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  17 ©2013, ALL RIGHTS RESERVEDISSN: 1555–7855INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY2013, VOL. 8, NO. 3-4 Using Mindfulness in the Treatment of Adolescent Sexual Abusers: Contributing Common Factor or a Primary Modality? Jerry L. Jennings 1 , Jack A. Apsche, Paige Blossom, & Corliss Bayles 1 Liberty Healthcare Corporation   Abstract  Although mindfulness has become a mainstream methodology in mental health treatment, it is a relatively new approach with adolescents, and perhaps especially youth with sexual behavior problems. Nevertheless, clini-cal experience and several empirical studies are available to show the effectiveness of a systematic mindful-ness-based methodology for treating adolescents who engage in sexual and physical aggression. In this article, the authors rst explore the elements of mindfulness that are inherent in traditional cognitive-behavioral therapy (CBT) and then review how mindfulness has been systematically incorporated into several “third wave” cogni-tive-behavioral therapies – ACT, DBT, MBCT, and MDT – each of which have been applied with adolescents. While it can be argued that mindfulness is a “common” therapeutic factor across approaches, mindfulness can also be considered to be, and applied as, a primary modality to enhance the effectiveness of most therapies with adoles- cents who engage in problem behaviors, including sexual offending. The key, however, is making modications to accommodate the unique developmental needs of adolescents. A case example is presented to demonstrate the clinical application of mindfulness with an adolescent victim and perpetrator of sexual abuse. Keywords Mindfulness, sexually abusive youth, sexual offender treatment, cognitive behavioral therapy, mindfulness-based therapies, “third wave” cognitive therapies Although the practice o mindulness is centuries old, it was not applied as a stand-alone technique in clinical psychology until Fritz Perls (1969) attempt-ed to uniy mind, body, and spirit with Gestalt Ter-apy. Drawing rom his studies o Zen Buddhism, Perls emphasized the principle o enhanced aware-ness in the present moment. Perls valued all orms o immediate awareness – sensation, perception, emotion, thought, behavior, and bodily eelings – and understood the natural therapeutic effects o staying with here-and-now experience. In the 1970s, others began to use the term “mindulness” and began to apply mindul awareness in a system-atic ashion (Kurtz, 1990; Kabat-Zinn, 1990). By the late 1990s, mindulness had become a common-place term in the field o mental health and is used today as a mainstream technique. Te application o mindulness to adolescents, however, is a relatively recent development and its recognized value with sexually abusive teenagers is just emerging (Apsche & DiMeo, 2010, 2012).Mindulness has been defined as the “intentional process o observing, describing, and participating in reality nonjudgmentally, in the moment” (Gre-co & Hayes, 2008, p. 4). In their definition or ad-olescents, Jennings and Apsche (2013, p. 5) define mindulness as “being ully aware o your immedi-ate present experience and accepting yoursel as you are in this moment without judgment.”Although some empirical support or the direct use o mindulness with adolescent sexual abus-ers is available, the first hal o this article reviews the many indirect ways in which mindulness has been incorporated into other mainstream cognitive treatment approaches that have been applied with adolescents. Tis raises the question o whether mindulness is a method unto itsel, or reflects a “common actor” across therapeutic approaches. Te second hal o the article presents empirical studies o mindulness with adolescents, and pres-ents a case example o how it can be applied in work with sexually abusive youth.    