Keywords

1 Introduction

In the present chapter, we will briefly describe current treatment manuals which focus on mindfulness and self-compassion as an intervention. Manuals are reviewed based on the form of intervention (group vs. individual) and on theoretical considerations that led to the versions for adolescents. MBIs in other manualized therapeutic approaches are briefly presented.

In a second step, specific aspects of psychotherapy in adolescents are proposed and the level of consideration in mindfulness-based treatment manuals for adolescents reviewed.

In a third step, specific aspects of group delivered mindfulness-based psychotherapy in youth are discussed.

2 Theoretical Background

Mindfulness-based interventions (MBIs) focus on introducing non-judgmental awareness of the present moment (Baer, 2003). The positive effects of MBIs on symptom reduction, well-being, and quality of life in adults have been reported extensively (Baer, 2003; Hofmann, Sawyer, Witt, & Oh, 2010; Khoury, Sharma, Rush, & Fournier, 2015). Reviews also describe neurological and biological evidence of its efficacy (Chiesa & Serretti, 2010; Tang, Hölzel, & Posner, 2015). However, reviews also point to the lack of high quality studies and to open questions regarding working mechanisms of MBIs (e.g. Davidson & Kaszniak, 2015). An extensive body of literature addresses mindfulness and MBIS, contributing to the ongoing debate on the definition, key conceptual aspects, working mechanisms, and origins of mindfulness (Brown, Creswell, & Ryan, 2016). More importantly, continuing research studies report evidence about the effectiveness of MBIs also in children and youth in clinical and non-clinical samples. A recent meta-analysis reports a small to moderate omnibus effect size (Zoogman, Goldberg, Hoyt, & Miller, 2015). The authors find higher effect sizes in clinical samples compared to generally healthy participants and higher effects on psychological symptoms compared to other outcome measures, such as somatic symptoms or mindfulness related measures.

These promising findings have further supported the development of mindfulness-based treatment manuals for adults which were then adapted for psychotherapy with adolescents (Wisner, 2017).

Compassion-based interventions (CBIs) aim at the establishment of a mindful attitude and a compassionate stance, which includes the awareness of the suffering of another person or oneself and the desire to alleviate the suffering (Goetz, Keltner, & Simon-Thomas, 2010). Though reported in the literature to a lesser degree, compassion-based interventions have shown promising outcomes in adults (Kirby, 2016) and have been proposed as important pathways to mental health in children and youth (Roeser & Pinela, 2014). To date, most interventions have focused on self-compassion or compassion towards the self as an intervention in psychotherapy and mental health prevention (Bluth, Gaylord, Campo, Mullarkey, & Hobbs, 2016).

3 Manualized Mindfulness-Based-Interventions in Psychotherapy with Adolescents

Many manualized psychotherapeutic approaches in adolescents predominately concentrate on MBIs or self-compassion as interventions. The most cited approaches in the literature have been adapted from an adult version of the psychotherapy manual (O’Brien, Larson, & Murrell, 2008). Given the lack of common adaptation mechanisms for the work with youth, it appears necessary to review manualized MBI psychotherapy approaches regarding their adaptation process. Since MBIs have been manualized for a broad range of clients and disorders, our present considerations focus on a few common psychotherapy approaches.

3.1 Mindfulness-Based Stress Reduction for Teens (MBSR; Biegel, Brown, Shapiro, & Schubert, 2009)

The MBSR for Teens program was one of the first intervention about mindfulness in young people. Though not being a specific psychotherapy manual, moderate effects on reduction of depressive symptoms have been reported for MBSR in adolescents (Chi, Bo, Liu, Zhang, & Chi, 2018). MBSR for Teens is a group-based program and its development was guided by the adult version of the program. Adaptation of the program for children includes considerations regarding the attention span of young people as well as a focus on experiential and body exercises (Saltzman & Goldin, 2008). In the adolescent program, which was designed for participants at the age of 14–18 years, mindfulness practices at home were shorter and there was no full day session. Issues common in adolescence were also discussed with the group, including self-image, life transitions, self-harming behaviors, and problems in interpersonal relationships (Biegel et al., 2009).

