed. Participants who attended one to ten sessions
reported a decrease in negative affect as expected. However, participants who
attended 11 sessions did not follow this trend. A summary of the mean, standard
72
deviation and range of scores for the positive and negative affect subscale of the
PANAS-SF can be located in Table 4.6.
Table 4.6 Mean, Standard Deviation and Range of Positive and Negative Affect Sub-
scales
Positive Affect Sub-scale Negative Affect Sub-scale

M (SD) Range M (SD) Range
Baseline (n=31) 18.35 (6.49) 23.00 14.67 (5.27) 19.00
Dosage 6-10 sessions (n=14) 23.00 (3.84) 14.00 11.28 (5.18) 17.00
The statistical results of the Wilcoxon Signed Rank Test for the PANAS-SF are
presented in Table 4.7 Participants who were categorised to the dosage group 5 (n =
31) did not show statistically significant changes in positive affect, z = -0.706, p =
0.245, r = -0.13. The positive affect data indicated that 11 participants decreased in
positive affect, 13 increased their levels of positive affect and seven participants had
no change. Of the 31 participants, twenty seven participants exhibited decreased
levels of negative affect, two had increased levels of negative affect and two
participants experienced no change. A statistically significant results was revealed in
negative affect, z = -4.078, p = <0.001, r = 0.73, with a medium effect size.
Participants who completed six to ten sessions (n = 14) showed no statistical
significant difference in positive affect, z = -1.298, p = 0.106, r = -0.35. Of the 14
participants in this dosage group, 11 participants experienced decreases in negative
affect; two participants reported increases in negative affect and one had no change.
The lower negative affect in participants is statistically significant, z = -2.850, p =
<0.001, r = 0.76, with a medium effect size. Participants who completed 11 sessions
73
(n = 5) did not reveal statistically significant results for positive or negative affect, z =
-1.084, p = 0.188, r = 0.48, and z = -1.219, p = 0.156, r = 0.54.
Table 4.7 Z-score, p-value and effect size of the Positive and Negative Affect Sub-
scales
Positive Affect Sub-scale Negative Affect Sub-scale

z (p-value) ES z (p-value) ES
Dosage 5 sessions (n=31) -0.706 (0.245) -0.13 -4.078 (<0.001*) -0.73
Dosage 6-10 sessions (n=14) -1.298 (0.106) -0.35 -2.850 (<0.001*) -0.76
Dosage 11 sessions (n=5) -1.084 (0.188) -0.48 -1.219 (0.156) -0.54
Note: *Statistically significant results
4.6 Arousal and Emotional Reactivity Scale
Participants who completed 5 sessions (n = 31) experienced statistically significant
changes in levels heart rate and breathing rate on the arousal subscale. One arousal
sub-scale item related to perspiration did not indicate any change in participants. All
participants experienced decreased levels of emotional reactivity (refer to table 4.8).
Participants categorised to the dosage group six to ten demonstrated decreased levels
of breathing on the arousal subscale, z = -2.158, p = 0.030, r = -0.55. Statistically
significant changes in levels of emotional reactivity were demonstrated in participants.
Participants in the dosage group of 11 sessions, demonstrated decreased levels of
heart rate and breathing rate. Participants reported statistically significant changes in
emotional reactivity. The statistical results of the arousal and emotional reactivity
scale are presented in Table 4.8.
74
Table 4.8 Z-score, p-value and effect size of the Arousal and Emotional Reactivity Scale
Item 1 Item 2 Item 3 - Item 4 - Item 5 - Item 6 - Item 7 - Item 8 - Item 9 - Item 10 -
Heart Rate Breathing Perspiration Angry Annoyed Upset Happy Depressed Confident Anxious
z (p-value) Rate z (p-value) z (p-value) z (p-value) z (p-value) z (p-value) z (p-value) z (p-value) z (p-value)
ES z (p-value) ES ES ES ES ES ES ES ES
ES
Dosage 5 -3.331 -2.841 -0.039 -3.507 -3.900 -3.743 -4.135 -3.919 -3.812 -4.762
(n=31) (<0.001*) (0.004*) (0.977) (<.001*) (<.001*) (<.001*) (<.001*) (<.001*) (0.005*) (<.001*)
-0.60 -0.51 -0.00 -0.63 -0.70 -0.67 -0.74 -0.70 -0.68 -0.85
Dosage 6-10 -1.664 -2.158 -0.170 -2.215 -3.010 -2.953 -2.783 -2.783 -2.840 -3.408
(n=15) (0.104) (0.030*) (0.890) (0.026*) (0.001*) (0.002*) (0.003*) (0.003*) (0.003*) (<0.001*)
-0.43 -0.55 -0.04 -0.57 -0.78 -0.76 -0.72 -0.72 -0.73 -0.88
Dosage 11 -2.197 -2.366 -1.521 -2.366 -2.028 -20.28 -2.366 -2.366 -2.197 -2.197
(n=7) (0.031*) (0.016*) (0.156) (0.016*) (0.047*) (0.047*) (0.016*) (0.016*) (0.031*) (0.031*)
-0.83 -0.89 -0.57 -0.89 -0.76 -0.76 -0.89 -0.89 -0.83 -0.83
Note: *Statistically significant results
4.7 PRN Sedation Rates
There were 407 instances of PRN sedation over the duration of the study (84 days).
Table 4.9 presents the frequency and percentage of PRN sedation, reasons why PRN
sedation was given, timing of PRN sedation, whether a sensory strategy was suggested
as an alternative to PRN sedation, whether this sensory strategy was trialled and the
outcome of strategy. Almost half the instances of PRN sedation were given for
insomnia (48.6%). This corresponded with the highest percentage of PRN being
administered between 8:00 pm 12:00 am (46.9%) and 12:00 am 4:00 am (13.8%).
In 79 of the 407 instances of PRN sedation (19.4%), clinical staff suggested a sensory
strategy to participants to trial. An additional 19.4 percent of the suggested sensory
strategies were refused by patients. In forty six per cent of PRN instances, it was not
reported whether a sensory strategy was suggested. Fifty per cent of the time clinical
staff did not trial the sensory strategy, with an additional 39.8 percent not reported.
PRN sedation was given to individuals 74 percent of the time, with an extra 24 per
cent not reported.
To investigate whether there was an association between group attendance and rate of
PRN sedation a Spearmans rank correlation co-efficient was used. Participants (n =
31) required PRN sedation during the study period. There was a negative correlation
between group attendance and rates of PRN sedation, r = - 0.182 p = 0.326. The
direction of the correlation was negative. This reveals that participants who increased
their group attendance, decreased their rates of PRN sedation. Figure 4.3 demonstrates
the negative correlation between group attendance and PRN sedation use.
Table 4.9 Frequency and percentage of PRN sedation rates
Frequency (%)
Reasons for PRN
Insomnia 198 (48.6)
Agitated / Irritable 126 (31.0)
Anxious 36 (8.8)
Not reported 19 (4.7)
Unsettled / Restlessness 12 (2.9)
Severe Distress 8 (2.0)
Highly Agitated 5 (1.2)
Psychosis 2 (0.5)
Aggression 1 (0.2)
Timing of PRN Sedation
20:00 00:00 198 (46.9)
00:00 04:00 56 (13.8)
16:00 20:00 47 (11.5)
08:00 12:00 33 (8.1)
12:00 16:00 33 (8.1)
04:00 08:00 8 (2.0)
Sensory Strategy Suggested
Refused by Patient 79 (19.4)
Strategies suggested by staff 79 (19.4)
No Sensory Strategy Suggested 52 (12.8)
Patient too Agitated 9 (2.2)
Sensory Strategy Trialled
No 205 (50.4)
Yes 40 (9.8)
Outcome of Strategy
PRN Given 302 (74.2)
Not completed 100 (24.6)
Patient Settled 5 (1.2)
Note: Not Reported Data was not completed on form
77
Figure 4:3 Scatter plot diagram of group attendance and PRN sedation
4.8 Seclusion Rates
During the three month study period, there were seven instances of seclusion. The
mean duration of seclusion was 69.00 minutes. The most commonly reported reason
for seclusion was aggression (n = 5, 71.4%). Clinical staff reported the most common
intervention used was verbal de-escalation (n = 3, 42.9%), using a combination of
verbal de-escalation and PRN sedation (n = 3, 42.9%) and using a combination of
verbal de-escalation, PRN sedation and medical officer review (n = 1, 14.3%). Table
4.10 provides the descriptive statistics of the duration of seclusion, the reasons for
seclusion and the interventions trialled and failed.
78
Table 4.10 Frequency and percentage of seclusion rates
Mean (SD) Frequency (%)