Mindfulness as a Therapeutic “Common Factor” in Traditional CBT O all the psychotherapies in mental health today, cognitive behavioral therapy (CB) has become the predominant approach and, or better or worse, is the principal approach in the field o sex offend-er-specific treatment (Jennings & Deming, 2013). As such, our discussion o mindulness begins with traditional CB, which uses our main strategies to change thinking and behavior: skills training, ex-posure therapy, cognitive therapy, and consistency management (Young, Weinberger, & Beck, 2001). Te exposure therapy component o CB can be  viewed as a process o immediate awareness. Al-though it may be intended differently, it contains the essential elements o an intense ocus on im-mediate awareness, incorporating mental, physical, and emotional experience, and can yield therapeu-tic effects through the “acceptance” o the immedi-ate discomort and irrationality. More broadly, the classic CB process o identiying and challenging the validity o cognitions can also be seen as a sort o mindulness to the degree that the client is sys-tematically and repeatedly “exposed” to his or her disturbing and dysunctional thoughts and emo-tions and, hopeully, becomes increasingly able to tolerate and accept disturbing cognitions without negative sel-judgment (Heimberg & Ritter, 2008). From a mindulness standpoint, the key thera-peutic element in CB is having the experience o non-judgmental acceptance during the process o challenging negative cognitions, which occurs in the context o a mutually “mindul” relationship with the CB therapist (Glass, Arnkoff, Wood-ruff, Maron, McMorran, Monahan, & Hirschhorn, 2013).Over fifeen years ago, Martin (1997) argued that mindulness can be seen as a “common actor” that cuts across therapeutic orientations, including CB, psychodynamic, humanistic, and amily systems therapy. Te presence and value o mindulness across treatment approaches has been similarly as-serted by Bell (2009). With regard to CB, specifi-cally, it is argued that a mutual process o mindul-ness is occurring on the part o both the therapist and the client (Glass et al., 2013). Mindulness or the CB therapist takes the orm o consistent and ocused attention on the client’s thoughts and expe-riences, while consistently providing nonjudgmen-tal acceptance o the client’s reports o dysunction-al thoughts and behavior. Mindulness or the CB client takes the orm o improving one’s awareness o inner thoughts and experience, observing and gaining more tolerance and acceptance o negative thoughts and emotions, and learning to regard one’s dysunctional cognitions as distinguishable rom one’s core sel and value as a person.    Mindfulness as an Explicit Technique in the “Third Wave” of CBTs While there may be mindulness elements in tra-ditional CB and other orms o psychotherapy, the explicit effort to integrate mindulness and ac-ceptance into traditional CB has clearly revolu-tionized the field and spawned the so-called “third wave” o cognitive behavioral therapies (Baer, 2006). Among other therapies, these include, in published chronology, Mindulness Based Stress Reduction (Kabat-Zinn, 1982); Acceptance and Commitment Terapy (Zettle & Hayes, 1986); Dialectical Behav-ior Terapy (Linehan, 1993); Mindulness-Based Cognitive Terapy (easdale, Segal, & Williams, 1995); and Mode Deactivation Terapy (MD) in 2002 (Apsche, Evile, & Castonguay, 2002). Mindfulness Based Stress Reduction (MBSR).  MBSR is a behavioral medicine program that translated the Zen Buddhism meditation techniques o Tich Nhat Hanh into a secular, classroom-based psy-choeducational program or stress reduction. It was first introduced in 1979 as a treatment or chronic pain by Jon Kabat-Zinn (1982). in 1979, MBSR is not a therapy per se, but rather a group-based train-ing curriculum that has been successully applied to various clinical syndromes, including depression and anxiety. MBSR continues to be a widely used program, but it is mentioned here or its important historical role in popularizing mindulness medita-tion and bringing it into mainstream clinical psy-chology.  Acceptance and Commitment Therapy (ACT).  Developed by Steven Hayes and his colleagues in the mid-1980s, AC retains the essential CB ocus on cognition, but shifs the ocus rom challenging or controlling cognitive distortions to simply no-ticing and “accepting” the occurrence o negative thoughts and emotions. AC teaches clients to first become mindul through intensive ocus on im-mediate awareness and then to accept their experi-  JENNINGS, APSCHE, BLOSSOM, & BAYLES 18 ences, rather than suppressing or avoiding them as unacceptable and judgmentally “bad.” One o the strongest principles o AC is helping clients to see themselves as being separate or different rom their current negative thoughts and behaviors (Gutierrez & Hagedorn, 2013). AC applies six core principles o acceptance, cognitive diffusion, contact with the present moment, observing the sel, values, and committed action (Hayes, 2004; Hayes, Stroshal, & Wilson, 2013) and has been