3.2 Dialectical Behavioral Therapy for Adolescents (DBT-A & DBT Skills for Adolescents; Miller, Rathus, & Linehan, 2007; Rathus, Linehan, & Miller, 2015)

Dialectical behavioral therapy was initially designed for the treatment of borderline-personality disorder but is now applied in the work with various patient and client groups (Linehan, 1993). DBT uses MBIs as a skill to reduce confusion about the self which is continuously practiced throughout the skill training groups. Skill training typically is a group-based program, but individual psychotherapy and skill groups are combined in DBT. DBT-A also includes parents in the treatment groups and has specific family sessions. The program was reduced, simplified, and a module for the dialectic view on dilemmas was implemented (“walking the middle path”; Fleischhaker, Sixt, & Schulz, 2011). Regarding assessment and diagnosis, DBT-A encourages therapists to include school and family contexts in their understanding of the case (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997).

3.3 Mindfulness-Based Cognitive Therapy for Children (MBCT-C & MBCT for Depression in Adolescents; Ames, Richardson, Payne, Smith, & Leigh, 2014; Semple, Lee, & Miller, 2006)

A genuine mindfulness focused psychotherapy program is the MBCT for adults, which was initially designed for the treatment of chronic depression (MBCT; Segal, Williams, & Teasdale, 2002). It has also been conceptualized as a manual for children at the age of 9–12 and most studies apply it in a group setting. Adaptations for child-friendly interventions include reduction of number of exercises, the reduction of the length of exercises, and the reduction of group size. Also included is a focus on body sensations and physical perceptions during the exercises. Parents are actively included in the program by attending sessions at the beginning and the end of the program, and by assisting exercises at home (Semple et al., 2006). The program has been administered in adolescents with a focus on depression but its conceptualization has not received as much attention as the version for children (Ames et al., 2014).

3.4 Making Friends with Yourself (MFY; Bluth et al., 2016)

MFY is a manualized psychotherapeutic program for children and youth at the age of 11–17 years to help them deal with depression and anxiety. The program was developed based on the mindful self-compassion program for adults (Neff & Germer, 2013), which aims at preventing mental disorders by establishing resilience through self-compassion. In comparison to the program for adults, MFY has reduced length of sessions, and includes more activity-based exercises and specific information on the adolescent brain. Studies on MFY are mainly administered in groups (Bluth et al., 2016).

3.5 Acceptance and Commitment Therapy for Adolescents (ACT-A; Turrell & Bell, 2016)

ACT is a manualized program which was developed for various contexts such as specific individual psychotherapy, psychotherapeutic groups, as well as general mental health prevention in schools. MBIs are seen as a way to implement an accepting stance (Turrell & Bell, 2016). The version for psychotherapy in adolescents is based on the assumption that acceptance and commitment are essential approaches in developmental challenges, such as identity development, and it also includes a functional analysis of the family and school context. Furthermore, the general style of ACT, which uses metaphors, a less directive approach and experiential exercises, is thought to especially suit young people (O’Brien et al., 2008).

3.6 Metacognitive Therapy (MCT; Wells, 2011)

MCT focusses on the change of metacognitions, which are controlling and judging thoughts about thoughts, in the therapy of depression and anxiety (Wells & Matthews, 1995). A central part of MCT is the teaching of detached mindfulness, a conceptualization of mindfulness, which is based on information processing ideas. Detached mindfulness aims at facilitating metacognitive states and de-centered relationships with thoughts (Wells, 2005). Detached mindfulness is introduced using cognitive exercises and experiments. Few studies have adapted MCT for the work with adolescents but there is initial evidence that adolescents are capable of metacognitive thinking (see Simons, 2016). A manualized treatment for children with generalized anxiety disorder exists, which proposes extensive ideas for the work with children. MTC for children teaches detached mindfulness, using a focus on guided practical exercises, metaphors, cue cards and parent workshops (Esbjørn, Normann, & Reinholdt-Dunne, 2015).

3.7 Common Adaptations

In summary, manualized mindfulness and compassion approaches all derive from treatment programs for adults and focus mainly on the group setting. Furthermore, the adaptation of an adult program to a program for adolescents is rarely described in full detail and was to a lesser degree based on theoretical considerations regarding psychotherapy in adolescents. However, a few common processes are inferable. Most adaptations include (1) a reduction of practice time (e.g. meditation exercises) and simplification of the program (e.g. via metaphors) to guarantee understanding, (2) a focus on experiential or physical exercises to take into account the reduced attention span, and, (3) the involvement or consideration of parents, families or schools to establish a contextual view or implement changes in the adolescents’ context.