Duration of Seclusion 69.00 (21.45)
Reason for Seclusion

Aggression 5 (71.4)
Self-harm 1 (14.3)
Aggression and Absconding 1 (14.3)
Interventions Trialled and Failed
Verbal De-escalation 3 (42.9)
Verbal De-escalation and 3 (42.9)
PRN Sedation
Verbal De-escalation, 1 (14.3)
Medical Officer review,
PRN sedation
The Spearmans rank correlation co-efficient was used to investigate the association
between group attendance and rates of seclusion. Seclusion was only applied to one
participant during the five day time frame. There was a negative correlation, r = -
0.263. p = 0.153. Figure 4.4 demonstrates the negative correlation between group
attendance and seclusion rates.
79
Figure 4.4 Scatter plot diagram of group attendance and seclusion
4.9 Consumer Feedback
Feedback was obtained from four participants throughout the study duration. A
number of the participants reported that the most important skills they learnt
throughout their involvement was developing their understanding of sensory and
mindfulness strategies and how these can be used to help control emotions.
My first of experience of sensory group I felt relaxed. Ive found that deep breathing
has helped control my anger. Participant 1
Ive learnt that mindfulness can help me to cope in the moment. And Ive learnt to
appreciate the activities and how I can use them to calm myself down.
Participant 2
80
I have a different view of my senses now. Ive learnt a way I can use them to my
benefit how it can help calm me down. Participant 3
I use my sensory activities, like the exercises, to help calm me down. Participant 4
A number of participants reported to use the Mindfulness and Sensory modulation
strategies during their admission to assist in regulating levels of arousal and emotional
reactivity. The participants reported to not need additional PRN sedation during their
admission.
Ive used the exercise band exercises, medicine ball and deep breathing while Ive
been here. Its helped calm me down if Ive felt annoyed. Participant 1
I havent required extra medication while Ive been here. Ive used the mindful hand
massage, bean bag tapping, made a stress ball. These have helped me to calm down
and refocus my thoughts. Participant 2
I had trouble sleeping and used to use anxiety and sleeping pills. Now I do the deep
breathing, muscle tension and release to help me sleep. Participant 4
Participants revealed that these mindfulness and sensory modulation strategies would
replace maladaptive behaviours when participants were discharged.
This is better than being stoned. Before I used to go home and get stoned, but now I
will go home, drink pink tea and do stretches I plan on making a sensory kit. Ill
even get the kids to do it too. Participant 1
I plan to develop my sensory kit when I get home. It will have candles, hand lotions,
bean bag and a stress ball. Participant 2
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The Mindfulness and Sensory modulation group was highly enjoyed by participants.
With most participants reporting in the feedback interview, that no other
improvements needed to be made.
I really enjoyed my time with the group and all that I learnt, it has been very
beneficial. Participant 1
No improvements necessary. The whole thing was good. But maybe make it longer.
- Participant 4
4.10 Synopsis
Of the study participants, 58.1% were male and 41.9% were female, with a mean age
of 24.71 years. Over half the participants were Australian (58.1%). The most frequent
mental health diagnoses for the sample were psychosis (25.8%) and major depression
(22.6%). The majority of participants were revealed to have moderate sensory
defensiveness (n = 11, 35.5%) which had occupational implications with maintaining
relationships with other people. The most common experience of trauma reported by
participants were multiple hospitalisations (58.1%) and a history of physical abuse
(58.1%).
Participation in the Mindfulness and Sensory Modulation group did not change levels
of awareness and acceptance significantly in participants. However, participants who
attended 11 sessions did demonstrate significant changes in awareness levels. This
must be viewed with caution due to the small number of participants in this dosage
group. Levels of positive affect in participants did not change due to their
involvement in the Mindfulness and Sensory Modulation group. Participants who
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attended one to ten sessions did experience significant changes in their negative affect.
Results for the Arousal and Emotional Reactivity Scale indicated that participants
experienced an immediate change in most aspects of arousal and emotional reactivity
after attending the Mindfulness and Sensory Modulation group. Negative correlations
were indicated for both PRN sedation and seclusion. This revealed that those
participants who attended more sessions of the Mindfulness and Sensory Modulation
group, did not require PRN sedation or seclusion.
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Chapter 5 Discussion
5.1 Introduction
Results from the Mindfulness and Sensory Modulation group program revealed
positive trending in young adults ability to regulate levels of arousal and emotional
reactivity. These findings indicated an increased ability of participants to self-regulate
levels of arousal immediately following intervention. Participants demonstrated
decreased levels of negative affect over time and the ability to self-regulate levels of
emotional reactivity following the intervention. This chapter will discuss the key
findings of the study, the limitations and recommendations for practice, education,
future research and policy.
5.2 Key Findings
5.2.1 Demographics
The demographics of this sample differed from other mental health demographics
reported in statistics of the Australian population. The study sample was compared to
statistics that included a larger age range (16 to 85). This is to be expected as Birunji
Youth Mental Health Unit is the first of its kind in Australia catering for young people
with mental health disorders. The study sample of 31 people reflects three months
within an acute care setting. Results from the study cannot be generalised to the wider
Australian population. Therefore, any conclusions should be interpreted with caution.
The sample from the study had a comparably higher percentage of males to females
(58.1% to 41.9% respectively). This is contradictory to other statistics of mental
health prevalence in Australia (Australian Bureau of Statistics, 2007; Australian
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Institute of Health and Welfare, 2012). Females (22%) generally have a higher rate of
mental health disorders in comparison to males (18%) (Australian Bureau of Statistics,
2007; Australian Social Trends, 2009). It is also reported that females (52.2%) are
more likely to be admitted to acute mental health care in public hospitals than males
(47.8%; Australian Social Trends, 2009). The mean age of participants in the study
was 24.71 years old. This age is consistent with other Australian statistics. The
prevalence of mental health disorder declines with age (Australian Social Trends,
2009). One in four individuals between the ages of 16 to 24 will experience a mental
health disorder (Australian Bureau of Statistics, 2007; T. Slade, et al., 2009).
A high proportion of participants reported to be single and unemployed. This was
higher compared to Australian mental health statistics. There was a notable difference
with participants education level. Australian mental health statistics reported that the
highest percentage of education level was diploma / advanced diploma (Australian
Bureau of Statistics, 2007). The study sample reported a level of education as
certificate I to IV. These differences are likely to be related to the sample being drawn
solely from a low socio-economic status in Sydney. The differences in marital status,
employment and education level could be due to experiences obtained at different life
stages. Young adulthood is a critical period of development for individuals, in which
foundational life choices are made. This period involves the development of education
and vocational pathways and the enhancement of relationships with peers (J. A.
Brown, 2011; Commonwealth Department of Health and Aged Care, 2000; Hunter,
Grealish, & Dowling, 2010). It was expected that the demographic profile of
participants would be different to the general adult population of people with a mental
health disorder.
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The majority of participants were Australian and a small number reported to be
Aboriginal or Torres Strait Islander. The percentage of participants with an Aboriginal
and Torres Strait Islander cultural background was smaller than those individuals who
engage acute mental health care service in public hospitals (Australian Institute of
Health and Welfare, 2012).
The most common reason participants were admitted to Birunji Youth Mental Health
Unit was for acute psychosis and major depression. This is not consistent with the
statistics of individuals admitted to acute mental health care in Australia during 2008
to 2009. These statistics state that the highest percentage mental health diagnoses of
individuals in acute care were depressive episodes, schizophrenia, bipolar affective
disorder and reaction to severe stress and adjustment (Australian Institute of Health
and Welfare, 2012). The reason for this difference may be due to the younger
population serviced by this unit. A number of participants (41.9%) in the sample had
their first admittance to acute care and did not have a definitive mental health
diagnosis. Medical officers are reluctant to diagnose these young adults early as some
symptoms of mental health disorders may still be developing. Further, the majority of
participants (22.6%) from the sample reported to not know their mental health
diagnosis and a 16.1% of the sample did not identify having a mental health disorder.
5.2.2 Sensory Defensiveness Screening
The majority of participants (35.5%) were categorised to have moderate sensory
defensiveness. The second highest category was mild sensory defensiveness (32.3%).
It is difficult to determine if these results are consistent with results from other studies.
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While a large proportion of research has identified a co-existence between the
prevalence of mental health disorders and sensory modulation dysfunction if has not
focused on the severity of the co-existence (C. Brown, et al., 2002; S. Brown, et al.,
2009; Engel-Yeger & Dunn, 2011; Rieke & Anderson, 2009). More research is
needed to establish the prevalence and severity of sensory defensiveness in individuals
with mental health disorders. Other factors that prevented a comparison with existing
studies was different aspects of sensory modulation dysfunction, for example sensory
processing styles, were investigated. Although, one study did establish a link between
sensory defensiveness and anxiety in adults without a mental health disorder (Pfeiffer
& Kinnealey, 2003). The researchers of this study did identify a positive correlation
between sensory defensiveness and anxiety. However, these cannot be compared to
our sample. For example, the sample recruited (n = 15) by Pfeiffer and Kinnealey
(2003) did not directly have mental health disorders. The Adult Sensory
Questionnaire and Adult Sensory Interview were used to measure sensory
defensiveness in their population. As such, it is unlikely that the sensory
defensiveness identified in this sample was a true representation of the population of
individuals with mental health disorder.
Participants reported experiencing difficulty in occupational performance due to their
sensory defensiveness. These occupations included their ability to enjoy platonic
relationships and intimate relationships with others. This is consistent with other
research (Abernethy, 2010; May-Benson, 2009, 2011). Research conducted into
exploring adults with sensory defensiveness identified people had difficulty with their
ability to engage in occupations. These occupations include work, leisure, social
events and activities of daily living (May-Benson, 2009, 2011). The investigators
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concluded that sensory defensiveness impacted on all aspects of their participants life,
and can contributed to an individuals ability to enjoy relationships (Abernethy, 2010).
A high proportion of participants reported to have a history of trauma. A positive
trend was identified that participants with past experiences of trauma had high levels
of sensory defensiveness. However, it is difficult to establish if this coincides with
other research. Previous research had identified a connection between sensory
modulation dysfunction, mental health disorders and a history of trauma (Champagne,
et al., 2010). However, this research does not contain detailed statistics that are easily
comparable.
5.2.3 Philadelphia Mindfulness Scale (PHLMS)
It was hypothesised that participants who attended more sessions of the Mindfulness
and Sensory Modulation group program would achieve greater levels of awareness and
acceptance. It was expected that the results from the study would have revealed
clinically significant change in awareness and acceptance. However, this was not the
case. Mindfulness is an abstract concept. It may have been difficult for participants to
grasp the concepts of awareness and acceptance with the small amount of time
exposed to the intervention coupled with the fact that they were in an acute phase of
their illness. Mean group attendance was 7 sessions for study participants.
Additionally, participants who are at this stage of their recovery have experienced
impaired cognitive functioning, as a result of being acutely unwell. This may also
impact on their ability to understand and comprehend abstract concepts.
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Awareness and acceptance subscales scores improved over time and participants who
attended more than 11 sessions on average had statistically significant results for
awareness. Participants reported that through mindfully using the sensory modulation
strategies they were able to understand and practice the techniques of awareness and
acceptance. Grounding the abstract concept of mindfulness in everyday activities,
participants were able to develop an awareness of using and feeling their senses work.
Acceptance was initially a challenging concept for participants to grasp. It was
difficult to expect participants at this stage in their recovery to focus and non-
judgementally accept emotions and thoughts. Through using the sensory modulation
strategies, participants were encouraged to non-judgementally accept thoughts and
emotions and bring their awareness back to the sensory modulation strategy.
Only a small portion of the results from the PHLMS can be compared to other
research. One study conducted by Cardaciotto and et al (2008) described the
development and psychometric testing of the PHLMS. The baseline awareness and
acceptance subscale means and standard deviation from the study sample is
comparable to this research study using a sample with individuals with mental health
disorders (Cardaciotto, et al., 2008). The sample awareness mean score was lower and
the acceptance mean score was higher than its counterparts from the research. To
date, no other known research has used this outcome measure as a pre and post-test
measurement.
5.2.4 Positive and Negative Affect Schedule Short Form (PANAS-SF)
Participants who attended the Mindfulness and Sensory Modulation group did
demonstrate increases in positive affect. Participants reported a high level of positive
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affect at baseline and this improved over time. However, these changes were not
statistically significant. Participants may have reported emotions they thought the
researchers expected, or due to their illness individuals may have experienced a lack of
insight impacting on their ability to accurately identify their emotions. Conversely, a
small number of participants reported to be relieved to be in acute care. For these
participants, being in a protected, safe environment with three meals a day was better
than other environments participants may be exposed too. These environments
include being homeless or exposed to further trauma experiences of physical or sexual
violence. The levels of positive affect at baseline may have given a ceiling effect. A
ceiling effect is defined as majority of scores at the high end of the distribution which
means it is not possible to obtain a higher score (Aron, 2008). The ceiling effect may
have made it difficult for participants to report a higher positive affect at midway and
follow up data collection points. These findings should also be viewed with caution.
Statistically significant results were identified on the negative affect subscale.
Participants who attended one to ten (n = 14) demonstrated a decrease in their negative
affect which means they experienced less distress, nervousness and decreased feelings
of fear and being scared. Participants who attended 11 or more sessions did not have
clinically or statistically significant changes in negative affect. A lack of statistical
power may have been encountered in this dosage group sample (n = 5).
5.2.5 Arousal and Emotional Reactivity Scale
Participants demonstrated decreased levels of arousal immediately following their
involvement in the Mindfulness and Sensory Modulation group program. Participants
experienced statistically significant decreased heart rates in dosage 5 and 11
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groups. Participants who attended six to ten sessions did not demonstrate a
statistically significant change in heart rate levels. This was not expected. Decreased
breathing rates were experienced by all participants. Participants did not demonstrate
any changes in perspiration across all dosage groups. This was not expected.
However, the Australian Bureau of Statistics (2007) reveals that individuals with a
mental health disorder have a sedentary lifestyle or experience low levels of exercise.
This indicates that these individuals have limited exposure to physical activity and
exercise. The Mindfulness and Sensory Modulation group program uses various
forms of exercise as sensory modulation strategies. Therefore, participants
demonstrated higher levels of perspiration after the group session.
Participants reported an immediate ability to self-regulate levels of emotional
reactivity after attending the Mindfulness and Sensory Modulation group. These
changes were statistically significant across all dosage groups. Participants reported
feeling less angry, annoyed and upset and more happy and confident.
The Mindfulness and Sensory Modulation group program had results indicating a
positive impact on participants ability to self-regulate levels of arousal in terms of
breathing rate and heart rate. Much stronger positive results were evident on the
emotional reactivity scale. Through these results it can be concluded that participants
experienced an immediate change because of their involvement in the group. Further,
most participants reported that the arousal and emotional reactivity scale was quick
and easy to complete. The concepts being noted were clear and easy to understand. It
was quick to administer and had a high compliance rate with participants. The arousal
and emotional reactivity scale was developed specifically for this pilot study.
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Therefore, it is impossible to compare these results as no other research has used this
outcome measure.
5.2.6 PRN Sedation
Throughout the duration of the study 407 instances of PRN sedation were given to all
individuals. Almost half the instances of PRN sedation were given for reasons of
insomnia, with majority of these given to participants at night. This is different to
other research that identifies the most common reasons for PRN sedation is agitation,
threatening behaviour and mood disturbances (Stein-Parbury, et al., 2008). It is
difficult to ascertain whether mindfulness and sensory strategies were offered to
participants at all as almost half of this data was not recorded by clinical staff.
Mindfulness and sensory strategies were suggested to participants 19 per cent of the
time. Of these participants, mindfulness and sensory strategies were refused by
participants 19 per cent of the time. Mindfulness and sensory strategies were not
offered at all 12 per cent of the time. There were only 40 instances in which the
sensory strategy was trialled, with only five instances where the participant settled.
The results were interpreted with caution due to this non-compliance of data collection
with the PRN sedation register.
It can be concluded that sensory strategies were only suggested as an alternative to
PRN sedation on a small number of occasions. However, this does indicate a slow
positive change by clinical staff. Change in clinical practice is usually slow, ongoing
and difficult at times (Dulaney & Stanley, 2005; Portoghese et al., 2012). Successful
change in clinical practice depends on those individuals who implement the change on
a daily basis and the strategies of support through education, re-training and
92
encouragement (Dulaney & Stanley, 2005). The clinical staff involved in the study,
received training and education to promote the importance of providing individuals
with an alternative, less restrictive intervention first before PRN sedation. However,
additional encouragement was required at stages throughout the study to clinical staff.
This was to be expected. Such change can be particularly difficult when working in a
medical environment strongly governed by the medical model.
As participants increased their attendance at the Mindfulness and Sensory Modulation
group, the number of PRN sedations required reduced. Although the negative
correlation was not statistically significant, it identified that those participants who
attended group did not require additional PRN sedation. This result was expected. It
supports the hypothesis that participation in the mindfulness and sensory group may
reduce the rates PRN sedation. This correlation required testing under the strict
conditions of a randomised control trial to establish true effect of the Mindfulness and
Sensory Modulation group program on sedation.
5.2.7 Seclusion
Rates of seclusion at Birunji Youth Mental Health Unit were lower than other statistics
reported from other mental health units in Australia. The mean duration of seclusion
(69 minutes) was lower compared to the 240 minutes reported by other recent research
(Department of Health, 2011; Happell & Gaskin, 2011; Roberts, et al., 2009). Other
studies have reported that six to ten per cent of their sample experienced seclusion.
The number of participants from our sample who experienced seclusion was 6.45 per
cent during our study. The most common reason for seclusion reported in other
research was high levels of agitation and protection of self and others (Happell &
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Gaskin, 2011). The most frequent reason for seclusion of study participants was
reported to be aggression.
Four instances of seclusion were provided to two participants involved in the study.
Although the mindfulness and sensory strategies were suggested 19 per cent of the
time by clinical staff before the use of PRN sedation, there was no indication that
mindfulness and sensory strategies were used as an alternative intervention to
seclusion. This could be due to the fact that the participants requiring seclusion were
too agitated to respond to these least restrictive care interventions. However, a weak
negative trend identified that participants who attended the group did not require
seclusion. It is difficult to compare these results with other research. Recent research
(Champagne & Sayer, n.d.; Champagne & Stromberg, 2004) use sensory rooms as the
primary intervention to reduce seclusion. Additionally, no correlation statistics were
reported. However, one study (Lee, et al., 2010) used sensory modulation strategies
through the provision of equipment to patients in order to reduce seclusion. The
researchers of the study identified that through the provision sensory modulation
equipment, clinical staff were able to engage with individuals and reduce the levels of
seclusion. This study conducted a thematic analysis and did not directly analyse the
correlation of sensory modulation strategies and rates of seclusion. As such, it is
difficult to compare the rates of seclusion identified in the study to other research.
5.2.8 Participant Feedback
Participants reported to enjoy the Mindfulness and Sensory Modulation group during
their admission at Birunji Youth Mental Health Unit. The Mindfulness and Sensory
Modulation group provided useful strategies that were used by participants to self-
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regulate levels of arousal and emotional reactivity. Participants indicated that these
strategies will replace maladaptive behaviours upon their discharge.
5.3 Discussion of Findings in relation to Research Questions
Sensory Modulation group program can have an impact on an individuals levels of
arousal
It was evident through the Arousal and Emotional Reactivity Scale that there were
immediate changes to participants levels of arousal due to their involvement in the
mindfulness and sensory modulation group. Breathing rate decreased with clinically
important and statistically significant results across all dosage groups. Statistically
significant and clinically important changes were also noted for participants heart rate
scores. Heart rate decreased in participants that attended 5 sessions and 11
sessions. The perspiration item did not indicate any clinically important and
statistically significant results. Perspiration, heart rate and breathing rate are impacted
by exercise. Exercise was the prominent form of sensory modulation strategy utilised
by the Mindfulness and Sensory Modulation group program. In Australian statistics,
individuals with mental health disorders have been identified to have a sedentary and
low activity lifestyle (Australian Bureau of Statistics, 2007). Therefore, it could be
expected that participants may not have achieved any difference in levels of
perspiration because of this.
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Sensory Modulation group program can have an impact on an individuals levels of
emotional reactivity
Participants demonstrated increased ability to self-regulate levels of emotional
reactivity. There were clinically important and statistically significant results on the
emotional reactivity items of the Arousal and Emotional Reactivity Scale across all
dosage groups. This indicated a positive immediate impact of the intervention on
participants levels of emotional reactivity. This reveals that the mindfulness and
sensory group had an immediate positive impact on a participants ability to regulate
levels of emotional reactivity. Participants demonstrated sustained changes in levels
of emotional reactivity over time through the PANAS-SF. There were significant
decreases in negative affect in participants in the dosage 5 and six to ten groups. As
a direct result of the intervention, participants demonstrated an ability to decrease their
negative affect in emotions of level of distress, becoming upset, feeling scared,
nervous or afraid.
Another indication that participants changed ability to modulate their levels of
emotional reactivity were the results of the PHLMS. Participants who attended 11 or
more sessions (n = 5) obtained clinically important and statistically significant changes
in awareness. Through practicing the concepts of awareness and acceptance,
participants have learnt how to regulate levels of emotional reactivity (Melbourne
Academic Mindfulness Interest Group, 2006). This was revealed through the positive
trending of levels of awareness and acceptance in participants. However, these results
were interpreted with caution due to the small sample size.
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5.3.3 Research Question 3: To assess if participating in a Mindfulness and Sensory
Modulation group program changes the use of PRN sedation
It was discovered throughout the study that participants who attended a greater number
of sessions required less rates of PRN sedation. In fact, only one third of PRN
sedation was given to participants during their involvement in the study. A weak
negative trend was identified, although results were not statistically significant. This
could be due a number of reasons. Firstly, over half the instances of PRN sedation
were given for insomnia overnight. Participants of the group were not encouraged by
clinical staff to do a mindfulness and sensory strategy at this time. This indicates that
further education and support of clinical staff is required. Secondly, a number of
participants who attended the intervention still required additional PRN sedation.
These participants did report improvements in self-regulating levels of arousal and
emotional reactivity. However, did not feel that the Mindfulness and Sensory
Modulation strategies were enough and requested PRN sedation.
5.3.4 Research Question 4: To evaluate if participating in a Mindfulness and Sensory
Modulation group program impacts rates of seclusion
Seclusion was only applied to one participant out of 31 participants during the first
five days of study participation. There was a weak negative correlation between rates
of seclusion and group attendance. This indicated that those participants who attended
the Mindfulness and Sensory Modulation group were less likely to require seclusion.
While the ability to determine direct causation is limited, promising results have
revealed the need for more rigorous evaluation.
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5.4 Limitations
Several limitations need to be considered in this study. Firstly, the small number of
participants engaged during the study duration. The sample size of 31 participants
meant that the study was adequately powered. However, the results were limited due
to number of participants categorised into each dosage group. Further, there was no
control group for comparison nor randomisation. This is a result of working within the
constraints of an acute mental health setting and the pragmatic need to have an open
group policy. This study had an open group policy, in which participants could attend
sessions when able. It was difficult to recruit participants to attend sessions daily due
to appointments with other health professionals, going on leave and participants
feeling unwell. Another constraint was that majority participants (n = 17, 54.8%) who
joined the study were discharged after attending between one to five sessions.
Therefore, the study results were underpowered in the dosage groups six to ten (n =
14) and 11 sessions (n = 5). The results were interpreted with caution due to the
possibility of type II error.
Another concern was the use of the subjective self-report outcome measures. All of
the outcomes measures were the best choice for the study due to the low number of
questions and simple language. However, there was concern with an individuals
ability to understand and subjectively rate their experience and emotions on Likert
scales. This is especially true of the acutely unwell participants enrolled in the study.
Furthermore, the use of the PHLMS was trial and error as this was the first study to
use it as a pre and post-test tool. Although, the developers suggested it could be used
as outcome measure, it is questionable whether this tool is sensitive to reflect change
in clinical participants. Each of these limitations indicates that results should be
98
interpreted with caution. Further research is needed to understand the effectiveness of
the mindfulness and sensory modulation group in regulating levels of arousal and
5.5 Recommendations
5.5.1 Practice
Revisions of the Mindfulness and Sensory Modulation group program are required to
ensure that the techniques of mindfulness are explicit within the program. It is
particularly important that the core concepts of awareness and acceptance are
embedded into each activity. The facilitators of the program need to be educated and
encouraged to promote mindfulness throughout each aspect of the session. This
recommendation will improve participants understanding and knowledge of
awareness and acceptance. An aspect that needs to be explicitly written into the
program is a specific warning given at the start of each session. For example, some
people the experience of certain sensations may trigger powerful memories, sometimes
related to previous trauma. If at any time you feel uncomfortable or experience
distress, stop participating in the activity and alert the facilitator. Clinicians running
groups need to be educated regarding this as well as trauma informed care.
An important recommendation for practice to facilitate environmental culture change
is that the mindfulness and sensory strategies are suggested by clinical staff as a least
restrictive intervention before providing PRN sedation. It is important that these
strategies are not just discussed, but that the mindfulness and sensory strategies are
trialled when individuals are experiencing agitation and high levels of arousal.
Although clinical staff received training and education of the importance of
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mindfulness and sensory strategies, it is unlikely that this was enough to facilitate and
sustain culture change. Further training and encouragement is required to be given to
clinical staff to ensure that the mindfulness and sensory strategy is offered and trialled
with individuals. These strategies can then facilitate self-regulating techniques that
can be used by participants upon discharge.
5.5.2 Education
The co-existence of sensory modulation dysfunction and mental health disorders is
prevalent. Occupational therapists have the skills to treat both using techniques of
mindfulness and sensory modulation strategies. The Mindfulness and Sensory
Modulation group program combines the use of both these strategies. As a specialised
occupational therapy designed intervention, this program needs to be taught to
undergraduate occupational therapy students. The Mindfulness and Sensory
Modulation group program provides an alternative least restrictive care intervention
that treats the symptoms of sensory modulation dysfunction, regulates levels of arousal
and emotional reactivity and encompasses the recovery journey of individuals. Post
graduate students are encouraged to do research in this area of practice. Continuing
professional education workshops are needed for already graduated occupational
therapists.
5.5.3 Future Research
A qualitative research project is recommended to interview the participants who took
part in the pilot program to explore their experience of using the Mindfulness and
Sensory Modulation techniques. Additionally, research into the development and
psychometric testing of the Arousal and Emotional Reactivity Scale needs to be
conducted. To date, this is the only outcome measure which subjectively rates levels
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of arousal and emotional reactivity in individuals. Further development of this
outcome measure could provide occupational therapists with information of which
intervention worked best for the individual to self-regulate levels of arousal and
Replication of this study is required over a larger period of time to ensure all dosage
groups are adequately powered. A larger sample size involving more mental health
settings is recommended. These results can then be used to determine the
effectiveness of the intervention and generalise the results to the population.
Additionally, more rigorous research could be conducted to prove the causal link
between participation in the Mindfulness and Sensory Modulation group and
decreased rates in PRN sedation and seclusion. As more research is conducted the
Mindfulness and Sensory Modulation group program can gain greater clinical
importance.
5.5.4 Policy
As the effectiveness of the Mindfulness and Sensory Modulation group program
becomes established then is should be incorporated into policy. The Mindfulness and
Sensory Modulation strategies are a positively impacting alternative intervention that
fits within governmental policies of the recovery framework and the least restrictive
care. It coincides with the national mental health goal of reducing rates of seclusion.
It is therefore important that the Mindfulness and Sensory Modulation group program
becomes a part of fundamental care for individuals with a mental health disorder. This
intervention provides individuals with strategies that can assist self-regulate levels of
arousal and emotional reactivity. These strategies are low cost and are transferrable to
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the community and can be used in a variety of settings. If these strategies are utilised
by individuals, it can assist them to remain well in the community. In turn, reducing
the need for assistance in acute care and reducing the strain on our mental health
system.
5.6 Conclusions
The occupational therapy designed Mindfulness and Sensory Modulation group
program has revealed positive results on regulating participants levels of arousal and
emotional reactivity. Sensory modulation strategies allow individuals to explore
sensory strategies and modulate levels of arousal by modifying occupations or
environments. These strategies are currently used in mental health facilities and
appear to be effective in regulating levels of arousal. This pilot study enhanced the
sensory modulation strategies by adding mindfulness techniques. This addition
provided an opportunity for individuals to increase their awareness and acceptance of
emotional reactivity while using sensory occupations. The combination of
mindfulness and sensory modulation strategies provided unique opportunities for
participants to self-regulate sensory information normalise levels of arousal and learn
techniques to control their emotional reactivity. This promoted an optimal zone of
occupational performance in participants. These mindfulness and sensory modulation
strategies are age appropriate and socially acceptable. The self-management strategies
provided to participants can be continued after discharge from acute care as they are
low cost and transferrable to the community.
Participants were empowered to develop these self-management strategies and take
responsibility to manage their levels of arousal and emotional reactivity. This
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provides techniques that replace maladaptive behaviours with adaptive behaviours and
effective coping strategies. The Mindfulness and Sensory Modulation group program
provided an alternative, trauma informed least restrictive care intervention. The use of
Mindfulness and Sensory Modulation strategies instead of seclusion, reduces the
trauma experienced by already traumatised individuals. The use of mindfulness and
sensory modulation strategies instead of PRN sedation and seclusion is likely to
facilitate a faster recovery of the individual. Reducing the trauma experiences of
seclusion for these already traumatised individuals will promote a positive recovery
journey. Ultimately, these strategies will reduce the length of stay of individuals
saving the health care system vital funds. Overall, the mindfulness and sensory
modulation group program provided important impacting results on young adults with
mental health disorders levels of arousal and emotional reactivity.
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Appendix A
119
The Mindfulness and