systematically applied to adolescents (Greco & Hayes, 2008).Te combined AC principles o contact with the  present moment   and  acceptance  are virtually syn-onymous with the definition o mindulness used in this article: immediate awareness o experience with acceptance (i.e., without judgment). Te goal in AC is to help clients to stay aware o their pri- vate memories, thoughts, and eelings without the need to change or avoid their experiences. Cogni-tive defusion  is learning to reduce the tendency to reiy thoughts, emotions, and memories by instead recognizing the transitory nature o thoughts, put-ting them into context, and making the distinction between one’s dysunctional thoughts and one’s core sel (Gutierrez & Hagedorn, 2013). Observ-ing the self   is learning to tap into a transcendent sense o sel that is able to neutrally observe one’s ever-changing experiences and emotions without  judgment (acceptance). At its optimum, the person taps into a calm, deeper continuity o conscious-ness that is, in the Buddhist tradition, one’s “true sel,” able to view onesel as universal and detached rom current behaviors and private experiences. In turn, this transcendent perspective provides the opportunity or the client to discover and clariy his or her most important values , and then take com-mitted action  toward those valued lie goals. Dialectical Behavior Therapy.  Published in 1993, Mar-sha Linehan’s Dialectical Behavior Terapy (DB) is a variation o CB that teaches skills to cope with stress, regulate emotions, and improve relation-ships with others. Key components o DB include cognitive behavioral therapy, validation, dialectics, and radical acceptance. Given her primary clinical population o borderline personality-disordered and suicidal clients, Linehan sought to modiy CB to accommodate their characteristic eatures o extreme emotional reactivity, high sensitivity to perceived rejection, and inability to sel-soothe. o the degree that CB repeatedly challenges the empirical and logical validity o the client’s belies, Linehan’s borderline clients elt as i their emo-tional pain was being discounted as not real, that their essential competency as a person was under attack, and that they were being rejected (as we will see later, this is a similar limitation o CB with adolescents). Tereore Linehan adapted CB by using validation  as a way o showing an acknowl-edgement o the client’s experience o real pain. Te DB therapist affirms that the client’s illogical or maladaptive actions make sense as a valid attempt to relieve suffering and promotes cooperation with the client in finding healthier alternatives. Linehan, Cochran, and Kehrer (2001) describe the DB principle o dialectics  as on-going dynamic applica-tion o various therapeutic strategies. Dialectics is the principle that all things are interconnected, that change is constant and inevitable, and that oppo-sites can ofen be integrated to orm a closer prox-imity to the truth. For example, the DB therapist and client work together to resolve what seems to be a contradiction between sel-acceptance o one-sel as is and changing onesel to be better. Radical acceptance  is helping the client to allow her or him-sel to have all sorts o thoughts, urges, and ideas (even negative or orbidden thoughts that are typ-ically suppressed), which spontaneously appear in the present immediate moment, but without nega-tive sel-judgment. Mindfulness-Based Cognitive Therapy.  Partly inspired by the mindulness-based stress reduction pro-gram first developed by Jon Kabat-Zinn (1990), Mindulness-Based Cognitive Terapy (MBC) was created as a group program or the treatment o depression (Segal, Williams, & easdale, 2002). Like CB, MBC seeks to interrupt habitual (“au-tomatic’) negative thinking patterns that can trig-ger a depressive episode. Whereas traditional CB ocuses on negative thinking in order to challenge its validity, MBC teaches the person to open his or her awareness to all sorts o incoming stimuli and to simply observe and accept all thoughts and experience without judgment. In MBC, the cli-ents are taught mindulness in an eight-week group session ormat, learning to concentrate attention on their immediate experience, including nega-tive, dysunctional, and ineffective thinking and belies – but without judgment. By allowing and acknowledging the presence o negative thoughts and emotions without judgment or avoidance, the person gains a decentered, objective