4 Mindfulness-Based-Interventions in Other Therapeutic Approaches

Before manualized programs focusing on MBIs were developed for psychotherapy with adolescents, practitioners tried to integrate MBIs and comparable exercises into their sessions as part of their usual psychotherapeutic treatment. The original definition of mindfulness with its four foundations of mindfulness proposes being mindful of body, feelings, mind/thoughts and others/surroundings (Cullen, 2011; Kabat-Zinn, 1994). These four different aspects of human experiences can in some way be found in behavior therapy as well. The treatment of mental disorders in behavior therapy is the observation of thoughts, feelings, body reactions and behaviors in different situations (compare the SORKC-model; Kanfer & Saslow, 1969). These so-called behavior analyses focus on reactions which are related to problematic symptoms and therefore are more focused than the general observant and non-judgmental openness for experiences described by mindfulness.

More similarities and differences between mindfulness and former cognitive behavior therapy emerge regarding the way MBIs have already been integrated in established therapeutic approaches. On the one hand, collections of mindfulness exercises have been published and are being used in psychotherapies. On the other hand, behavioral manuals contain exercises that are similar to MBIs, and are presented without necessarily explaining the concept of mindfulness at all. Several examples of these integrative approaches are presented in the following passages.

4.1 Collections of Mindfulness Exercises for Individual and Group Psychotherapy

One use of integrating mindfulness in established therapeutic approaches is the general use of stand-alone MBIs which have been adapted for children and youth and focus on the beginner spirit (Greco & Hayes, 2011; Geisler & Muttenhammer, 2016). Hereby, mindfulness is introduced through different exercises that can be used by practitioners as one part of the overall treatment of typical mental disorders. Most of these exercises are based on MBIs that are commonly used in adult psychotherapy, only content and length is adapted to children and youth’s context. A general introduction to mindfulness is suggested, yet it is optional. In addition, these collections of MBIs also contain exercises which focus on self-compassion and meta-cognition (detached mindfulness) by learning how to recognize thoughts and actions, and to observe them instead of starting to immediately value or change them.

4.2 MBIs as Parts of Other Therapeutic Manuals

In addition to these collections of mindfulness exercises, which are labeled as MBIs, other manualized intervention programs for different mental disorders use comparable exercises without using the word “mindfulness” in their descriptions. One of these examples in the German context is the “training of emotional competences” (Training emotionaler Kompetenzen; Berking, 2017), which was developed for adults and young adults at 16 years of age or older. One of the competences taught in this training is the difference between “evaluation and reaction” and “awareness without evaluation”. It must be noted that the word “mindfulness” is not used in the description for patients and only included in the practitioner’s manual. However, the taught and practiced competence is one major aspect of mindfulness.

Another example is the body image therapy for eating disorders (Vocks & Legenbauer, 2010). In individual or group settings, patients are confronted with their body image and are introduced to exercises focusing on pleasure and body experiences without immediately evaluating them. By focusing on pleasant aspects of their body, they should learn to view their body from another perspective, treat it well, start to enjoy it, and so change their negative body image. These exercises known as “pleasure exercises” are general awareness exercises, but calling them positive experiences is biased in a way which is incompatible with mindfulness.

Such pleasure exercises which focus on developing a better feeling about oneself and establishing a routine of pleasurable and self-enjoyment enhancing activities, have a conceptual overlap with self-compassion exercises and can also be found in manuals for anxiety (Traub & In-Albon, 2017) and depression (Groen & Petermann, 2015).

5 Specific Aspects of Psychotherapy in Adolescents

Apart from general challenges connected with mindfulness, a closer look at specific challenges during adolescence must now follow.

5.1 Developmental Aspects and Challenges

Adolescence is defined as the time of transition from childhood to adulthood, beginning at the start of puberty and ending at the time of adult responsibilities (Levesque, 2011). Not only a physical but also a social transition takes place during this period: Peer relationships become more complex and important, self-consciousness is heightened, and comparison with others is one major aspect of identity development (Steinberg & Morris, 2001). Havighurst (1972) conceptualized the various challenges adolescents face in different developmental tasks, which can be summarized as achieving new and mature relationships, accepting sexual roles and one’s body, emotional independence of parents, preparing for occupation and adult family life, and acquiring values as a guide to socially responsible behavior.