Sensory Modulation
Program for Young Adults
Developed by Amy Wilson, Deborah Lockeridge, Dr Julia Bowman and

Elisabeth Marsland
A Pilot Program to be trialled at Birunji Youth Mental Health Unit 2012
120
Disclaimer
The Mindfulness and Sensory Modulation Group Program was specifically designed
for implementation in an acute care mental health setting. It should be implemented with
qualified mental health staff. The information presented in this book is not intended to
replace the advice of a doctor or therapist.
We would like to formally acknowledge that sections of this book have been inspired
by:
Moore, K. (2005). The Sensory Connection Program: Activities for Mental Health Treatment.
Framingham: Therapro Inc.
Huxter, M., & Hall, R. (2008). Mindfulness and a path of kindness, wisdom and happiness: A
workbook for young people aged 15 to 55.
Nhat Hanh, T. (2008). Mindful Movements: Ten exercises for well-being. China: Parallax Press.
121
10 Session Overview
PHASE 1: PHASE 2: PHASE 3: PHASE 4: PHASE 5:

CENTERING MINDFUL SENSORY MINDFUL REPLACING
AWARENESS AWARENESS ACCEPTANCE MALADAPTIVE
BEHAVIOURS
WITH
MINDFUL AND
SENSORY
STRATEGIES
Session 1 Mindful Mindful Bean Bag Discussion Exploring
Stretches Tea/Hot Tapping sensory diets
Deep Breathing Chocolate
Session 2 Mindful Mindful Looking Resistance Discussion Write Your
movements Band Worry Away
Exercises
Session 3 Mindful Mindful Walking Medicine ball Discussion What would
Stretches exercises you do if?
Deep Breathing
Session 4 Mindful Mindful Deep Discussion Goals for
movements Listening Pressure Discharge
Hand
Massage
Session 5 Mindful Mindfulness of Wall Discussion Exploring
Stretches Sound Exercises Emotions
Deep Breathing Meditation
Session 6 Mindful Mindful Tasting Sun Discussion Explore
movements Salutations Sensory Kits
Session 7 Mindful Mindfulness of Exercise Discussion Social Skills

Stretches Breath Circuit
Meditation
Session 8 Mindful Mindful Balance Discussion Exploring our
movements Smelling Routine Senses
Session 9 Mindful Mindfully Eating Self-Foot Discussion Getting Ready

Stretches Chocolate Massage for Discharge
Deep Breathing
Session 10 Mindful Mindful Touch Dumbbell Discussion Assertiveness
movements Weights
122
Session 1
Welcome and Overview of Senses and Mindfulness

Timing 5 minutes
Materials - Arousal and Emotional Reactivity Scale
- Pens
Directions - Make sure all participants complete the arousal and emotional reactivity
scale before starting the group
- Welcome participants to group.
- Introduce group rules
- Discuss the information below with participants
Information - Today we are going to be learning two types of skills, which hopefully
you will be able to use to cope with stress and calm yourself down when
you are feeling distressed.
- These are: sensory experiences and mindfulness.
Sensation
- Sensation is food for the nervous system. Our brain needs a continuous
variety of sensation to develop and function (Ayres, 1979, pp.33)
- We have 6 external senses, which many of us would be familiar with
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
VI. Oral motor (when we suck a lolly pop or chew gum)
- Activities which include these senses can help us change our mood and
are often called sensory snacks or a sensory diet (Willbarger, 1995).
But these only last for a short amount of time
- We also have 3 internal senses and these are:
VII. Vestibular sense or balance
VIII. Proprioceptive sense or movement
IX. Deep pressure touch
- Input from these internal senses has a strong long lasting effect on our
nervous system, which helps us feel calmer for longer.
- Exercise, heavy work and good breathing use our internal senses.
Mindfulness
- Mindfulness, is a strategy in which we pay attention to the present
moment or the here and now, in a non-judgemental way (Siegel,
Germer & Olendzki, 2010; Bishop, et al., 2004)
- It is remember what is happening in the present moment and
remembering to stay in the present, rather than dwelling on the past or
worrying about the future.
- Mindfulness strategies often require us to pay attention to the senses we
have just talked about.
123
Phase 1: Mindful Stretches

Focus of Phase This phase is used to centre the participants through movement and
promote a state of alert calmness.
Sensory
Mindfulness Modulation
Strategies
Timing 10 minutes
Materials Mindful Stretches CD
CD Player
Mindful Stretches Folder
Senses Exercised Proprioception, vestibular and deep pressure touch
Directions - This activity is completed at the movement area.
- Ensure participants have enough space to move.
- Using the background music, guide participants through 8 to 10 stretches
from the mindful stretches folder (Appendix 1; Moore, 2005a).
124
Phase 1: Deep Breathing

Focus of Phase This phase promotes relaxation and a state of calm alertness in participants.
Sensory
Strategies
Timing 5 minutes
Materials Nil
Senses Exercised Respiration
Directions - This activity is completed at the table.
- Guide participants through the deep breathing exercise below.
Mindfulness Introduction
Script
- We are going to practice some deep breathing.
- Deep breathing is a very useful coping strategy which each of you can use
at any time, with no cost or equipment. Better still, it is a coping strategy
which is normal and can be used discretely in social situations like work,
school, in the shopping centre or on the bus (Moore, 2005a)
- Deep breathing is the most basic relaxation exercise (Moore, 2005a,
pp.111). It works best if you do it on a daily basis and even a few deep
breaths can help your body calm down.
Exercise
- Lets get started. Make yourself comfortable in the chair with your feet
flat on the floor.
- Close your eyes and place your hands gently on your stomach in order to
feel your breaths. You can close your eyes if you wish.
- Inhale deeply through the nose and feel your abdomen expand as you
breathe in.
- Pause then slowly exhale through your mouth with your lips puckered as if
blowing bubbles. Continue exhaling until your lungs feel empty.
- Continue to breathe in and out slowly and deeply in through your nose
and out through your mouth.
- Make sure your stomach expands and contracts with each breath. If your
shoulders rise and fall instead, your breathing is shallow. Try to focus on
expanding your stomach.
- One way to make the breaths more rhythmic is to count to three slowly as
your inhale, pause and then exhale slowly to the count of three. Lets do
this. Breathe in, 1, 2, 3. And now breathe out, 1, 2, and 3. (Repeat this 3
125
times)
- Try to focus only on your breathing. If your thoughts wander, just bring
the focus of your attention back to your breathing. If any worries pop into
you mind, let them pass by and refocus your attention to your breathing.
- Each time you breathe out try to relax your body a little bit more. If a
particular area is tense, focus on relaxing that area as you exhale.
- Breathe in, 1, 2, 3. And now breathe out, 1, 2, and 3. (Repeat this 3 times)
- Continue to observe your breathing for one minute without my voice
guiding you.
- When you are ready to stop, open your eyes slowly.
(Moore, 2005a)
126
Phase 2: Mindful Tea / Hot Chocolate Drinking

Focus of Phase This phase promotes mindfulness through everyday sensory experiences. It
encourages participants to obtain a mindful awareness of their external
senses.
Sensory
Strategies
Timing 10 minutes
Materials 4 clear water jugs (3 x boiling water, 1 x cold water)
Different flavours of tea bags
Hot chocolate sachets
10 to 12 foam cups
Senses Exercised Smell, taste, touch
Directions - Have participants sit at the table.
- Place the various tea bags in the middle of the table. Have participants
select and make a tea of their choice.
- Hot chocolate is an option for those who do not like tea.
- Lead participants through the mindful tea / hot chocolate drinking
exercise below.
Mindfulness - We are now going to participate in a mindful tea/hot chocolate drinking
Script exercise. Try your best to concentrate only on the tea/hot chocolate and
the sensation of drinking the tea/hot chocolate. If any other thoughts or
worries pop into your mind, just let them go, and re-focus your attention
to the tea/hot chocolate.
- During this exercise I am going to give you some instructions and I will be
posing some questions to help you concentrate on the task of tea drinking.
I dont want you to answer these questions aloud, but instead use these
questions to focus your attention to the sensation of drinking tea/hot
chocolate.
- Lets get started. Focus your attention to the cup of tea/hot chocolate in
front of you. Remember why you selected the particular tea/hot
chocolate you did.
- Dont pick up the cup just yet, but instead focus your attention to the
physical appearance of the tea/hot chocolate. Note if there is steam
coming from the top of the cup. Pay attention to the colour of the tea/hot
chocolate and the colour and physical appearance of the cup.
- Pick up the cup in your hands. Use your sense of touch to notice the
temperature of the tea/hot chocolate. Can you feel the warmth in your
hands?
- Now lift the cup up towards your nose and use your sense of smell to
absorb the aroma of the tea/hot chocolate. Note if this is a familiar smell.
127
Have you smelt something like this in the past? Is it a calming smell? What
does it smell like? Remember, dont answer out loud. Take note of the
smell and we will talk about it later.
- Bring the cup to your mouth and run the rim of the cup along your lips.
Feel the texture of the foam cup against your lips. Is it smooth or rough?
Can you feel the warmth of the tea/hot chocolate on your lips? Are you
noticing the aroma of the tea/hot chocolate?
- Take a sip. What do you immediately notice with this sip? Is it the
temperature of the tea / hot chocolate? Is it the sensation of the hot
liquid in your mouth? Or is your attention drawn to the flavour of the tea
/ hot chocolate?
- Keep your attention focused on the tea / hot chocolate. The feeling of the
hot liquid in your mouth. Can you feel the warmth as the tea travels down
to your stomach?
- Take another sip. Notice the urge to swallow, but try not to. Just let the
tea/hot chocolate sit in your mouth for a short moment before you
swallow. Can you notice a difference in the feeling of sipping to
swallowing?
- Continue to slowly bring the cup towards your mouth. Take slow sips, and
slowly swallow. Notice the senses of smell, taste and touch, with each sip
you take. If your mind should wonder, just slowly and carefully bring your
attention back to the cup of tea/hot chocolate and the sensation of
drinking it.
- With each sip you take you are becoming calmer and calmer.
- When you are ready, you may place your cup down. Now bring your
awareness back to the room we are in, notice the people around you and
the sounds of the room.
- May the mindfulness you cultivated during this exercise guide you through
the rest of your day.
(Moore, 2005a; Smith, 2005).
128
Phase 3: Bean Bag Tapping

Focus of Phase This phase provides strong sensory input from the internal senses. It
promotes body awareness and self-regulation in participants.
Sensory
Strategies
Timing 15 minutes
Materials Bean bags
Senses Exercised Deep pressure touch
- Guide the participants through the bean bag tapping instructions below.
(Moore, 2005a, pp.100)
To Begin
Bean bag tapping wakes up our muscles and gets us in

touch with our body. Tapping can help us feel calm and
organised. It sets off the feel good chemicals, just like a
deep massage.
Tapping should be done with an attitude of kindness

towards the body. So tapping should be firm, not hard
and not light. Make sure you dont tap your face, neck
and stomach.
When tapping, hold the top of the bean bag and make
sure that all the beans are at the bottom of the bag.
Lets get started. Hold the bean bag in your right hand.
129
Tapping on the Fingers
Begin by laying the left hand on the table. Begin

tapping each finger and thumb.
Tapping should be done with kindness to your body.