perspective that is better able to cope with emotional distress and more resistant to depression. Mode Deactivation Therapy  . Apsche developed MD specifically to overcome the limitations o tradi-tional CB with disturbed adolescents, especially conduct disordered and aggressive youth. Apsche integrated Beck’s (1996) theory o “modes” and schema therapy rom traditional CB with ele-ments rom Linehan’s DB and Functional Ana-lytic Behavior Terapy (Kohlenberg & sai, 1993). Beck conceived o “modes” as powerul sub-orga-nizations o the personality. Modes are comprised o integrated networks o cognitive, affective, moti- vational, and behavioral components, which srci-nally developed as protective strategies and belies in response to traumatic and abusive lie experi-ences. Modes are emotionally charged and become ingrained, maladaptive, “automatic” responses to perceived threats. Indeed, because clinically dys-unctional adolescents are instantaneously flooded with powerul anxiety, rage, and ear, Apsche et al. (2005) ound that they were unable to override their primal, automatic “mode” responses by em-ploying CB-like cognitive controls. Given their  volatility and histories o victimization, such youth are distrustul, guarded, earul, and acutely sensi-tive to adult-child power issues in the therapeutic alliance. Like Linehan’s borderline clients, Apsche ound that traditional CB was requently coun-terproductive and alienating or adolescents. No matter how delicately it may be done, the CB pro-cedure o repeatedly challenging aulty thoughts and belies is negatively experienced by the youth as an attack on his or her ragile sense o sel-es-teem and world-view, which requently backfires into increased resistance and distrust. Tis is espe-cially problematic with dysunctional adolescents, who have developed rigid belies and automatic dysunctional “mode” responses to protect them-selves rom the pain and ear o trauma and abuse. Given the developmental primacy o autonomy or adolescents, even non-clinical teens can be highly sensitive to power dynamics with adults and may react with oppositional defiance when their belies are challenged.o accommodate this inherent “oppositional” dy-namic with adolescents, MD adopted the prin-ciples o validation, radical acceptance, balancing, and mindulness rom DB. Rather than challeng-ing cognitive distortions and irrational belies, the goal is to join with the youth in collaboratively discovering how the individual’s belie system is a legitimate reflection o his or her lie experience, relationships, sense o sel, and world view. MD radically accepts  the adolescent’s belies as truths in his or her lie, no matter how irrational, and even i there is only a “grain o truth.” MD continually validates  the adolescent’s perception o reality, ac-cepting the youth or who he is based on his be-lies, which builds trust and collaboration with the therapist. Ten MD collaboratively applies cogni-tive balancing   to introduce increasing flexibility or balance into the individual’s rigid and maladaptive dichotomous (either/or) belies by opening consid-eration to a continuum o truth or a continuum o possibilities.In particular, MD uses direct training in mind- fulness skills  as a major intervention in the pro-cess o deactivating the adolescent’s ingrained maladaptive “mode” responses (i.e., emotional deregulation). Given the resistance and reactivi-ty o severely dysunctional adolescents, Apsche and Jennings (2013) developed a diverse “toolkit” o non-threatening ways o teaching mindulness skills, including breathing exercises, guided imag-ery meditation, visual concentration tasks, nature walks, sensory explorations, and intentionally un exercises that incorporate sports and adven-ture to engage youth. Te diversity o tools offers more ways o engaging youth and gives them the autonomy o choosing mindulness exercises that they preer. Since the mindulness exercises are re-laxing in nature, they do not trigger the emotional disruptions and oppositional reactivity o “modes.” Moreover, the mindulness exercises typically do not involve traditional “talking” therapy, which can ofen be experienced as aversive, intrusive, boring, or upsetting or teen clients.Most importantly, the mindulness training com-ponent o MD serves multiple therapeutic pur-poses. Research with adolescent offenders has shown deficits in identiying, labeling, and manag-ing emotions (Moriarty , Stough, idmarsh, Eger, & Dennison, 2001). Mindul