5.2 Implications for Therapy

Regarding psychotherapy with adolescents and their developmental tasks at this stage of development, it is obvious that the four foundations of mindfulness are challenges in general. Being mindful of their own body, feelings, minds, and the world around them is not easy for adolescents who experience changes in all areas. MBIs and similar exercises need to be adapted to meet these challenges. The following age-related aspects should be considered:

  • Cognitive level: The newly gained ability to think on a meta-cognitive level starts during adolescence and opens up new possibilities for psychotherapeutic treatment: meta-cognitive strategies are usable and first manuals for specific mental disorders are published (for example OCD, Simons, 2012). Meta-cognitive therapy (MCT) is adapted to be specifically experience based by using a lot of metaphors (Simons, 2018).

  • Motivation: Commitment is one of the major concerns of child and youth psychotherapists, because most adolescents are rather forced to see a therapist by parents, friends or teachers. Especially the DBT-A program described above has as strong emphasis on commitment strategies (Miller, Rathus, & Linehan, 2007). Commitment is necessary for MBIs as well, that’s why token systems for children (Van der Oord, Bögels, & Peijnenburg, 2012) and encouragement for adolescents is proposed as a technique (Geisler & Muttenhammer, 2016).

  • Comparison with others: Due to the high pressure for better achievements in school and the typical challenges during adolescence, most of the adolescents form their identities by comparing themselves and their achievements with their peers. This is one important part of identity formation, but also significant for psychotherapy. Especially group settings lead to possible comparisons with others, which can be self-esteem enhancing or diminishing. Some MBIs rely on the feedback and exchange with others afterwards. In youth group settings it should therefore be considered to practice these exercises individually and silently, with minimal and directed feedback, described for example in Geisler and Muttenhammer (2016). In that way the evaluative comparisons between participants can be held at a minimum. However, as discussed in the next section, the positive effects of group therapy partially rely on an extensive exchange of experiences.

  • Shame: Shame is usually evoked when failure is recognized, when expectations cannot be met, but also when something is very intimate. Recognizing shame in patients is very important for psychotherapy because it can be crucial to symptoms and can lead to therapy termination by the patient (Dearing & Tangney, 2011). For adolescents, shame is likely to be triggered by focusing on their body or becoming aware of thoughts and feelings they would like to forget in the present moment in order to feel “at ease”. Mindfulness could help to deal with shame (Hooker & Fodor, 2008). However, it could also increase the momentarily experienced shame (e.g. due to feelings of failure) and practitioners should be aware of this possible effect.

  • Autonomy: One major developmental challenge during adolescence is the achievement of emotional independence from parents. As mentioned above, peers and their opinion become more important. As a result, adolescents strive for autonomy and distance themselves from their parents during that time (Levesque, 2011). This can be one explanation for the often experienced personal resistance towards mindfulness exercises by the adolescent, which are introduced by other adults and regarded positively by peers.

5.3 Specific Aspects of Group Psychotherapy in Adolescents

Given the focus of most manualized mindfulness and self-compassion programs on the group setting, therapeutic working mechanisms in group therapy with adolescents should be discussed. Challenges in group therapy with adolescents are partially overlapping with developmental challenges in the transition to adulthood, as described above. However, they offer an alternative perspective on the therapeutic process. Like group therapy for adults, many group programs for adolescents focus on specific interventions (e.g. psychoeducation, practicing of new behavior) as working mechanisms. Apart from that, general working mechanisms of group therapy have been proposed and discussed regarding their importance for working with adolescents. Haen and Aronson discuss several group working mechanisms, initially proposed by Yalom and Leszcz for adult groups with regard to their role in working with adolescents (Haen & Aronson, 2017; Yalom & Leszcz, 2005). These include universality, imparting information, recapitulation of the family experience, altruism, socializing techniques, cohesion, installing a sense of hope, and importance of interpersonal relations.