Make sure the tapping is firm, but not hard.
Tapping on the Hand
Move the tapping to the hand on both sides.
Tapping on the Arm
Now tap the forearm.
Tapping all the various surfaces waking up all the

muscles in your forearm.
Move the tapping to your upper arm.
Continue tapping all the muscles of your upper arm,

waking them up.
130
Tapping on the Shoulder
Tap the front, side and back of your shoulder.
Remember to keep the tapping firm.
Tapping across the Chest
Tap across the upper chest, waking up the pectoral

muscles.
Tapping the Opposite Fingers, Hand, Arm and Shoulder
Now, hold the bean bag in the left hand.
Repeat the tapping process of the right fingers. Moving

up the right hand, arm and shoulder.
Tapping all the various surfaces waking up all the

muscles.
Tapping on the Back
Tap across your back, as far as you can comfortably

reach.
Can you feel the tingling effect?
131
Tapping on the Upper Leg
Now start tapping the thighs.
Tap all the surfaces you can, waking up your muscles.
Tapping on the Lower Leg
Move the tapping to the knees and shins.
Wake up all of the muscles tapping the front and the

back of the lower leg.
Tapping on the Feet
Continue to tap the top and bottoms of both feet.
Remember to keep the tapping firm.
132
Phase 4: Discussion
Focus of Phase This phase promotes mindful acceptance of participants. Participants
accept the thoughts and feelings experienced throughout the phases and
identify what strategies were successful.
Sensory
Strategies
Timing 5 minutes
- Lead the participants in a discussion of the following questions
Questions
- What was your favourite technique?
- Which technique made your feel most calm?
- Which technique/s do you think you will practice outside of the group
while you are still on the ward?
- Which technique do you think you will continue to practice after leaving
hospital?
- How could you build mindfulness and sensory activities into your daily
routine?
133
Phase 5: Exploring Sensory Diets

Focus of Phase This phase promotes replacing maladaptive strategies with adaptive
strategies in participants using problem based learning.
Sensory
Strategies
Timing 10 minutes
Materials My personal sensory diet worksheet
Pencils / Pens
Objectives - Participants to identify items or activities that can be applied to their
individuals sensory diet
- To prepare for transition to the community
- Explain to participants that they are currently learning about how different
senses and strategies are used to calm or alert us.
- Allow the participants to identify activities or items that they would like to
incorporate into their daily routine.
- Instruct the participants to complete the my personal sensory diet
worksheet, circling one or more activity that they liked under each of the 9
senses.
- By the end of the activity each participant will have their own personalised
sensory diet of activities.
Closing
Timing 1 minute
- Pens
Directions - Make sure all participants complete the arousal and emotional
reactivity scale at completion of the group
- Thank participants for coming todays session.
- Advertise the next session
134
Session 2

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
135
Phase 1: Mindful Movements

Sensory
Strategies
Timing 15 minutes
Materials Mindful Movements Folder
Senses Exercised Proprioception and vestibular
- Guide the participants through the movements in the Mindful Movements
folder (Appendix 2; Nhat Hanh, 2008).
136
Phase 2: Mindful Looking

senses.
Sensory
Strategies
Timing 10 minutes
Materials Alerting Visual Stimulus (with a red sticker on the back)
Calming Visual Stimulus (with a blue sticker on the back)
Senses Exercised Vision
- First section: place the visually alerting pictures on the table. Have
participants select their own pictures. Lead the participants through the
mindful script. Leader to select 1 or 2 questions and guide participants in
the discussion below.
- Second section: place the visually calming pictures on the table. Have
participants select their own pictures. Lead the participants through the
mindful script below. Leader to select 1 or 2 questions and guide
participants in the discussion below.
Script
- We are going to participate in a visual exercise, where we will be looking
at a visually alerting picture, and then a calming picture.
- During this exercise, I am going to give you some instructions and I will be
posing some questions to help you concentrate on the task. I dont want
you to answer these questions aloud, but instead use these questions to
focus your attention on the sensation of looking at the pictures.
- Try your best to concentrate only on the pictures in front of you.
Remember that if any thoughts or worries enter into your mind, just let
them go and re-focus your attention on the sensation of looking at the
pictures.
Mindful Script - Visually Alerting
- Bring your attention to the picture in front of you and look at it for a
couple of minutes. Try not to be distracted by thoughts or feelings.
Remember to always, bring your thoughts back to what we are doing,
looking at the picture.
- Take note of the colours, are they bright or soft? Are there many colours
and are the colours of a similar shade or are they vastly different?
- Pay attention to the picture itself, what is happening in the picture? Who
or what is in the picture?
137
- Let yourself be absorbed into the picture.

- When you are ready look up and we will talk about your experiences with
this picture.
Discussion
- What did you notice in the picture? Were there flowers, people, or a
landscape?
- How do you feel about the picture?
- Were you able to concentrate on it?
- Did you enjoy looking at it? Or not?
- What specifically did or did not you like? The bright colours? The soft
colours?
- Do you feel calm or excited after looking at the pictures?
Mindful Script - Visually Calming
- Bring your attention to the picture in front of you and look at it for a
couple of minutes. Try not to be distracted by thoughts or feelings.
Remember to always, bring your thoughts back to what we are doing,
looking at the picture.
- Take note of the colours, are they bright or soft? Are there many colours
and are the colours of a similar shade or are they vastly different?
- Pay attention to the picture itself, what is happening in the picture? Who
or what is in the picture?
- Let yourself be absorbed by the picture.
- When you are ready look up and we will talk about your experiences with
this picture.
Discussion
- What did you notice in the picture? Were there flowers, people, or a
landscape?
- How do you feel about the picture?
- Were you able to concentrate on it?
- Did you enjoy looking at it? Or not?
- What specifically did or did not you like? The bright colours? The soft
colours?
- Do you feel calm or excited after looking at the pictures?
(Henry, Wheeler & Sava, 2005; Moore, 2005a).
138
Phase 3: Exercise Band Exercises

Focus of Phase This phase provides strong sensory input from the internal senses.
Promotes body awareness and self-regulation in participants.
Sensory
Strategies
Timing 15 minutes
Materials 10 x 130cm piece of exercise band with the ends knotted together in a firm
knot to form a ring
Senses Exercised Vestibular, proprioception
Directions - This activity is started with participants in chairs and then moved to the
movement area
- Lead participants in the exercise band exercises below.
Bicep Curls
Sitting on the edge of the chair, make sure the feet

are flat on the floor, and knees are bent at 90
degrees.
Place one end of the exercise band under the right

foot. Hold the exercise band in the right hand ready
to begin.
Slowly lift the right hand up to the right shoulder.
Slowly move the right arm back down.
Repeat this sequence 10 times. Repeat the exercise

using the left arm.
139
Crunches
Sitting down on the floor with your feet out in front of

you. Loop the exercise band around the middle part
of both feet. Make sure you keep your feet together
and toes pointing upwards throughout the exercise.
Hold the exercise band with two hands. Slowly lower

your upper body towards the ground.
Dont lower yourself all the way to the ground. Hover

just above the floor.
Hold this for 2 seconds, and then slowly lift yourself

back to a sitting position.
Repeat this exercise 10 times.
Leg Lifts
While sitting, loop the exercise band around the right

foot. Tightly hold the exercise band with both hands
and lay down on the floor.
Hold the exercise band in both hands just above the

right hip.
Keeping the knee straight, lift the leg up until the sole
of your foot faces the ceiling. Slowly lower the leg to
the ground.
Repeat this exercise 10 times. Repeat the exercise

using the left leg.
140
Leg Circles
Sitting on the floor, loop the exercise band over the

right foot. Hold the exercise band in the left hand.
Place the right hand behind you for balance.
Lift your foot until it is 20 centimetres off the floor.
Start slowly circling the foot in a clockwise direction

10 times. Circle the foot in an anti-clockwise direction
10 times.
Repeat this exercise with the left foot.
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
141
Phase 5: Write your worries away

Sensory
Strategies
Timing 10 minutes
Materials Post it notes
Pencils
Rubbish Bin
Objectives - To practice techniques to reduce stress.
- Improve mindfulness techniques of non-judgementally remove thoughts
and focus on the present moment
- Give each person a post it note and pen
- Educate participants that worries and stresses are common in everyones
life. Have the participants think of some worries and stresses.
- Instruct the participants to write down one worry or stress, big or small
that prevents them from enjoying life. Tell the participants that this is a
private exercise and they wont need to share.
- Once the participants have written their worry down, instruct them to
scrunch up the piece of paper tightly and throw it away.
- Explain that this mindfulness technique of throwing away your worries
refocuses your thoughts and attention to the present moment.
- If time allows, complete this exercise again.
Discussion
- How did everyone feel after completing that exercise?
- Did the exercise work for you?
- Do you think this is something that you could do at home to stop
worrying?
Closing
Timing 1 minute
- Pens
142
Session 3

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
143

Sensory
Strategies
Timing 10 minutes
CD Player
144

Sensory
Strategies
Timing 5 minutes
Materials Nil
Script
Exercise
flat on the floor.
breathe in.
145
times)
guiding you.
(Moore, 2005a)
146
Phase 2: Mindful Walking

senses.
Sensory
Strategies
Timing 10 minutes
Materials Nil
Senses Exercised Nil
Directions - This activity can be completed in the movement area or in the therapy
garden.
- Ensure there is enough space around participants to walk a few paces in
front and behind them.
- Lead the participants through the mindful walking meditation below.
Script
- Make the intention that for the next 10 minutes when your mind gets
dragged off somewhere else you will remember to come back to the here
and now and be mindful of walking.
Exercise
- Begin by standing and bringing awareness to the way you are standing.
See if you can be upright but relaxed, with eyes looking a few metres in
front of you. Let your chest be open, relax your shoulders. Make sure your
knees are not locked and place your hands where they are comfortable.
- Let standing be in the centre of your awareness.
- Open your awareness so that it drops to the feet and its sensations.
Notice what your feet feel like, whether they are cold or hot. Notice the
pressure of the floor or ground beneath them.
- Now, when you are ready, take a step.
- Notice the changing sensations as the weight shifts onto one foot. Now
pick the other foot up and take another step.
- Observe how your foot feels as it travels through the air. Notice the
changing sensation of the pressure as you place it on the ground.
- Walk at a slow pace and find a rhythm that is comfortable for you.
- When thoughts, sounds, sights and emotions pull your attention away
from walking, simply notice the experience. Do not struggle with these
distractions and refocus your attention onto walking.
- When you come to the end of your walking pathway, stop and turn
147
around. Be aware of the sensation of turning and walk mindfully back

along your pathway.
- Continue walking for a few moments and when you are ready come to a
stop.
- Let the mindfulness cultivated during this mindful walking exercise carry
over into your daily life.
(Huxter & Hall, 2008; Smith, 2005)
148
Phase 3: Medicine Ball Exercises

Sensory
Strategies
Timing 15 minutes
Materials Medicine Balls
Senses Exercised Proprioception, vestibular, deep pressure touch
Directions - This activity is started with participants in chairs and then moved to the
movement area
- Hand out medicine balls to participants.
- Guide the participants through the medicine ball exercises below.
(Moore, 2005a; 2005b)
To Begin
Sit with the medicine ball in your lap, and observe the
weight of it. Is it heavy? Does it feel calming?
Lift Over Head
With two hands, lift the ball over head.

Repeat this 4 times.
Does it feel different to when it was in your lap?

Can you feel the stretch down the back of your arms
when you lift the medicine ball overhead?
149
Sitting on the Floor
Now we are going to move with the ball down to the

floor. While you are walking with the ball, hold it close
to your body.
How does it feel when you walk with the ball?
Sit down with your feet and legs out in front of you.
Place the medicine ball in your lap.
Lift Over Lap
Lift and hold the ball just above your lap. Hold this for
4 seconds.
Place the ball back on your lap.
150
Side to Side
Hold the medicine ball in both hands above you lap.

Lean slightly back.
Move the ball to one side. Then slowly back to the

centre.
Move the ball to the other side. Then slowly back to

the centre.
Repeat this process 4 times.
Roll Down Legs
Place the medicine ball on your lap. Roll the medicine

ball down the outstretched legs, as far as possible
without letting the ball go.
Can you feel the weight moving down your legs?
151
Roll the medicine ball back up to your lap.
Hand to Hand
Hold the ball above your lap. Hold the ball in one hand.
How does the weight feel in your hand?
Move the ball to the other hand.
Repeat this process four times.
152
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
153
Phase 5: What would you do if?