ocusing on immediate experience directly promotes the development o introspective awareness and helps the adolescent to learn to tolerate emotional pain, negative emo-  MINDFULNESS IN THE TREATMENT OF ADOLESCENT SEXUAL ABUSERS 19 tions, and the anxiety o new experiences without avoiding them or losing control. Like DB, the MD mindulness exercises provide opportunities or adolescents to regulate their emotional reactivi-ty and let go o deensive hyper-vigilance. Trough calm, neutral observation, adolescents learn to “accept” whatever experiences enter awareness – without negative judgment, reactive ear, aggres-sive outbursts, or harsh sel-criticism – ultimately leading to greater sel-acceptance and sel-confi-dence in controlling dysunctional behavior and emotional reactivity.     Applications of Mindfulness with Forensic and Offender Populations Although limited, there has been a recent in-crease in efforts to apply mindulness and accep-tance-based techniques with orensic and offend-er populations. In their review article, Gillespie, Mitchell, Fisher, and Beech (2012) ocused on the potential value o mindulness with adult sex offenders, in particular, because negative affect and deficient regulation o emotional states ofen have a causal role in pathways to sexual offending (Hudson, Ward, & McCormick, 1999). In par-ticular, they hypothesize that mindul breathing concentration applies directly to the neurobiolog-ical centers o emotional control. Howells (2010) has likewise recommended expanding the “third wave” o mindulness-based cognitive therapies to include orensic mental health populations. In ap-plying mindulness to the treatment o anger and aggression, or instance, Wright, Day, & Howells (2009) state that “acceptance based approaches at-tempt to teach clients to eel emotions and bodily sensations more ully and without avoidance, and to notice ully the presence o thoughts without ol-lowing, resisting, believing or disbelieving them (p. 398).” Samuelson, Carmody, Kabat-Zinn, and Bratt (2007) directly applied Mindulness-Based Stress Reduction with male and emale inmates to reduce hostility and mood disturbances and to improve sel-esteem.Berzins and restman (2004) reviewed six different adult orensic programs that used group-based psy-choeducational programs in Dialectical Behavior Terapy, o which two had an explicit mindulness training component. Te Colorado Mental Health Institute program delivered three mindulness ses-sions (8% o the total o 37 DB group sessions) to male orensic patients, while the Correctional Services o Canada program delivered 6 mindul-ness sessions (14% o the 42 DB group sessions) to emale orensic patients. No outcome data was reported or either program, but it appeared to help reduce overall physical and sexual aggression and rule-violations.Finally, in a series o several studies, Singh and his colleagues (Singh et al., 2010) have used mindul-ness to treat the aggression problems o adults with mental illness and adults with intellectual disabil-ities, as well as to manage deviant sexual arousal with adult sex offenders and adolescents with in-tellectual disabilities. O particular interest to this discussion, the Singh group used five consecutive days o 30-minute training in mindulness-based “meditation on the eet” to train three adolescents with autism to sel-manage their physical aggres-sion, reducing hitting rom 14-20 events per week to 1 per year over three years o ollow-up (Singh et al., 2007).     Applications of Mindfulness with Adolescents Te recent growth o interest in mindulness inter- ventions or youth is reflected in two recent reviews by Black, Milam, and Sussman (2009) and Burke (2010), who conducted the first systematic review o the available research. At that time, Burke ound a total o only 7 studies o mindulness with children and 8 studies with adolescents, most o which were preliminary and exploratory. One large random-ized study applied the standard Mindulness-Based Stress Reduction course (Kabat-Zinn, 1990) as an adjunct to “treatment as usual” (AU) or a group o 102 adolescent outpatients with heterogeneous psychiatric diagnoses (Biegel, Brown, Shapiro, & Schubert, 2009). Participants sel-reported great-er reductions in symptoms o anxiety, depression, and somatic distress, and increased sel-esteem and sleep quality compared to the AU control group (without MBSR). Similarly, Zylowska et al. (2008) applied the same 8-week MBSR adult mindulness training