Working mechanisms for MBIs in groups could draw upon these considerations to improve outcomes. For example, mindfulness exercises and the sharing of individual experiences during the exercises can create a feeling of universality regarding the nature of attention and cognitions. However, especially in adolescents, the sharing of personal or intimate thoughts might be shameful and connected to the fear of being judged by others. Therefore, establishing a sense of cohesion and trust in the group appears to be a necessary first step in MBIs in group settings. Furthermore, a sense of belonging and trust in the group is possibly a new experience for troubled adolescents and can play an important role in the reinstallation of a positive view on the self, given the identification with the group (Haen & Aronson, 2017).

Compassion-based interventions, which aim at altering compassionate feelings towards the suffering of others, could in turn lead to altruism (Leiberg, Klimecki, & Singer, 2011). Also in a group setting, an attitude of altruism can be implemented by fostering helping behavior in peers. Therefore, not only the work with parents but also with peers should be considered in group therapy (Rubin, Bukowski, & Laursen, 2009). Examples of group programs, which especially work with peer relations, can be found in social work with troubled youth. For example, Positive Peer Culture (PPC, Vorrath, & Brendtro, 1985) aims at the implementation of generosity and prosocial helping behavior in peers in a strongly group-guided program. Other examples are the training of social competencies for adolescents, which include role plays in the group and the discussion of interpersonal behavior (for example Petermann & Petermann, 2010).

6 Conclusion and Challenges for the Field

MBIs are increasingly implemented in diverse psychotherapy approaches for adolescents. Given the focus of manuals and studies on group psychotherapy, group processes are considered in detail in the present chapter. Various questions remain unanswered and should be addressed in future studies.

First of all, adaptation processes of treatment manuals, which were originally designed for adults should be revised regarding their underlying understanding of youth specific aspects in psychotherapy. Whereas motivation and the cognitive level of adolescents is widely considered in most adapted manuals, important steps in the identity formation of adolescents, such as comparison with others, shame, and autonomy have been neglected.

For example, resistance towards MBIs can be heightened in group settings, given the setting of permanent possible comparison with others. This could be diminished with preparation. In other manuals which combine individual and group setting, relaxation exercises are learned and practiced individually and only then become part of group sessions (compare THAV, Görtz-Dorten & Döpfner, 2010). More familiarity with the exercises, will reduce the occurrence of shame in the group setting. In addition, knowing the exercises helps participants in group settings to stay focused on themselves instead of comparing their behavior to others’ behaviors. Also, a tailored approach of the introduction to mindfulness is possible in individual therapy. Exercises can be shortened and adapted to the patient’s level of understanding and mastery. If questions arise, they can be addressed immediately and the training can proceed, whereas questions during exercises in a group setting can lead to lengthy discussions and significantly interrupt the training sessions. Consequently, future MBIs could combine individual and group training to improve the practice of exercises in groups. Future studies should compare the effects of MBIs and their acceptance by adolescents when they are learned in individual versus group settings.

The integration of peer-guided exercises in group psychotherapy can be considered to address issues of autonomy and resistance towards new ideas, that are introduced by adults. Adolescents who already know an exercise could teach their peer group members. This is one way to strengthen the adolescent teacher’s self-esteem and could lead to more model learning. If their peers support them, even shy or timid adolescents could try to introduce short MBIs or lead the training of well-known exercises, thus gain more mastery and trust their own competences.

These considerations are closely linked with fostering peer interaction and establishing positive peer values such as trust and cohesion. Given the importance of peer relations in adolescence, peer interactions should not only be seen as problematic dynamics that complicate the training of mindfulness in groups. Though being outside of the mainstream research, establishing positive values in groups, has been shown to have positive implications for troubled youth (Rubin et al., 2009).

One way of looking at peer processes in therapy, and considering its possible detrimental effects, is the integration of working mechanisms of group psychotherapy. Especially interpersonal mechanisms such as group cohesion, universality or altruism could add to existing group programs of MBIs. Furthermore, interpersonal values such as compassion could be pathways to altering group dynamics regarding prosocial behavior (Roeser & Pinela, 2014).

In general, working mechanisms of group therapy in adolescents should be addressed in future studies to answer open questions regarding the use of MBIs in groups.

In sum, further research efforts should focus on the topic of application and implementation of mindfulness in psychotherapy, especially in groups and with adolescents. It should be asked, whether the constant struggle and debate about the origins and nature of mindfulness as a concept has led to the neglection of these practical considerations.