Sensory
Strategies
Timing 10 minutes
Materials What would you do if cards
Objectives - To practice problem solving
- Review safety strategies
- Role play emergency responses
- Prepare for transition into the community
- Place cards face down on the table, making sure colours are scattered.
- Explain that in this activity each participant takes turns to select a card and
read out the scenario. Participants then answer the question with what
they would do in that situation who would they call and what would
they say.
- Leader goes first.
(Moore, 2005a)
Closing
Timing 1 minute
- Pens
154
Session 4

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
155

Sensory
Strategies
Timing 15 minutes
156
Phase 2: Mindful Listening

senses.
Sensory
Strategies
Timing 10 minutes
Materials CD with alerting and calming music
CD Player
Senses Exercised Hearing
- First section: Lead the participants through the mindful script below. Play
the first track of music, the alerting music. Leader to select 1 or 2
questions and guide participants in the discussion below.
- Second section: Lead the participants through the mindful script below.
Play the second track of music, calming music. Leader to select 1 or 2
questions and guide participants in the discussion below.
Script
- We are now going to use your sense of hearing to participate in a listening
exercise. Try your best to concentrate only on the music you will hear.
- I am going to give you some instructions to help you concentrate on the
task. I dont want you to answer these out loud, just use them to help you
focus on the task at hand, the sensation of listening to the music.
- Remember that if any other thoughts or worries pop into your mind, just
let them go and refocus your attention to the music.
- Lets get started. Listen carefully to the music and then later we will talk
about how we felt about it.
Mindful Script - Play track 1 Alerting Music
- Pay attention to the pace / rhythm of the music. Is it fast and upbeat or is
slow and rhythmic?
- Is the rhythm or beat predictable and consistent?
- Pay attention to the style of the music Is it classical, romantic, ambient or
upbeat?
- Pay attention to how the music makes you feel? Is it calming or alerting?
Discussion
- What did you notice about the music? Fast? Loud? Slow? Soft? Steady
beat?
- How do you feel about the music? Were you able to concentrate on it?
- Did you enjoy or not enjoy listening to it?
157
- What specifically did or didnt you like? The loudness? The beat? Was it
fast or slow?
- Do you feel calm or excited after listening to the music?
Exercise- Play track 2 Calming Music
- Pay attention to the pace / rhythm of the music. Is it fast and upbeat or is
slow and rhythmic?
- Is the rhythm or beat predictable and consistent?
- Pay attention to the style of the music Is it classical, romantic, ambient or
upbeat?
- Pay attention to how the music makes you feel? Is it calming or alerting?
Discussion
- What did you notice about the music? Fast? Loud? Slow? Soft? Steady
beat?
- How do you feel about the music? Were you able to concentrate on it?
- Did you enjoy or not enjoy listening to it?
- What specifically did or didnt you like? The loudness? The beat? Was it
fast or slow?
- Do you feel calm or excited after listening to the music?
- When do you think listening to calming or alerting music could be helpful?
(e.g. calming music as a relaxing technique, alerting music to promote
concentration or to increase alertness)
- How could you use music in your daily routine?
(Henry, Wheeler & Sava, 2005; Moore 2005a)
158
Phase 3: Deep Pressure Hand Massage

Sensory
Strategies
Timing 15 minutes
Materials Containers of hand creams varying scents
Senses Exercised Deep pressure touch and smell
- Guide the participants through a mindful hand massage.
Discussion:
- What made you choose the hand cream you selected?
- Does the hand massage feel good?
- How could you incorporate a hand massage into your daily routine?
(Moore, 2005a)
Mindful Hand Massage
Place a small amount of cream into the palm of your

hand.
Pay attention to the feeling of the cream. Is it cold? Is
it warm?
Bring your palm up to your nose and focus your

attention on the scent of the hand cream.
Is it a smell youve smelt in the past? Does it make your
feel calm or alert?
Focus your attention to the colour of the hand cream.
Does the colour match the scent?
Notice the texture of the cream; is it smooth, grainy or
lumpy?
159
Bring your palms gently together and gently rub back

and forth, paying attention to the cream between your
palms.
Clasp your hands together by interlocking your fingers.
Gently and firmly rub the palms of your hands together.
Using the heal of your right hand; massage the palm of

your left hand with large circular motions.
With each circular motion you can feel yourself
becoming calmer and calmer.
Using the heal of your left hand massage the palm of
your right hand with large circular motions.
Using your right thumb, massage the left palm using

small circular motions.
Then swap over, using your left thumb to massage the
palm of your right hand with small circular motions.
Using your right thumb, massage the back of your left

hand by moving the thumb in small circular motions.
Then swap over, using your left thumb to massage the
back of your right hand. Then release your hands.
Using your right thumb and index finger, massage

between the webs of each of the fingers on the left
hand. Then using your left thumb and index finger,
massage between the webs of each of the fingers on
the right hand.
Apply pressure to each of the fingers on the right hand,

gently pulling the finger then release.
Do the same for the left hand, gently applying pressure
to each of the fingers, gently pulling to release.
160
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
161
Phase 5: Goals for Discharge

Sensory
Strategies
Timing 10 minutes
Materials Goal for Discharge Cards
Objectives - To identify ways in which one can make positive lifestyle changes and
choices that promotes good physical and mental health.
- To build skills for staying well.
- To facilitate the use of problem solving and communication skills.
- Scatter the cards face up on the table.
- Instruct the participants to select one or more goals that are important to
them.
- Once all the participants have selected a goal, have participants take a
turn in answering one of the questions below.
Discussion
- What is your goal?
- When do you plan to achieve this goal in the immediate (within a week),
short term (within a month), and medium term (within six months) or long
term (within a year or longer)?
- How will you go about achieving this goal?
- How important is this goal to you?
(Moore, 2005a)
Closing
Timing 1 minute
- Pens
162
Session 5

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
163

Sensory
Strategies
Timing 10 minutes
CD Player
164

Sensory
Strategies
Timing 5 minutes
Materials Nil
Script
Exercise
flat on the floor.
breathe in.
165
times)
guiding you.
(Moore, 2005a)
166
Phase 2: Mindfulness of Sound Meditation

senses.
Sensory
Strategies
Timing 10 minutes
Materials Nil
Senses Exercised Hearing
Directions - This activity can be completed in the therapy garden. Invite participants
to sit on bench chairs or the grass.
- Lead participants through the mindfulness of sound meditation below.
Script
- Make the intention that for the period of this exercise you will not follow
concerns about things other than being here and now being mindful of
sound.
- Be open and kind to other experiences if and when they come up.
Exercise
- Make yourself comfortable, sitting upright and relaxed.
- Scan your body and release whatever tension you might have.
- Now bring your awareness to sound. Be aware of sound as sound and
vibration.
- There may be sounds of music, birds, cars, traffic, wind, rain, or just the
hum of silence.
- Notice how you may create pictures and names around the sound such as
my favourite music track, dog barking, traffic, and birds.
- Dont struggle with the names or the pictures and simply listen to the
sounds and vibrations. Noticing how the sounds rise and pass away.
- Notice how some sounds are pleasant, some sounds are unpleasant and
some sounds are neither pleasant nor unpleasant.
- Be aware of all your judgements, feelings and thoughts but dont worry
about them. Simply remember to be aware of sound as sound.
- Now arising.........now changing.........now passing away.
- Let your mind be as if it is the sky, open, expansive and clear. Let sounds
rise and pass through.
- By listening to sounds, as an orchestra of life, you can become very
167
peaceful.
- By listening to sounds and noticing how they all change you can become
very peaceful.
- Be content and at peace to listen to sounds.
- When the time is right you can end this period of mindfulness.
- If mindfulness of sounds was helpful to you, remember that you can be
mindful of sounds whenever it feels like the right thing to do.
(Huxter & Hall, 2008, pp. 49-50; Smith, 2005).
168
Phase 3: Wall Exercises

Sensory
Strategies
Timing 15 minutes
Materials Wall space
Directions - Ensure that there is enough wall space for each participant.
- Guide the participants through the wall exercises below.
(Moore, 2005a; 2005b)
Wall Pushes
Place both hands flat on the wall, shoulder distance

apart and have one foot out in front of the other.
Push against the wall. Hold this for ten seconds.
Swap legs and push the wall again. Hold for ten
seconds. Repeat this twice.
Wall Touches
Stand with the feet shoulder-width apart. Bend legs

slightly at the knees.
169
Jump up and tap the wall at arms length, keeping your

arms straight.
Wall Sits
Lean your back against the wall.
Slide down until your knees are at approximately a 90

degree angle, with your hands at your sides.
Hold the position and focus on keeping your abdominal

muscles contracted.
Hold this exercise for 20 seconds.
Wall Crunches
Lie on your back. Place your feet flat on the wall. Bend
your knees and hips so they are at 90-degree angles.
Tighten your abdominal muscles while raising your

head and shoulders off the floor.
Relax your neck and shoulders back down to the floor.

170
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
171
Phase 5: Exploring Emotions

Sensory
Strategies
Timing 10 minutes
Materials Exploring Emotion Cards
Posters of Emotion Words
Objectives - To identify emotions, increase self-expression of emotions and learn self-
regulation in dealing with feelings.
Directions - Place the emotions posters face up on the table.
- Instruct the participants that this game will be taken in turns.
- One participant will select a card and act out the emotion to the rest of
the group.
- After participants have guessed the emotion, ask 1 to 2 of the questions
below.
Discussion
- Is this an emotion that you feel often?
- When was the last time you felt this way?
- How do you deal with the feeling?
- If the emotion is good, what is one thing you could do to promote this
feeling again?
- If the emotion is bad, what is one thing you can do to avoid feeling this
way again?
(Moore, 2005a)
Closing
Timing 1 minute
- Pens
172
Session 6

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
173

Sensory
Strategies
Timing 15 minutes
174
Phase 2: Mindful Tasting

senses.
Sensory
Strategies
Timing 10 minutes
Materials Containers with food samples (hard candy, orange slices, gum, dried fruits,
popcorn, raw vegetables, crunchy cereal, crushed ice)
Small plates for participants
Serviettes
Senses Exercised Taste, oral motor
- Open the containers of food and place in the centre of the table.
- Encourage participants to take a small plate of preferred sample food
items.
- While participants taste their food, lead the participants through the
mindful script below.
- Leader to select 1 or 2 questions and guide participants in the discussion
below.
Script
- We are now going to participate in a tasting exercise.
- Try your best to concentrate only on the food you will taste. And
remember, that if any other thoughts or worries pop into your mind just
let them go, and re-focus your attention to the food.
- I am going to guide you with some instructions and questions I dont want
you to answer these aloud. Instead, use these to help you focus on the
sensation of tasting the food.
Exercise
- Select one piece of food and place it in your mouth.
- Use your oral motor sense and pay attention to the way the food feels in
your mouth.
- Pay attention to how your mouth is moving while eating the food. Do you
need to suck, chew or crunch on the food to eat it?
- Use your sense of taste and focus on how the food tastes. Is it spicy, salty,
sweet or sour?
175
Discussion
- What did you notice about your mouth movements? Did you need to
crunch, chew or suck the food?
- Did you enjoy or not enjoy the taste of it? Was it sour, salty, spicy or
sweet?
- What specifically did / didnt you like?
- Did the food help you concentrate, feel calm or excited?
Oral Motor:
Calming/Sucking: Organizing/Chewy: Alerting/Crunchy:
- Hard/boiled lollies - Chewing gum - Pop corn
- Thick liquid in a - Bagel - Pretzels
straw such as a
- Gummy Bears - Raw vegetables
thick shake
- Liquorice sticks - Crunchy cereal such
- Sweet orange slices
as Nutrigrain
- Dried fruits
- Lollypop
- Crushed ice
Taste:
Calming Taste Sensations: Alerting Taste Sensations:
- Mild flavours - Strong or spicy
- Sweet - Sour or bitter (e.g. lemon)
- Sweet hard boiled lollies - Bitting a lemon or lemon drop
- Lollipop - Strong mints (e.g. peppermint)
- Pleasant tasting foods - Distasteful foods
- Oatmeal and brown sugar - Chilli
- Apple juice - Lemonade
- Sweet fruits like cherries and - Pickles
grapes
(Henry, Wheeler & Sava, 2005; Moore, 2005a)
176
Phase 3: Sun Salutations

Sensory
Strategies
Timing 10 minutes
Materials CD Player
Music CD
Directions - Ensure that there is enough floor space for each participant.
- Guide the participants through the sun salutation exercises below.
Sun Salutation
Start with your feet together and hands in prayer at the

heart.
Inhale and stretch your arms above your head, while

hands are still in the prayer position. Look up towards
the sun.
Lengthen your spine and enjoy the stretch.
Standing Forward Bend
Exhale and bring your hands down toward your feet or

shins. Rest your stomach against your thighs and your
head toward your knees.
Relax into this stretch.
177
Standing Forward Half Bend
Inhale and look forward. Walk your hands out in front

of you 30 cm. Keep your back flat.
Step Through
Exhale and keeping your hands flat on the floor, step

back into the plank position. First your right leg, then
your left leg.
Plank Pose
Inhale and hold this position. Enjoy the stretch.
Downward Facing Dog
Exhale and move into the downward dog position. Feet

hip width apart.
Try and press your heels into the floor.
178
Step Through
Inhale and bend your knees. Look forward and step

your right foot between your hand and then your left
foot.
Standing Forward Bend
Exhale and fold forward again. With your hands down

toward your feet (or shins), resting your stomach on
your thighs, and your head toward your knees.
Relax into this stretch.
Sun Salutation
Inhale and take your arms above your head in prayer

position. Look up toward the sun.
Lengthen your spine and enjoy the stretch.
Exhale and return your hands to a prayer position in

front of your heart.
Complete a total of two repetitions.
179
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
180
Phase 5: Exploring Sensory Kits

Sensory
Strategies
Timing 10 minutes
Materials Various sensory items used in the program (scented candles, scented hand
cream, music items from other sessions)
Sensory Kit Worksheet
Pens
Objectives - For participants to identify items or activities that can be applied to their
individual sensory diet
Directions - This activity is completed at the table. Set the sensory items out in the
middle of the table.
- Allow the participants to explore the items.
- Instruct the participants to complete the Sensory Kit worksheet, listing
one or more items that they would like in their personal sensory kit.
- By the end of the activity each participant will have planned their own
Sensory Kit.
Closing
Timing 1 minute
- Pens
181
Session 7

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
182

Sensory
Strategies
Timing 10 minutes
CD Player
183
Phase 2: Mindfulness of Breath Meditation

senses.
Sensory
Strategies
Timing 10 minutes
Materials Nil
Senses Exercised Respiration, touch, hearing
Directions - This activity can be completed in the therapy garden. Invite participants
to sit on bench chairs or the grass.
- Lead participants through the mindfulness of breath meditation below.
Script
- We are now going to practice a mindfulness of breath exercise. You may
wish to sit in your chair or lie on the ground.
- During this exercise, if you feel uncomfortable of being mindful of your
breath, you may shift your attention to something else. For example, be
aware of sight, sounds, and your body or be aware of movement. Try not
to force yourself to do anything that will not benefit yourself or others.
- Make the intention that for the period of this exercise you will not follow
concerns about things other than being here and now being mindful of
sound.
- Be open and kind to other experiences if and when they come up.
Exercise
- Allow yourself to be as comfortable as you can, either lying face up or
sitting on a chair.
- If you are sitting, make sure that your back, neck and head are upright and
straight in a relaxed way. You can close your eyes, or if they remain open,
dont look around or focus on anything in particular.
- Set a goal that for the next 10 minutes, you will not fidget or move
unnecessarily. Nor will you be too worried by anything in the past or
future. Try to focus your attention on the here and now.
- Bring your attention to your body as a whole and let go of tightness. If you
want you can do an awareness scan throughout your body. Find any tight
spots and let them go using your out breath to help you.
- As you let go of tightness, it is as if your awareness of the here and now
184
experiences of your body becomes clearer and sharper.

- As you sit or lie there, notice the movement of your breath in your belly. If
you cant feel the movement in your belly, be aware of the movement in
your chest or in both your chest and belly.
- Dont force your focus but rather let your aware mind be open and
sensitive to what is happening. Just watching, just being present, and
letting the breath breathe you. Dont worry about trying to control the
breath.....just let it be completely natural.
- Keep your breathing natural, neither speeding it up or slowing it down. Let
yourself be accepting of the breath without worrying that it should be
other than it is.
- You can use noting such as rising or falling to help you bring your
attention to the movement of your belly or chest as you breathe.
- If it feels right, pay attention to the beginning, middle and end of the
falling movement of the breath and the beginning, middle and end of the
falling movement.
- Otherwise it is enough to know that you are breathing here and now.
- Do not struggle with thoughts, feelings, or other experiences but let them
come and go, bringing your awareness back to your breath.
- Allow your open and focused mind to notice just one breath at a time.
- Continue to let the breath be central in your awareness and do not be
concerned about thoughts, sounds and other things that come and go.
- When you are ready to finish your meditation period. Think back over this
meditation and what happened and what worked to bring you peace.
- At times throughout the rest of today or in the future you can be mindful
of your breath. In this way mindfulness of breath can be an anchor back to
the present moment and the freedom that can be found here and now.
- Slowly open your eyes, if they are closed. Stretch your body and go into
the world in a wise and mindful way.
(Huxter & Hall, 2008, pp. 50-51).
185
Phase 3: Exercise Circuit

Sensory
Strategies
Timing 15 minutes
Materials Cross Trainer
Medicine Balls x 4
Water bottle dumbbells x 8 (4 sets)
Exercise band x 4
Instruction Cards for each station
Directions - Set up a circuit with the above equipment.
- Check if anyone has an injury that may prevent them from participants.
- Allow participants to select which station they wish to go to.
- For safety, participants using the exercise bike or cross trainer must have
closed in shoes. No thongs or slip on shoes.
- Get participants to select two exercise stations they would like to
complete. Allow 4 minutes for each station. When time is up, have
participants swap to another station.
- Have participants guide themselves through the exercises using the
instruction cards.
(Your Online Resource for Dumbbell Exercises, 2010)
Station 1: Cross Trainer
Stand on the cross trainer and move in a forward

direction. Pay attention to the muscles you are using to
make the cross trainer move.
How do your muscles feel when you stride and when

you stop? Are you able to get into rhythm? Is that
rhythm calming?
186
Station 2: Medicine Ball - Lift Over Lap
Lift and hold the ball just above your lap. Hold this for
4 seconds.
Place the ball back on your lap.
Medicine Ball - Side to Side
Hold the medicine ball in both hands above you lap.