course with a mixed group o 24 adults and 8 adolescents with attention deficit hyperactivity disorder, which reduced sel-reported symptoms o ADHD, anxiety, and depression, while improving perormance measures in attention and cognitive inhibition tasks. Other examples o research show-ing the application o MBSR with youth include re-duction o childhood anxiety (Semple & Lee, 2010) and improving behavioral control and attention or adolescents with ADHD (Van de Weijer-Bergsma, Formsma, de Bruin & Bogels, 2012).In a broader meta review, Black, Milam, and Suss-man (2009) reviewed 16 empirical studies o the health-related effects o “sitting-meditation” inter- ventions with youth aged 6 to 18 years in medical, school, clinic, and community settings rom 1982 to 2008, encompassing a total population o 860 participants. Tey ound median effect sizes were slightly smaller than those or adults, ranging rom 0.16 to 0.29 or physiological outcomes and 0.27 to 0.70 or psychosocial/behavioral outcomes (0.5 is considered a medium effect size, and a value o 0.8 or more is considered a large effect size). More specifically, 5 o the 7 studies o anxiety showed improvement, 1 o 3 studies o depression showed improvement, and 7 o 9 studies related to so-cial-behavioral problems showed improvements in  various measures o attention, attendance, sel-es-teem, and school behavior.Overall, the application o mindulness with chil-dren and youth is becoming well-established and growing, although most o it is ocused on stress reduction and/or occurs in medical and school set-tings and typically entails group-based, classroom training like that o MBSR. Te clinical application o mindulness with adolescents with psychiatric disorders, however, is limited, with perhaps two exceptions. o the degree that DB and AC are mindulness-based therapies, there is a sizeable literature dedicated to both the use o DB with multi-problem suicidal adolescents (e.g., Miller, Rathus, & Linehan, 2007) and the use o AC with children and adolescents (e.g., Greco & Hayes, 2008), but such a review would exceed this discus-sion. Moreover, neither DB nor AC is acknowl-edged as evidence-based practice or sexually reac-tive or sex offending adolescents. Modifying mindfulness to meet the needs of adolescents Although none o the above mindulness stud-ies involves adolescent sex abusers, a recent study by Jennings and Jennings (2013) is notable or its practical recommendations by which to modiy traditional adult mindulness training to meet the differing developmental needs and interests o ad-olescents. Each o these modifications can be valu-able in work with sexually reactive and sexually abusive adolescents. Te first, and most important, assertion is that adolescents respond well to  guided imagery   protocols that incorporate mindul breath-ing concentration (as long as the skills training is delivered in relatively brie sessions and has appeal-ing content). Based on the methods o MD, mind-ulness guided imagery is a spoken protocol that guides adolescents through an imagined mountain climbing adventure, or a day at the beach, or some other peaceul and sae scenario, while requently drawing attention to ocused breathing and accep-tance throughout (Apsche & Jennings, 2013). Youth thus enjoy the relaxing sensations o the experience while actively learning the mindulness skills o o-cused breathing, meditative concentration, and ac-ceptance. Critics might reject this guided approach as too structured, arguing that “true” mindulness should be completely open-ended, allowing any thoughts, images, or eelings to spontaneously en-ter awareness. Instead, this modified approach or adolescents endeavors to create conditions that are conducive to mindul attention and acceptance, using guided protocols that requently acknowl-edge the appearance o spontaneous thoughts and instructing the youth to simply notice the thoughts and let them pass on.Te second recommendation rom Jennings and Jennings (2013) is that the content o the guided imagery should be  fun and engaging   and should offer a varied “toolkit” o mindulness exercises and activities that have an innate appeal to youth, such as sports, nature, adventure, and discovery (Apsche & Jennings, 2013). As practiced in MD, it is important to present adolescents with multi- ple pathways  or learning mindulness skills, which better accommodates the differing learning styles and preerences o individual teens. Tis toolkit ap-proach