How We Practice Autism Awareness (Kamal Witharana)

This guest entry is from Dr Kamal Witharana (MD, MSC, FRSPH, PTLLS, IFL),  an Associate Member of the Positive Psychology Guild and member of the Buddhist Pali Text Society in the UK. Dr Witharana shares insights from his professional journey through Autism Awareness and Positive Psychology, and findings from a mindfulness research project on autism conducted in 2019.

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How did your journey in Positive Psychology or Autism Awareness begin?

As far as I am aware, the field of “Positive Psychology” involves supporting people to help them realise their life’s worth regardless of their disabilities while understanding their thoughts, feelings, and behaviour.

I started treating and supporting people with learning disabilities and Autism in Sri Lanka in 1993 and then in 2006 in the UK.

In Sri Lanka, I was working as a medical doctor and regional director of health services dealing with curative medicine, preventive medicine as well as conducting health education programmes for people in need including people with learning disabilities and Autism and their support workers. In the UK, I started this journey as a postgraduate student studying for MSc in Public Health at the University of Bedfordshire and one of the co- units was “Research”. I did a research following a submission of my dissertation. During this time, I was an active team member on a part time basis for a care organisation serving people with dementia, learning disabilities and Autism. I also led the team and taught staff to provide the necessary support. Since I graduated, I continued my journey practising positive psychology in various job roles.

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How do you practice Positive Psychology or Autism Awareness?

When I started practicing positive psychology with people diagnosed with learning disabilities and Autism, I first studied their individual characteristics, positive experiences, and behaviours, which helped me to build upon their strengths. I enjoyed working with people with mental health issues, mainly dementia, and young adults and elderly with learning disabilities and Autism. I worked with them as part of my job and I enjoyed that job, because I could make a real difference to their physical and mental well-being with my team to give more quality and value to their life in a person-centred way.

The most important thing I have noticed was, sometimes even though we do not notice major changes around us; they were able to notice even very minor changes such as withering of leaves and fluttering birds. They did not judge others, so they were somewhat more mindful than others despite their mental capacity.

Knowledge I have gained through practice and going through the national guidelines were:

Different types of learning disabilities and Autism and the way people may present, their behaviour patterns, ASD specific observational assessment tool, Buddhist philosophy in mindfulness practice, alternative methods used for behaviour management such as none abusive psychological physical intervention and challenging behaviour awareness.

The characters, virtues, and strengths I drew in my practice were:

Continuous learning through research and experience; (self-enhancing) humour; love and kindness; empathy; (interpersonal) fairness; (intellectual) open-mindedness and creativity

Skills I used:

Conducting research and assessments, analysing and interpreting outcomes, coaching, team working, guiding people using effective communication skills, dissertation writing (reflecting on my master’s research)

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Please describe your research project design and implementation.

The topic of the study was: 

“To understand behaviour of care staff towards service users with learning disabilities and Autism and behaviour of service users towards care staff and study the correlation between mindfulness meditation and changing staff attitudes and behaviour towards service users (adults) with learning disabilities and Autism and develop continuous mindfulness programme for staff and service users at workplace.”

It was a qualitative observation and investigation of mindfulness practice on care staff and service users and some family members

I used one-to-one interviews, observation before and after mindfulness put in place, direct observation of role plays and scenarios, semi-structured questionnaires and finally I analysed the patterns of behaviour charts were completed over three months by care staff. The grounded theory method was used in analysing results.

I implemented the project involving care staff, care managers, care coordinators and service users with learning disabilities and Autism and some family members in 2019 at a day centre of a care agency over three months.

The rational was that many incidents of challenging behaviour had been reported to the management, even though the staff had annual training in challenging behaviour and physical intervention. Before starting the study, a short explanation was given, and obtained informed consent as appropriate. Demographically it was determined that most of the staff worked with the same service users on different shifts. The staff had 6 to 15 years of experience working with such service users. Possible level of risk by practising mindfulness with service users was discussed with health care team including GPs prior to the project by management.

Data were collected based on interview questions and semi structured written questionnaires before and after the actual project, and we analysed ABC (Antecedent behaviour consequence) charts. (Questionnaires were attached on the appendix of the study but not provided in here). The study was analysed based on grounded theory. All the results and other data were well protected as per GDPR 2018.

Challenges and issues:

Some care staff missed some sessions and it was the case even with some service users due to their care schedules. The service users were unable to take part in the interviews or do the questionnaires. It was very interesting to note that even though annual skills-based training sessions did not change the attitudes and behaviours of care staff, mindfulness practice made a significant change in their approach towards service users.

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Please describe the findings of the research.

I did a literature search and learnt that not many studies had been carried out on this particular field. Not many qualitative studies could be found either. However, I have noticed that, although mindfulness was used widely in clinical practice, there was a gap in the literature to demonstrate how clinicians could use mindfulness with clients. And practitioners were using a variety of methods of mindfulness rather than the technique taught in the original scriptures (establishment of four foundations).

We analysed closed-ended questionnaires, direct observation results, and antecedent behaviour consequence charts (ABC charts).

I have used semi-structured interviews with care staff, managers and family members involved. The open-ended questionnaire required participants use of mindfulness practice overall and, use of mindfulness practice with service users who present with anxiety and agitation.

Summary of outcomes:

The findings were: 

• Mindfulness meditation could make a significant positive difference on the behaviour of care staff towards service users with learning disabilities and Autism.
• “Managing challenging behaviour of service users with learning disabilities and Autism” through mindfulness gives better results compared to simple traditional mandatory training.
• Though it is hard to change certain attitudes of care staff towards service users through existing mandatory health and social care training, mindfulness training could do it if practiced on a regular basis
• Mindfulness of breath for staff and family members.
• All the participants among staff could use the technique of focus on breath successfully.
• Applying mindfulness helped the staff to carry out daily caring tasks more effectively.
• Both staff and family members noticed a positive impact on their life by practicing loving-kindness

For service users:

• The technique of focusing and concentrating on a “blue spot” (meditation object) was successful when practiced over time and it helped them with their attention span.
• Paying attention to the bell was very successful and in fact they all enjoyed the ringing tone and paid attention throughout.
• Walking along between parallel lines was also well received.

After about six sessions had been completed, the interaction and relationship between both service users and care givers improved. Being in the present moment non-judgementally, the staff was able to cope with the stress and agitation better. Some service users managed the tasks very easily while others could not concentrate at all. The lack of concentration could be due to the severity of the condition. However, the mindful practices of listening to a bell and walking along a line were taken easily by most of them. The most important finding was that the staff started to become less judgemental towards the behaviour of service users.

Through regular practice of mindfulness, the number of episodes of challenging behaviour of service users was reduced nearly by about 14% (after three months of practice) and staff attendance also improved according to the manager.

Recommendations for future research:

I believe more research should be carried out with bigger sample groups to justify (may be to condemn) the outcome of this research and also conduct a randomised control trial having a control group.

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What motivated you to conduct this research?

What motivated me…

I have realised:

• Attitudes and behaviours could be changed not by changing the external factors, but by changing the internal factors such as perception of staff and learning to approach the service users in a non-judgemental manner.
• Developing knowledge and skills through traditional training did not change the attitudes and behaviours of staff so there was a gap between the training and the performance.
• I used experience I have gained, and I reflected on my own practice while guiding others to do so.
• In summary, my professional and personal experience and knowledge and skills I have gained over the years in this subject, motivated me to conduct this research.