Lean slightly back.
Move the ball to one side. Then slowly back to the

centre.
187
Move the ball to the other side. Then slowly back to

the centre.
Medicine Ball - Roll Down Legs
Place the medicine ball on your lap. Roll the medicine

ball down the outstretched legs, as far as possible
without letting the ball go.
Can you feel the weight moving down your legs?
Roll the medicine ball back up to your lap.
Medicine Ball - Hand to Hand
Hold the ball above your lap. Hold the ball in one hand.
How does the weight feel in your hand?
188
Move the ball to the other hand.
Repeat this process four times.
Station 3: Dumbbell Routine - Palm In Alternating Shoulder Press
Hold the two dumbbells on top of the shoulders.
Lift one dumbbell straight up and straighten your arm.

Lower your arm back down. Alternate hands after the
full motion have been completed.
Be careful not to jerk your back in an effort to help you

raise the dumbbells.
Complete 10 repetitions
Dumbbell Routine - Shoulder Press
Stand up and hold two dumbbells close to your

shoulders, palms facing forward.

raise the dumbbell.
Raise the dumbbells straight up until your elbows come

close to locking. Hold for 5 seconds and lower them
back down.
Complete 10 repetitions.
189
Dumbbell Routine - Dumbbell Side Bend
Hold both dumbbells at the side of your body.
Tilt your upper body to one side. Hold for five seconds.
Straighten your body to upright.
Tilt to the opposite side. Hold for five seconds then

straighten your body.
Be careful not to tilt your upper body too far sideways

where it may be difficult to bring it back.
Dumbbell Routine - Lateral Raise
Hold one dumbbell in each hand at the side of your

body, palms facing each other.
Raise the dumbbells out to the side until your arms are
close to being parallel to the ground. Hold for 10
seconds. Lower your arms back down to the side.
Dumbbell Routine - Front Raise
Hold one dumbbell in each hand in front of your thighs,

palms facing your body.
190
Raise the dumbbells up until your arms are close to

being parallel to the ground. Hold for 5 to 10 seconds.
Lower them back to the starting position.
Keep your arms extended throughout.
Dumbbell Routine - Shoulder Shrug
Stand up and hold one dumbbell in each hand in front

of your thighs, palms facing your body.
Raise your shoulders in a shrug. The dumbbells rise as

your shoulders shrug. Hold for 5 seconds. Release
your shoulders. Hold for 5 seconds.
Dumbbell Routine - Bicep Curls
Hold one dumbbell in each hand, palms facing forward.
One arm at a time, raise one dumbbell by curling your

elbow and lift the dumbbell to your shoulder. Hold for
5 seconds and lower to the starting position.
Alternate hands after the full motion are completed.

Do the exercise slowly to feel the muscle movement.
191
Dumbbell Routine - Hammer Curl
Hold one dumbbell in each hand along the sides of your

Raise the dumbbell by curling your elbow, lifting the

dumbbell to your shoulder. Hold for 5 seconds and
lower down to starting position. Alternate arms after
Keep your upper arms still throughout.
Dumbbell Routine - Triceps Curl
This can be completed sitting or standing.
Hold one dumbbell with both hands behind your head,

elbows at 90 degree angles, upper arms straight up.
Raise the dumbbell with both hands until your arms are
close to being fully extended. Hold for 5 seconds.
Slowly lower to starting position.
Keep your upper arms still throughout. Do the exercise

slowly to feel the muscle movement.
192
Station 4: Exercise Band Exercises - Bicep Curls
Sitting on the edge of the chair, make sure the feet are
flat on the floor, and knees are bent at 90 degrees.
Place one end of the exercise band under the right

foot. Hold the exercise band in the right hand ready to
begin.
Slowly lift the right hand up to the right shoulder.
Slowly move the right arm back down.
Repeat this sequence 10 times. Repeat the exercise

using the left arm.
Exercise Band Exercises - Crunches
Sitting down on the floor with your feet out in front of

you. Loop the exercise band around the middle part of
both feet. Make sure you keep your feet together and
toes pointing upwards throughout the exercise.
Hold the exercise band with two hands. Slowly lower

your upper body towards the ground.
Dont lower yourself all the way to the ground. Hover

just above the floor.
Hold this for 2 seconds, and then slowly lift yourself

back to a sitting position.
193
Exercise Band Exercises - Leg Lifts
While sitting, loop the exercise band around the right

foot. Tightly hold the exercise band with both hands
and lay down on the floor.
Hold the exercise band in both hands just above the

right hip.
Keeping the knee straight, lift the leg up until the sole
of your foot faces the ceiling. Slowly lower the leg to
the ground.
Repeat this exercise 10 times. Repeat the exercise

using the left leg.
Exercise Band Exercises - Leg Circles
Sitting on the floor, loop the exercise band over the

right foot. Hold the exercise band in the left hand.
Place the right hand behind you for balance.
Lift your foot until it is 20 centimetres off the floor.
Start slowly circling the foot in a clockwise direction 10

times. Circle the foot in an anti-clockwise direction 10
times.
Repeat this exercise with the left foot.
194
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
195
Phase 5: Social Skills

Sensory
Strategies
Timing 10 minutes
Materials Social Skills Cards
Objectives - Improve self-esteem, socialisation and self-expression
- Place the cards face down on the table.
they would do in that social situation.
(Boyd, 2004; Mental Health Foundation of Australia, 2004)
Closing
Timing 1 minute
- Pens
196
Session 8

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
197

Sensory
Strategies
Timing 15 minutes
198
Phase 2: Mindful Smelling

senses.
Sensory
Strategies
Timing 10 minutes
Materials Alerting / Calming Candles
Senses Exercised Smell
- Hand participants various alerting and calming smelling candles. Have
participants select a smell of their choice.
- Lead the participants through the mindful script below while participants
smell their melt.
- Leader to select 1 or 2 questions and guide participants in the discussion
below.
Script
- We are now going to participate in a smelling exercise. Try your best to
concentrate only on the scent you have chosen.
- Remember, that if any other thoughts or worries pop into your mind just
let them go, and re-focus your attention to the scents.
- I am going to give you some instructions and asking some questions. Do
not answer these questions aloud. Use these questions to focus your
attention to the sensation of smelling the melt.
Exercise
- Purposively breathe in to absorb the aroma of the candle.
- Pay attention to the intensity of the aroma. Is it a strong or mild scent?
- Does the scent make you feel either calm or alert?
Discussion
- What did you notice about the smells? Nice? Relaxing? Strong?
- How do you feel about the scents? Were you able to concentrate on it?
- Did you enjoy or not enjoy smelling the candles?
- What specifically did / didnt you like? Strong scent? Pleasant? Mild
scent?
- Do you feel calm or excited after smelling that candle?
199
Phase 3: Balance Routine

Sensory
Strategies
Timing 15 minutes
Materials Chairs for support if required
- Guide the participants through the balance routine below.
(Liebenson, 2005; Strongshape.com, 2011)
Single Leg Balance
Stand on one leg with arms extended out to the side.
Try to hold this for 10 seconds.
Complete two repetitions with each leg.
Standing Pose
Place your left foot flat against your right ankle.
Bring your hands together in front of you. Palms

together, elbows bent.
200
Slide your left foot up your right leg to just above the
knee.
Keeping your hands pressed together in front of you,

hold this position for 2 seconds. Slide your left leg
down to your right ankle. Repeat this movement once
more.
Repeat this sequence with the opposite leg.
Single Leg Lift
Begin with your feet shoulder width apart and hands by

your side.
Lift one leg out behind you. Try to keep this leg
straight. Use your arms for balance if required.
Keep raising your leg until it is parallel with the ground.
Bend forward at the waist. Use your arms for balance if

required.
Hold this position for five seconds. Repeat this once

more. Repeat this sequence with the opposite leg.
If it is difficult to balance, use a chair to hold onto for

extra support.
Single Hip Rotation
Lift one leg off of the ground, bending at the knee and
pointing your toes down to the floor.
Use your arms for balance if required.
201
Rotate at the hip, and move your leg out to the side.
Keeping your leg bended at the knee.
Hold this for 2 seconds.
Repeat this exercise twice with each leg.
Upward Stretch
To begin, stand with your feet shoulder width apart.

Arms by your side.
Start lifting your arms straight out in front of you to

above your head. While moving your arms, stand on
your tippy toes.
Stretch as high as you can. Hold this for 2 seconds.
Return to standing position.
Single Leg Balance Reach
Lift one leg off the ground in front of you.
Extend your arms out to the side for balance.
Lift your leg out in front of you as high as you can. Hold
this for five seconds.
Move the lifted leg out to the side. Lift this as high as
you can while keeping your trunk straight.
Hold this for five seconds.
202
Move the lifted leg behind you. Lift it as high as you

can.
Do this sequence with the other leg.
Side Bends
Standing on your tippy toes with your feet together.
Lift both hands above your head. Stretching high.
Bend at the waist to one side. Maintain your balance

and hold this for five seconds.
Move back to centre position. Remain standing on

your tippy toes.
Bend to the opposite side, keeping your arms straight.

Stay standing on tippy toes.
Hold this for five seconds. Move back to the centre

position again.
Repeat this sequence twice.
203
Single Leg Side Bends
Stand on one leg. Stretch your hands above your head,

keeping your arms straight.
Stretch up high.
Bend at the waist to one side. Keeping your arms

straight. Remain on one foot.
Hold this position for five seconds.
Move to the centre position again.
Keeping your arms straight and standing on one foot.

Hold this for five seconds
Bend to the opposite side, keeping your arms straight.

Stay standing on one foot.
Hold this for five seconds. Move back to the centre

position again.
Repeat this sequence twice.
204
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
205
Phase 5: Exploring the Senses

Sensory
Strategies
Timing 10 minutes
Materials Sense Posters
Exploring the Senses Cards
Objectives - To generate discussion about how each of the senses can be used in real
life situations (e.g. in the supermarket or on a bus) to help the individual
to self-regulate their emotions.
- To prepare for transition to community.
- Each participant is given one of the 9 sense posters.
- Scatter the cards face up on the table.
- Participants then categorise the scattered cards into one of the nine
senses it belongs too.
- Educate participants that sensory activities can be both alerting and
calming depending on when and how they are used. For example, having
a shower in the morning can be alerting, while having a shower at night
can be calming.
- Explain that sensory activities can also use more than one of the nine
senses. For example, driving a car, rollerblading, skating and cleaning the
house.
Closing
Timing 1 minute
- Pens
206
Session 9

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
207

Sensory
Strategies
Timing 10 minutes
CD Player
208

Sensory
Strategies
Timing 5 minutes
Materials Nil
Script
Exercise
flat on the floor.
breathe in.
209
times)
guiding you.
(Moore, 2005a)
210
Phase 2: Mindfully Eating Chocolate

senses.
Sensory
Strategies
Timing 10 minutes
Materials Dairy milk snack size chocolates
Senses Exercised Smell, taste, touch
- Place a chocolate in front of each participant.
- Lead participants through the mindfully eating chocolate exercise below.
Mindfulness - We are going to participate in a mindful exercise centred on eating a piece
Script of chocolate.
- Try your best to concentrate only on the chocolate and the sensation of
eating it. If any other thoughts or worries pop into your mind, just let
them go, and re-focus your attention to the chocolate.
- Lets get started. Dont open the chocolate yet.
- Focus your attention on the chocolate in front of you. Bring your attention
to the physical appearance of the chocolate. Observe the colour and
shape.
- Now, pick it up in your hand. Notice the weight of the chocolate in your
hand.
- Look at it closely. Generate 3 words in your mind to describe it to
yourself.
- Now lift the wrapped chocolate to your ear, and rub the packaging
between your fingertips observing the sound of the wrapper.
- As you unwrap the chocolate, listen carefully to the sounds of the
wrapper.
- Now bring the chocolate up to your nose and inhale deeply. Notice what
thoughts come into your mind as you do this. Does the smell of the
chocolate evoke any memories or powerful feelings?
- Deeply inhale again. Enjoy the smell of the chocolate.
- Should any critical thoughts pop into your mind like I shouldnt eat this,
just let these thoughts go, like you are releasing a balloon.
- Now, place the chocolate on your tongue. You might have the urge to bite
or suck the chocolate, resist that urge. Let it sit there for a few moments.
- Pay close attention to the flavour, richness and texture of the chocolate as
it sits in your mouth.
- Notice how the sensations change as it candles and moulds into your
mouth.
211
- You may wish to suck or bite the chocolate now, but resist the urge to
swallow for a few moments longer.
- Now as you swallow, follow the sensations as the chocolate slips down
your throat into your stomach. Notice how swallowing feels different to
eating the chocolate.
- Savour this feeling. When you are done savouring your chocolate, revisit
this feeling throughout your day, and feel more relaxed.
(Nhat Hanh, 2009; Smith, 2005)
212
Phase 3: Self-foot Massage Using a Tennis Ball

Sensory
Strategies
Timing 15 minutes
Materials Tennis Balls
Directions - Get participants to remove their shoes.
- Instruct participants to stand side on to the wall, place the tennis ball a
little out from the wall in line with their left foot. Place their right hand on
the wall for balance.
- Guide the participants through the self-foot massage below.
Foot Massage Heal of foot
Standing side on to the wall for balance, place your

left foot on the tennis ball.
Start with the ball under the heal of your foot. Apply
some pressure and roll the ball towards the arch of
your foot.
Foot Massage Arch of foot
Apply some pressure, and then slowly and

rhythmically roll the ball over the arch of the foot.
Foot Massage Ball of foot
Keep rolling the ball to the front of your foot.

Continue to roll the ball back and forth slowly and
rhythmically. Pay attention to the feeling in your left
foot and how it is different to your right.
Repeat the massage with the right foot.
213
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
214
Phase 5: Getting Ready for Discharge

Sensory
Strategies
Timing 10 minutes
Materials Getting Ready for Discharge Cards
Objectives - To foster discussion and consideration of some issues participants might
face following discharge from hospital.
- Place the cards face down on the table.
they would do in that situation.
(Moore, 2005a)
Closing
Timing 1 minute
- Pens
215
Session 10

Timing 5 minutes
- Pens
Sensation
including:
I. Vision
II. Hearing
III. Taste
IV. Smell
V. Touch
Mindfulness
216

Sensory
Strategies
Timing 15 minutes
217
Phase 2: Mindful Touch

senses.
Sensory
Strategies
Timing 10 minutes
Materials Prepared balls of rice wrapped in plastic bags
Scissors
Various coloured balloons
Senses Exercised Vision, touch
- Have participants select a ball of plastic bag of rice and two or three
coloured balloons of their choice.
- Instruct the participants to cut the top off of 3 balloons.
- Place the balloons over the plastic bag of rice, in different directions so
that the entire ball is covered by the balloon.
- Once participants have finished, guide the participants through the
mindful script below.
Mindfulness Exercise
Script
- We are now going to participate in a touching exercise. Try your best to
concentrate only on the sensation of your stress ball.
- Remember, that if any other thoughts or worries pop into your mind just
let them go, and re-focus your attention to the scents.
- I am going to give you some instructions and asking some questions. Do
not answer these questions aloud. Use these questions to focus your
attention to the task at hand.
- Lets get started. Examine your stress ball. Notice its shape, colour and
patterns.
- Pick it up in one hand. Feel the weight of the stress ball. Now, shift it to
the other hand and observe how it feels.
- Use your sense of touch and take the ball and squeeze it in one hand.
Then the other hand. Does it feel better in one hand than the other?
- Take the ball and rub it in a circular motion between your two flat palms
that are facing each other. Now rub it in another direction.
- Observe the texture of the ball; can you feel the grains of rice?
Discussion
- In what situations could you use a stress ball?
218
Phase 3: Dumbbell Weights

Sensory
Strategies
Timing 15 minutes
Materials Water bottles filled with water (two per participant)
Senses Exercised Proprioception, vestibular
Directions - Have participants select their water bottle dumbbells
- Guide the participants through the dumbbell routine below.
(Your Online Resource for Dumbbell Exercises, 2010)
Palm In Alternating Shoulder Press
Hold the two dumbbells on top of the shoulders.
Lift one dumbbell straight up and straighten your arm.