also osters the adolescent’s developmental need or autonomy because each teen is allowed to try various mindulness tools and choose the ones that work best or him or her.Te third recommendation rom Jennings and Jen-nings (2013) is to deliver mindulness skill training in shorter experiential sessions , which is better suit-ed to the shorter attention spans o youth. radi-tional adult programs or mindulness training re-quire about eight weeks o extended class sessions  JENNINGS, APSCHE, BLOSSOM, & BAYLES 20 (Carmody & Baer, 2009; Segal, Williams, & eas-dale, 2002). In act, the most widely used program o Mindulness-Based Stress Reduction entails one 6-hour class and eight 2.5-hour classes (Ka-bat-Zimm, 1990). However, Jennings and Jennings allowed a teenager to select and deliver a series o mindulness exercises to a non-clinical group o eight high school peers in just our 50-minute ses-sions. Results rom the 3-week pilot study showed a surprisingly strong reduction in cognitive anxiety and mild reductions in social anxiety. Given the prohibitive time demands o attending an eight week program like MBSR, other researchers have begun testing mindulness interventions that re-quire ewer hours and/or a shorter period o time. In act, a recent review showed no evidence that shortened versions o MBSR were any less effec-tive than longer ormats with adults (Carmondy & Baer, 2009).    MDT: Applications of Mindfulness with Adolescent Sexual Abusers o the best o our knowledge, Mode Deactivation Terapy is the only mindulness-based treatment that has been empirically validated with sexually abusive adolescents. Tere is a strong body o re-search studies and meta-analytic studies that show the effectiveness o MD with a variety o dis-turbed adolescents. In one randomized controlled experiment, Apsche and his colleagues (Apsche et al., 2005) compared the effectiveness o traditional CB, Social Skills raining (SS), and Mode De-activation Terapy (MD) or 60 male adolescents with serious sexual and physical aggression prob-lems, with an average length o residential treat-ment o 11 months. While all three therapies were effective in reducing rates o physical aggression, only MD, with its ocus on mindulness, demon-strated a significant reduction in rates o sexual aggression. wo years ollowing treatment, the re-cidivism rate or the MD group was 7% with no serious offenses, such as sexual offenses or physical assaults (Apsche, Bass, & Siv, 2006). By compari-son, 20% o the CB group engaged in chargeable offenses, including sexual aggression and physical aggression, auto thef, and drug sales, while 49.5% o the SS group committed offenses, including at-tempted murder, rape, aggravated assault, and oth-er serious offenses.In another study, Apsche, Bass, Zeiter, and Hous-ton (2009) compared the effectiveness o Family MD with “treatment as usual” (AU) amily ther-apy and CB amily therapy or 40 adolescents with sexual and physical aggression problems and oppo-sitional behavior. Afer 18 months, the 20 adoles-cents in the MD group showed three incidents o physical aggression compared to 12 incidents or the AU group.Apsche and DiMeo (2010) conducted a meta-anal-ysis o the effectiveness o MD over the course o ten years o application, which included data rom all published MD studies as well as yet unpub-lished studies. O the total o 458 male adolescent cases reviewed in the meta-analysis, more than hal had sexual offenses (55.5%), while roughly hal were diagnosed with conduct disorder (52%), oppositional defiant disorder (45%), and Post-trau-matic Stress Disorder (51%). Collectively, 92% o the adolescents had experienced our types o abuse, 54% had witnessed violence, and 28% pre-sented with parasuicidal behaviors. Te meta-anal-ysis showed large effect sizes or the use o MD or the categories o Sex Offender/Physical Aggres-sion (1.78), Conduct Disorder/Physical Aggression (1.85), otal Physical Aggression (1.82), and Sexual Aggression (1.80), in which, as previously noted, e-ect sizes o 0.5 are considered medium and values over 0.8 represent large effect sizes. Tis suggests that a mindulness based approach, such as MD, is effective in treating complex conditions and be-haviors, including sexually troubled behavior.Subsequently, Apsche, Bass and DiMeo (2011) con-ducted a larger meta-analysis o MD effectiveness with a total o 573 adolescents, including 369 ado-lescents with sexual aggression. Te results again showed large effect sizes or Sex