Lower your arm back down. Alternate hands after the

raise the dumbbells.
Complete 10 repetitions
Shoulder Press
Stand up and hold two dumbbells close to your

shoulders, palms facing forward.

raise the dumbbell.
219
Raise the dumbbells straight up until your elbows come

close to locking. Hold for 5 seconds and lower them
back down.
Dumbbell Side Bend
Hold both dumbbells at the side of your body.
Tilt your upper body to one side. Hold for five seconds.
Straighten your body to upright.
Tilt to the opposite side. Hold for five seconds then

straighten your body.
Be careful not to tilt your upper body too far sideways

where it may be difficult to bring it back.
Lateral Raise
Hold one dumbbell in each hand at the side of your

Raise the dumbbells out to the side until your arms are
close to being parallel to the ground. Hold for 10
seconds. Lower your arms back down to the side.
220
Front Raise
Hold one dumbbell in each hand in front of your thighs,

palms facing your body.
Raise the dumbbells up until your arms are close to

being parallel to the ground. Hold for 5 to 10 seconds.
Lower them back to the starting position.
Shoulder Shrug
Stand up and hold one dumbbell in each hand in front

of your thighs, palms facing your body.
Raise your shoulders in a shrug. The dumbbells rise as

your shoulders shrug. Hold for 5 seconds. Release
your shoulders. Hold for 5 seconds.
221
Bicep Curls
Hold one dumbbell in each hand, palms facing forward.

One arm at a time, raise one dumbbell by curling your
elbow and lift the dumbbell to your shoulder. Hold for
5 seconds and lower to the starting position.
Alternate hands after the full motion are completed.
Do the exercise slowly to feel the muscle movement.
Hammer Curl
Hold one dumbbell in each hand along the sides of your

Raise the dumbbell by curling your elbow, lifting the
dumbbell to your shoulder. Hold for 5 seconds and
lower down to starting position. Alternate arms after
Keep your upper arms still throughout.
Triceps Curl
This can be completed sitting or standing.
Hold one dumbbell with both hands behind your head,

elbows at 90 degree angles, upper arms straight up.
Raise the dumbbell with both hands until your arms are
close to being fully extended. Hold for 5 seconds.
Slowly lower to starting position.
Keep your upper arms still throughout. Do the exercise
slowly to feel the muscle movement.
222
Phase 4: Discussion
Sensory
Strategies
Timing 5 minutes
Questions
hospital?
routine?
Phase 5: Assertiveness
Sensory
Strategies
Timing 10 minutes
Materials Assertiveness Posters
Assertiveness cards
Objectives - To develop assertiveness skills
- To improve problem solving and self-expression
Directions - Explain that in this activity each participant takes turns to select a card and
they would do in that situation.
- (Moore, 2005a, pp. 78; Communication Styles, 2010)
223
Closing
Timing 1 minute
- Pens
224
Appendix 1 Mindful Stretches
Stretch 1: Trunk Turns
Interlock your fingers and place them on top of your

head.
Turn slowly in one direction, twisting at the waist, until

you feel a gentle stretch.
Turn slowly to face forward again.
Turn slowly in the opposite direction until a gentle

stretch is felt.
Repeat this stretch twice.
Stretch 2: Neck Rolls
Drop your head and chin forward. Slowly roll your

head to one side until the chin is over the shoulder.
Roll your head back to the centre.
Now roll your head to the opposite side until the chin is
over the shoulder.
Move your neck gently and slowly. Never crane your

neck.
225
Stretch 3: Chin up
Standing with your arms beside your body.
Lower your chin until it touches your chest.
Slowly lift your chin until it points towards the ceiling.
Move your neck slowly and gently. Never crane your

neck.
Stretch 4: Neck Stretch
Place your left hand on your right shoulder.
Slowly turn head towards that shoulder until a gentle

stretch is felt. Hold for 4 seconds.
Keeping that hand in place, rotate the head to the

opposite shoulder. Giving a gentle stretch, hold for 4
seconds.
Bring your head back to the centre, and repeat the

process with the right hand on the left shoulder.
226
Stretch 5: Back Stretch
Extend both arms out in front of your body.
Roll your shoulders forward, straighten your arms and

spread your fingers. Arch your back and try to reach
for the opposite side of the room.
Hold for 4 seconds. Repeat this stretch twice.
Stretch 6: Arm Lengthener
Extend one arm in front of the body.
Concentrate on your fingers and try to stretch your arm

as if it is lengthening. You will feel this stretch from the
top of your shoulders to your fingertips. Hold for 4
seconds.
Repeat this sequence using the opposite arm.
Repeat the whole sequence twice.
Stretch 7: Shoulder Rotation
Bend your elbows and bring your fingertips to your

shoulders.
Make small and large circles with your elbows.
Repeat four times in a forward direction.

Repeat four times in a backward direction.
227
Stretch 8: Triceps Stretch
Bring one hand behind your shoulder and reach down

your back.
Bring the other hand on top apply gentle pressure on

the elbow. Hold this stretch for 4 seconds.
Repeat this stretch with the opposite arm.
Stretch 9: Shoulder Extension
Reach over head with one arm, looking up as your

reach.
Stretch up and extend your fingers, opening your hand.
As you lower that arm, start to reach up with the

opposite arm.
Stretch 10: Hug Yourself
Bend your elbows and cross your arms placing each

hand on the opposite arm.
Clasp your hands firmly and give a tight squeeze.

Hold the squeeze for 4 seconds.
Stretch 11: Shoulder Raises
Place both arms at your side. Shrug your shoulders

upwards. Hold for 4 seconds.
228
Drop your shoulders down and stretch your arms

downwards. Hold for 4 seconds.
Stretch 12: Fence Painter
Extend one arm out to the side of your body at

shoulder height.
Move your arm and hand across the front of your body
to the opposite side. Flexing your elbow and wrist.
Wave your arm and hand back to the original position.

Extending your elbow and wrist.
Repeat this stretch four times.
Repeat this sequence with the opposite arm.
Stretch 13: Hand Press
Press your fingers and palms together and hold for 4

seconds.
Keeping your palms pressed together slowly move your

hands upwards.
Raise your hands to a comfortable position above your

head.
229
Keep your palms pressed together and slowly move

your hands downwards.
Stretch 14: Ball Circles
Place your hands out in front of you. Pretend you are

holding an imaginary ball.
Move your hands in a circular arch, pretending to

rotate the ball.
Do this in one direction and then the other.
Stretch 15: Arm Extension / Flexion
Stretch both arms out in front of you.
Raise the right hand up, and the left hand downwards.
Make large sweeping movements.
Repeat this sequence four times.
Stretch 16: Wrist Flexion / Extension
Hold both hands in front of you with fingers touching

your thumb.
Drop both wrists, so your fingers are closer to your

forearm. Hold this for 4 seconds.
230
Raise both wrists and stretch it in the opposite

direction. Allow your fingers to open as you do this.
Hold this for 4 seconds.
Stretch 17: Finger Opposition
Bring both hands up in front of your body.
Press each of the tips of the fingers to the tip of the

thumb. Hold each position for 4 seconds.
Stretch 18: Foot Flexors
Sitting in a chair, extend both legs out in front of you.
Point your toes towards the ground. Hold this for 4

seconds.
Flex your ankle and point your toes towards your body.
Hold for 4 seconds.
231
Appendix 2 Mindful Movements
To Begin
Stand with your feet firmly on the ground, shoulder-

width apart. Stand upright and relaxed. Your
shoulders are loose. Keep your body straight; tuck
your chin in slightly so your neck can relax.
Be conscious of your breathing. Allow your in-breath

to come down into your belly. Then exhale
completely. Continue to breathe slowly. Smile and
enjoy standing like this for a moment.
Mindful Movement #1
Begin with your feet slightly apart, arms at your sides.
Breathing in, lift your arms in front of you keeping

them straight. Lift your hands until they are at
shoulder level, horizontal to the ground.
Breathing out, bring your arms down to your sides.

Repeat the movement three more times.
232
Mindful Movement #2
Begin with your arms at your sides.
Breathing in, lift your arms in front of you. In one

continuous movement, bring your arms all the way up,
stretching them above your head. Touch the sky!
Breathing out, bring your arms slowly down to your

sides.
Repeat three more times.
Mindful Movement #3
To begin, lift your arms out to the side, at shoulder

level. Have your palms facing up.
Touch your shoulders with your fingertips, keeping

your upper arms horizontal.
Breathing in, open your arms, extending them until

theyre stretched out to a horizontal position again.
When you breathe in, you are like a flower opening to

the warm sun.
Breathing out, bend your elbows, bringing your

fingertips back to your shoulders.
Breathing out, the flower closes.

From this position with your fingertips on your
shoulders, do the movement three more times. Then
lower your arms back down to your sides.
233
Mindful Movement #4
In this exercise, you make a large circle with your arms.

To begin, bring your arms straight down in front of you,
centred between your hips, palms together.
Breathing in, raise your arms up and separate your

hands so your arms can stretch up over your head.
Breathing out, continue the circle, arms cycling back,

until your fingers point toward the ground.
Reverse the circle. Breathing in, lift your arms back.

Breathe out as you bring your palms together and your
arms come down in front of you.
Repeat three more times.
Mindful Movement #5
Start by putting your hands on your waist. As you do

this exercise, keep your legs straight but not locked,
and your head centred over your body.
Breathing in, bend forward at the waist and begin to

make a circle with your upper body.
When youre halfway through the circle, your upper

body leaning back, breathe out and complete the
circle, ending with your head in front of you while
youre still bent at the waist.
On your next breath in, begin a circle in the opposite

direction. On your out-breath, complete the circle.
Repeat the series of movements three more times.
234
Mindful Movement #6
This exercise is called the Frog. Begin with your hands

on your waist, heels together, feet turned out to form
a V.
Breathing in, rise up on your toes.
Breathing out, stay on your toes, keep your back

straight, and bend your knees.
Keeping your upper body centred, go down as low as

you can, maintaining your balance.
Breathing in, straighten your knees and come all the

way up while still standing on your toes.
From this position, repeat the movement three more

times, remembering to breathe slowly and deeply.
Mindful Movement #7
Begin with your feet hip-width apart.
Breathing in, bring your arms up above your head,

palms forward. Stretch all the way up and look up as
you touch the sky.
Breathing out, bend at the waist as your bring your

arms down to touch the earth. Release your neck.
From this position, breathe in and keep your back

straight as you come all the way back up and touch the
sky again.
Touch the earth and sky three more times.
235
Mindful Movement #8
Start with your feet together and your hands on your

waist. Begin by putting all your weight on to our left
foot.
Breathing in, lift your right thigh as your bend your

knee and keep your toes pointed toward the ground.
Breathing out, stretch your right leg out in front of you,

keeping your toes pointed.
Breathing in, bend your knee and bring your foot back
toward your body.
Breathing out, put your right foot back on the ground.
Next put all your weight on to your right foot and do

the movement with the other leg.
Repeat the series of movement three more times.
Mindful Movement #9
In this exercise, you make a circle with your leg.
Begin with your feet together and your hands on your

waist. Put your weight on your left foot.
Breathing in, lift your right leg straight out in front of

you and circle it to the side.
Breathing out, circle it to the back and bring it down

behind you, allowing your toes to touch the ground.
Breathing in, reverse the circle. Lift your leg up behind

you and circle it around to the side.
Breathing out, continue to circle to the front, and then

lower your leg and put your foot on the ground.
236
Now do the exercise with the other leg.
Repeat the series of movements three more times.
Mindful Movement #10
This exercise is done in a lunge position. Begin with

your left hand on your waist and your right arm at your
side.
Breathing in, bend your right knee, bringing your

weight over your right foot as you lift your right arm.
Stretch it to the sky!
Breathe out as your straighten your knee and bring

your right arm back to your side.
Repeat the movement three more times.
Switch legs, putting your right hand on your waist.

Repeat the same movement on the left four times.
Then bring your feet back together.
237
References
Ayres, J. (1979). Sensory integration and the child. Los Angeles: Western Psychological
Services.
Bishop, S., Lau, M., Shapiro, S., Carlson, L., Anderson, N., Carmody, J., et al. (2004).
Mindfulness: A proposed operational definition. Clinical psychology: Science and
practice, 11(3), 230-241.
Boyd, G. A. (2004). Adult Life Skills: A Primer for Those in Recovery. Retrieved March 14th,
2012, from Mudrashram Institute of Spiritual Studies:
http://www.mudrashram.com/adultlifeskills.html
Champagne, T. (2011). Sensory Modulation and Environment: Essential elements of
occupation (3rd ed.). Sydney: Pearson PsychCorp.
Communication Styles - Passive - Aggressive - Assertive. (2010). Retrieved March 14th, 2012,
from Squidoo: http://www.squidoo.com/passive-aggressive-assertive
Henry, D., Wheeler, T., & Sava, D. I. (2005). Sensory integration tools for teens: Strategies to
promote sensory processing. Arizona: Henry OT Services, Inc.
Huxter, M., & Hall, R. (2008). Mindfulness and a path of kindness, wisdom and happiness: A
workbook for young people aged 15 to 55.
Liebenson, C. (2005). Better balance exercises. Journal of Bodywork and Movement
Therapies, 9(2), 148-149.
Mental Health Foundation of Australia. (2004). Social Skills. Retrieved March 12th, 2012,
from Embrace the Future: Resilient Youth:
http://www.embracethefuture.org.au/youth/social_skills.aspx
Moore, K. (2005a). The sensory connection program: Activities for mental health treatment.
Framingham: Therapro Inc.
238
Moore, K. (2005b). The sensory connection program: Activities for mental health treatment.
Framinham: Therapro Inc.
Nhat Hanh, T. (2008). Mindful Movements: Ten exercises for well-being. China: Parallax Press.
Nhat Hanh, T. (2009). Happiness: Essential mindfulness practices. California: Parralex Press.
Siegel, R., Germer, C., & Olendzki, A. (2010). Mindfulness: What is it? Where did it come
from? In F. Didonna (Ed.), Clinical Handbook of Mindfulness (pp. 17-36). New York:
Springer.
Smith, J. (2005). Relaxation, meditation and mindfulness: A mental health practitioners guide
to new and traditional approaches. New York: Springer Publishing Company.
Strongshape.com. (2011, November). Balance Exercises. Retrieved March 8th, 2012, from
Strongshape.com: http://www.strongshape.com/balance-exercises.html
Willbarger, P. (1995). The sensory diet: Activity programs based on sensory processing
theory. Sensory Integration Special Interest Section, 18(2).
Your Online Resource for Dumbbell Exercises. (2010). Retrieved March 13th, 2012, from
dumbbellexercises.com: http://www.dumbbell-exercises.com/
239
Appendix B
PARTICIPANT DEMOGRAPHIC QUESTIONNAIRE
Name:
1. How old are you?
2. What is your sex?

Male
Female
3. What is your current marital status?
Single, never married
Unmarried partner
Married
Divorced
Widowed
Separated
240
4. What is your highest level of education?

Year 9 or 10, no School Certificate
School Certificate
Year 11 or 12, no Higher School Certificate
Higher School Certificate
Certificate 1 to IV
Diploma/Advanced Diploma
Bachelor Degree
Masters Degree
Doctoral Degree
5. What is your current employment status?
Student
Unemployed
Employed casual/part time
Employed full time
6. Do you have a diagnosis of a mental health disorder (s)?

Major Depression
Bipolar Disorder
Schizophrenia
Schizoaffective disorder
Other, please list
241
7. Who do you usually live with?

Live alone
Parents/Guardian
Partner
Partner/children
Extended family
House mate/ friend
8. Are you an Aboriginal or Torres Strait Islander?
Yes
No
9. What is the primary language spoken at home?

English
Other, please list
10. Were you born in Australia?

Yes
No, please list the country
11. Please specify your cultural background
242
12. Do you require access to an interpreter or cultural liaison officer?

No
Yes, an interpreter
Yes, a cultural liaison officer
13. Who is in your support network?
14. Have you participated in a program using mindfulness strategies?

No
Yes, please describe
15. Have you participated in a program using sensory techniques?

No
Yes, please describe
THANK YOU
243
Appendix C
Name: ____________________
PHLMS
Date: _____________________
Baseline Midway Follow Up D/C
Instructions: Please circle how often you have experienced each of the following statements
within the past week.
1. I am aware of what thoughts are passing through my mind.

1 2 3 4 5
Never Rarely Sometimes Often Very Often
2. I try to distract myself when I feel unpleasant emotions.

1 2 3 4 5
3. When talking with other people, I am aware of their facial and body expressions.
1 2 3 4 5
4. There are aspects of myself I dont want to think about.

1 2 3 4 5
5. When I shower, I am aware of how the water is running over my body.

1 2 3 4 5
6. I try to stay busy to keep thoughts and feelings from coming to mind.
1 2 3 4 5
7. When I am startled, I notice what is going on inside my body.

1 2 3 4 5
8. I wish I could control my emotions more easily.

1 2 3 4 5
9. When I walk outside, I am aware of smells or how the air feels against my face.
1 2 3 4 5
244
10. I tell myself that I shouldnt have certain thoughts.

1 2 3 4 5
11. When someone asks how I am feeling, I can identify my emotions easily.
1 2 3 4 5
12. There are things I try not to think about.

1 2 3 4 5
13. I am aware of thoughts Im having when my mood changes.

1 2 3 4 5
14. I tell myself that I shouldnt feel sad.

1 2 3 4 5
15. I notice changes inside my body, like my heart beating faster or my muscles getting
tense.
1 2 3 4 5
16. If there is something I dont want to think about, Ill try many things to get it out of
my mind.
1 2 3 4 5
17. Whenever my emotions change, I am conscious of them immediately.

1 2 3 4 5
18. I try to put my problems out of mind.

1 2 3 4 5
19. When talking with other people, I am aware of the emotions I am experiencing.
1 2 3 4 5
20. When I have a bad memory, I try to distract myself to make it go away.
1 2 3 4 5
245
Appendix D
THE PANAS-SF
Name: ______________________________________ Date: ___________________________
Baseline Midway Follow Up D/C
This scale consists of a number of words that describe different feelings and
emotions. As I read each item, I ask that you tell me to what extent / duration you
have felt this way during the past week.
1 2 3 4 5
Not at all A little Somewhat Quite a bit Very much
a. ____ excited h. ____ nervous

b. ____ distressed i. ____ determined
c. ____ upset j. ____ afraid
d. ____ scared
e.____ enthusiastic
f. ____ alert
g. ____ inspired
246
Appendix E
Arousal & Emotional Reactivity Scale
Name: _____________________________________ Date: ____________________

Before Session After Session
Arousal Scales
Abnormally
Normal heart
fast heart
rate
rate
Abnormally
Normal fast
breathing rate breathing
rate
No Excessive
perspiration perspiration
Emotional Reactivity Scales
Very
Not Angry
Angry
Not Very
Annoyed Annoyed
Very
Not Upset
Upset
Very Happy Not Happy
Not Very
Depressed Depressed
Very Not
Confident Confident
Not Very
Anxious Anxious
247
Appendix F
Please DO NOT throw this form away. This information is required for a research study. Please place completed sheet
at back of clipboard. OT will collect these forms regularly. Please only use sensory strategies suggested by OT.
PRN Register: If PRN is for agitation, anxiety or insomnia please suggest a Mindfulness and Sensory strategy and complete ALL items of the
table.
If PRN is for any other symptoms, such as pain, constipation or ESPE, you DO NOT need to suggest a Mindfulness and Sensory strategy.
However, you can still record the time, patient name, symptoms reported and PRN amount.
Date and Shift: ___________________________________ (start a new sheet for each new shift).
Time Bed Patients Full Symptoms Mindfulness & Sensory Was Outcome: PRN Reason Staff Name
Name reported: Strategies Offered Sensory (Patient Medication & PRN Given:
(eg. stretches, hand Strategy settled or Amount:
massage, tennis ball Trialled: PRN given)
massage, bean bag tapping, (Yes / No)
medicine ball etc)
248
Appendix G
249
Appendix H
250
251
Appendix I
Feedback Interview
1. What were the most important skills you learnt in the Mindfulness and
Sensory Modulation group?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. Can you think of a situation during this admission where you have used a skill
from the group? What skill was it, what effect did it have? What would you
have normally done instead of using this skill?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
3. Are you using these skills before requesting PRN medication?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
4. Have you been secluded during this admission? Did you use any of the
Mindfulness and Sensory group skills while in seclusion?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
252
5. Will you use any of these skills when you go home? Which skills will you use
and when will you use them?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
6. Do you plan to develop your own sensory kit at home?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
7. Would you like a community group?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
8. Any other feedback?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
253
Appendix J
PARTICIPANT INFORMATION SHEET AND CONSENT FORM
Study Title: Mindfulness and sensory modulation strategies to regulate

arousal and emotional reactivity in young adults with mental health disorders
Chief Investigator: Dr Julia Bowman, University of Western Sydney
Invitation
You are invited to participate in a research study investigating the effects of
learning mindfulness strategies and skills to manage how you interpret and
respond to situations using your senses, for example, taste and touch.
The study is being conducted by the Birunji Youth Mental Health Unit and the
University of Western Sydney.
Before you decide whether or not you wish to participate in this study, it is
important for you to understand why the research is being done and what it will
involve. Please take the time to read the following information carefully and
discuss it with others if you wish.
What is the purpose of the study?

The purpose of the study is to determine whether participating in a Mindfulness
and Sensory group will help you improve your ability to cope in stressful
situations.
Who will be invited to enter the study?

You are invited to participate in this study because you are a young adult aged
between 16 and 40 and currently receiving treatment at the Birunji Youth
Mental Health Unit.
Do you have a choice?

Participation in this study is voluntary. It is completely up to you whether or not
you participate. If you decide not to participate, it will not affect the treatment
you receive now or in the future. Whatever your decision, it will not affect your
relationship with the staff caring for you or influence your discharge planning in
any way. If you wish to withdraw from the study once it has started, you can do
so at any time without having to give a reason.
254
What will happen in the study?

If you agree to participate in this study, you will be asked to sign the Participant
Consent Form, meaning that you understand the information about the study
and give your voluntary consent to participate.
This study will be conducted over 3 months. If you agree to participate in this
study, you will be asked to attend the Mindfulness and Sensory group as many
days as you can for the duration of your treatment at the Birunji Youth Mental
health Unit. If you agree to participate in this study, you will also be asked to
complete a couple of short questionnaires with one of the therapists. You will
be asked to complete these questionnaires before attending the Mindfulness
and Sensory group for the first time and again prior to your discharge from
Birunji Youth Mental Health Unit. In addition, the researchers would like to
have access to your medical record to obtain information relevant to the study.
Are there any risks?

All programs involve some level of risk. Use of mindfulness strategies and
sensory techniques are designed to have a calming effect. However, each
person is different, and what may be calming for one person, may be mildly
distressing to another.
If you experience any distress or discomfort at any time during the program,
please alert the staff member running the group.
Confidentiality / Privacy
Any identifiable information that is collected about you in connection with this
study will remain confidential and will be disclosed only with your permission,
or except as required by law. Only the researchers named above will have
access to your details and results that will be held securely at the Birunji Youth
Mental Health Unit.
Will taking part in this study cost me anything, and will I be paid?
Participation in this study will not cost you anything. You will not receive
payment or any other incentive for participating in this study.
What happens with the results?

If you give us your permission by signing the consent document, we plan to
publish the results in a peer-reviewed journal as well as present the results at
conferences or other professional forums. In any publication, information will
be provided in such a way that you cannot be identified. Results of the study
will be provided to you, if you wish.
Complaints
This study has been approved by Western Sydney Local Health District
Human Research Ethics Committee. Any person with concerns or complaints
about the conduct of this study should contact the Ethics and Research
255
Governance Office, SWSLHD Locked Bag 7017, LIVERPOOL BC, NSW, 1871
on 02 9612 0614, fax 0612 0611 or email xxxxx and quote [HREC project
number xxxx]. Additionally, if you have any concerns about the conduct of the
study, or your rights as a study participant, you may contact:
Ms Elizabeth Manning, Telephone No 9845 4192; Email address

Elizabeth.Manning@wsahs.nsw.gov.au
Contact details
When you have read this information, researcher Amy Wilson will discuss it
with you and any queries you may have. If you would like to know more at any
stage, please do not hesitate to contact her on (02) 4634 4282.
If you have any problems while on the study, please contact:
Dr Julia Bowman, (02) 4620 3340
Thank you for taking the time to consider this study.
If you wish to take part in it, please sign the attached consent form.
This information sheet is for you to keep.
256
CONSENT TO PARTICIPATE IN RESEARCH
Chief Investigator: Dr Julia Bowman

1. I understand that the researcher will conduct this study in a manner conforming to ethical
and scientific principles set out by the National Health and Medical Research Council of
Australia and the Good Clinical Research Practice Guidelines of the Therapeutic Goods
Administration.
2. I acknowledge that I have read, or have had read to me the Participant Information Sheet
relating to this study. I acknowledge that I understand the Participant Information Sheet. I
acknowledge that the general purposes, methods, demands and possible risks and
inconveniences which may occur to me during the study have been explained to me by
____________________________ (the researcher) and I, being over the age of 16
acknowledge that I understand the general purposes, methods, demands and possible
risks and inconveniences which may occur during the study.
3. I acknowledge that I have been given time to consider the information and to seek other
advice.
4. I acknowledge that refusal to take part in this study will not affect the usual treatment of my
condition.
5. I acknowledge that I am volunteering to take part in this study and I may withdraw at any
time.
6. I acknowledge that this research has been approved by the Western Sydney Local Health
District Human Research Ethics Committee.
7. I acknowledge that I have received a copy of this form and the Participant Information
Sheet, which I have signed.
8. I acknowledge that any regulatory authorities may have access to my medical records
relevant to this study to monitor the research in which I am agreeing to participate.
However, I understand my identity will not be disclosed to anyone else or in publications or
presentations.
Before signing, please read IMPORTANT NOTE following.

IMPORTANT NOTE:
This consent should only be signed as follows:
1. Where a participant is over the age of 16 years, then by the participant personally.
Name of participant ________________________________ Date of Birth _______________
Address of participant _________________________________________________________
Signature of participant _______________________________ Date: ____________________
Signature of researcher ______________________________ Date: ____________________
Signature of witness _______________________________ Date: ___________________
257
Appendix K
FAMILY NAME MRN

GIVEN NAMES MALE FEMALE
DOB ___ / ___ / ______ M.O.
ADDRESS
MENTAL HEALTH SERVICES

LOCATION
AFFIX PATIENT LABEL HERE
Participant Disclose of Physical Injuries:

Participation in the Mindfulness and Sensory Modulation Group program will involve you
participating in physical activities (including cardio, stretching, weights, resistance and joint
compression).
Please list any medical conditions, injuries or physical conditions which may affect your ability
to participate in physical activity (asthma, epilepsy, back / neck injury, arthritis etc):
____________________________________________________________
____________________________________________________________
Signature: ___________________________________________________________________
Date: _______________________________________________________________________
Medical Clearance to Participate in Physical Activity:

Various group programs at Birunji Youth Mental Health Unit including the sensory modulation
program will involve the patient participating in physical activities (including cardio,
stretching, weights, resistance and joint compression)
The patient has been assessed to be PHYSICALLY FIT to participate in physical activities
The patient has been assessed to be PHYSICALLY UNFIT to participate in physical activities
Please list any injuries or physical conditions which may affect the patients ability to
participate in physical activity:
____________________________________________________________
____________________________________________________________
Name of treating doctor: _______________________________________________________
Signature: ___________________________________________________________________
Date: _______________________________________________________________________
258

Thesis - Mental Health

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Thesis - Mental Health

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Mindfulness and sensory modulation strategies to

regulate levels of arousal and emotional reactivity in

Supervised by Dr Julia Bowman and Amy Wilson

Thesis submitted in fulfilment of the degree:

Bachelor of Applied Science (Honours)

University of Western Sydney

knowledge and belief, contains no material previously published or written by another

Name: Deborah Lockeridge

Individuals with mental health disorders commonly experience problems associated

with regulating arousal and emotional reactivity, resulting in sensory modulation

the individual to achieve and maintain an optimal range of performance. Currently,

impact of a Mindfulness and Sensory Modulation Group Program on levels of arousal

sedation appear to reduce as a result of participation in the program.

by a multidisciplinary team of occupational therapists, social workers and nurses. The

program was specifically designed to teach participants mindfulness and sensory

modulation skills to regulate their moment-to-moment thoughts, feelings, sensations

and behaviours. A pre-test, post-test design was employed using a convenience

sample (N = 31). Participants were inpatient consumers aged between 16 and 45

Defensiveness Screen was completed. Participant outcomes on the Philadelphia

on participants arousal and emotional reactivity, 10 visual analogue scales (VAS)

were used to identify trends in the data.

The greatest proportion of participants had moderate levels of sensory defensiveness.

impacted on participants ability to normalise levels of arousal and emotional

listen to my complaints and having faith in my ability to reach my maximum potential.

Student Declaration .......................................................................................................i

Table of Contents .......................................................................................................... v

List of Tables ................................................................................................................. x

List of Figures ...............................................................................................................xi

List of Appendices .......................................................................................................xii

Chapter 1 - Introduction .............................................................................................. 1

1.1 Introduction ...................................................................................................... 1

1.2 Statement of the Problem ................................................................................. 6

1.3 Study Scope ...................................................................................................... 6

1.4 Definition of Terms .......................................................................................... 9

1.5 Structure of the thesis ..................................................................................... 12

Chapter 2 Literature Review .................................................................................. 14

2.1 Introduction ......................................................................................................... 14

2.2 Occupational Therapy in Mental Health ............................................................. 15

2.3 Sensory Modulation ............................................................................................ 18

2.3.1 Sensory Modulation Dysfunction ................................................................ 19

2.3.2 Arousal ......................................................................................................... 19

2.3.3 Emotional Reactivity ................................................................................... 21

2.4 Sensory Modulation Dysfunction and Mental Health Disorders ........................ 23

2.5 Impact of the Person on Occupational Performance ........................................ 27

2.6 Sedation and Seclusion ....................................................................................... 28

2.6.2 Seclusion ...................................................................................................... 29

2.7 Impact of the Environment on Occupational Performance .............................. 31

2.8 Recovery ............................................................................................................. 32

2.9 Impact of Occupation on Occupational Performance ...................................... 33

2.11 Sensory Modulation Strategies ......................................................................... 37

2.12 Occupational Therapy Intervention and Occupational Performance ................ 39

2.13 Conclusion ........................................................................................................ 40

2.13.1 Significance of the Study ........................................................................... 40

2.13.2 Research Questions .................................................................................... 41

2.13.3 Research Hypothesis .................................................................................. 41

2.13.4 Expected Outcomes ................................................................................... 42

2.14 Synopsis ............................................................................................................ 42

Chapter 3 Methodology ........................................................................................... 44

3.1 Introduction ......................................................................................................... 44

3.2 Study Design ....................................................................................................... 44

3.3 Sampling and Recruitment .................................................................................. 47

3.3.1 Sampling ...................................................................................................... 47

3.3.2 Recruitment .................................................................................................. 48

3.4 Intervention Mindfulness and Sensory Modulation Group ............................. 49