Offender/Physical Aggression (1.81), Conduct Disorder/Physical Ag-gression (1.85). otal Physical Aggression (1.86), and Sexual Aggression (1.94).Based on the empirical and meta-analytic data, there is strong support that MD, a mindul-ness-based treatment, is effective with a variety o disturbed adolescents, including sexually reactive and sexually offending adolescents, and demon-strates that a systematic mindulness-based meth-odology can reduce both sexual and physical ag-gression in adolescents (Apsche & DiMeo, 2010, 2012; Apsche, Bass & DiMeo, 2011).Tus, by helping adolescents to stay ocused in the here-and-now, rather than in the past or uture, as suggested by Apsche and DiMeo (2012), mindul-ness can enhance the effectiveness o most thera-pies with adolescents who engage in problem be-haviors, including sexual offending.    Case Example: Applying Mindfulness with an Adolescent Sexual Abuser  Te ollowing transcript o a therapy session with an adolescent sexual abuser, excerpted rom Ap-sche and DiMeo (2012), illustrates a blended ap-plication o traditional CB techniques with mind-ulness and acceptance techniques rom AC, DB, MBC, and MD as briefly described earlier and shown in table 1 below. Te client is a 16-year–old male, who was arrested or having repeated inter-course with an underage emale. As a child, rom ages 7 to 9, he was abused and repeatedly raped by his stepather. Afer ailing to respond to outpatient treatment, he had also been terminated rom a day program and residential treatment or aggression and fighting. Tis therapy session was conducted in a subsequent residential program or sexually abu-sive youth, using various techniques drawn rom CB, AC, DB, and MD (presented in italics). Therapist (T): Let’s take a second and do some breathing beore we talk about anything. [ ypi-cally, the MD therapist both begins and ends the therapy session with a brief five-minute practice of mindful breathing  .] Adolescent (A): Okay…FIVE MINUES LAER… (T): Open your eyes and allow yoursel to get o-cused in this moment. [ Use of mindful here-and-now awareness. ] Are you good? (A): I eel like I am moving through these painul eelings and thoughts in a different way than I have in the past with other therapists. [ Based on prior mindfulness training, the adolescent has learned to allow painful memories and emotions to enter awareness and observe them without  judgment. ] Now what? (T): Well, let’s talk about it. You have let yoursel think these thoughts and eel the pain and you are still here. [  Acceptance and validation .] So, is it possible that you can accept that these painul thoughts and eelings are part o you, whether it sucks or not? [ Cognitive diffusion: distinguishing core self from the experience of dysfunctional thoughts and painful emotions. ] (A): Yeah. (T): And, it’s clear you can experience them and not all apart. [ Validation .] Can you then commit yoursel to move on with all o your pain and thoughts and not let them control your lie? [  AC commitment and cognitive balancing  .] (A): I can try, but this isn’t easy. (T): You are right. It’s not easy. [ Validation .] Howev-er, you have just successully accepted that they are part o you and you can move on with your lie. [  Acceptance and cognitive diffusion .] (A): Yeah, I did. (T): So, maybe there are also times when there are no painul eelings and thoughts? [ Cognitive balancing  .] (A): Maybe, sometimes there are. (T): In the last session, we discussed how you couldn’t eel anything. (A): Yeah, I am numb. Empty. (T): You endorsed the belies “Anything is better than eeling unpleasant” and “Whenever I hurt, I do what it takes to eel better” as “Always.” Remember? [ CB. Te therapist is referring to an earlier assessment of beliefs endorsed by the client  .] (A): Yeah, so? (T): Let’s talk about your emptiness and numbness. (A): Okay. (T): ell me what your numbness eels like. [  Mind- ful here-and-now awareness .] (A): It eels like nothing. (T): And, where is the nothing? (A): What do you mean, where? (T): Where on or in your body do you notice the nothing—the emptiness and numbness? [  Mindful here-and-now awareness .] (A): [Points to chest.] (T): Where on your chest? [  Mindful here-and-now awareness .] (A): Here, right in my chest. (T): Describe how the numbness eels. What does the emptiness eel like in your chest? [  Mindful here-and-now awareness .] (A): It eels like an empty hole.
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