Psychology and Psychoanalysis

Objectives: Mindfulness is taught in DBT as one of several skills offered in the treatment of multi-problem suicidal adolescents. This study explored adolescent’s experiences of engaging with mindfulness during a Dialectical Behaviour Therapy (DBT) Programme. Design: This study used an Interpretative Phenomenological Analysis design. Methods: Semi-structured interviews were conducted with seven adolescents with experience of mindfulness in DBT and the interview transcripts were analysed using Interpretative Phenomenological Analysis. Results: Four Superordinate themes were developed from the analysis: i) Being uncertain of how mindfulness will help; ii) The challenge of mindfulness; iii) Experiencing a new perspective; iv) A tension between being aware of painful thoughts or emotions or zoning out. Conclusions: These themes offer an awareness of the adolescent experience of mindfulness

• Adolescents may find participating in mindfulness difficult due to being unsure of the purpose of mindfulness and a tendency to distract away from rather than participate in their experiences.
• Factors such as developmental stage or mental disorder such as trauma or ADHD may make developing mindfulness particularly challenging.
• Adolescents may need an individualised approach to learning mindfulness due the potential of experiencing barriers to being mindful and misunderstanding the purpose of mindfulness in DBT.

Introduction
Dialectical Behaviour Therapy for Adolescents (DBT-A) is a therapeutic approach adapted for use with 'multi-problem suicidal adolescents' from the original DBT programme which was developed to treat people with Borderline Personality Disorder [1].As with the original programme, DBT-A incorporates mindfulness as one of the core elements of the treatment, teaching mindfulness as a repertoire of skills as part of a skills training programme and also during problem solving of target behaviour during individual sessions.
Mindfulness has been developed as a clinical intervention for mental and physical health conditions and adapted for use with adolescents [2].However, were gained via purposive sampling as participants needed to have engaged in DBT as a treatment [10].Gatekeepers from each service were identified to assist in identifying potential participants.The Gatekeeper had knowledge of the service user and ensured safeguarding and risk issues were considered prior to participation.The specific tasks given to the gate keeper were to: 1. Provide suitable young people with the participant information sheet (appendix H).They only offered this to those who fulfilled the inclusion criteria.
An information video was also made available to enhance accessibility of the information.
2. Sign the research reply form to declare that the respondent was fit to take part in the study.
3. Act as a contact for the researcher to feed back any safeguarding issues or distress that the young person wished to be followed up.
No case information about the service user was shared with the researcher as this was deemed superfluous to the aims of the study and may have introduced bias during the interview and subsequent analysis.
Participants could be approached for inclusion in the study if they had completed at least one module of DBT skills training which has included mindfulness within the last year and remained open CAMHS.Participants were not approached for inclusion in the study if they were currently suffering from mental distress or illness that would make it unsafe for them to take part or none of the participants were previously known to the interviewer.

Consent
Consent forms were developed from the research consent template.Before the interview the researcher checked that the participant had read and understood the information sheet.The consent form was explained, including consent for verbatim extracts to be used in reports, and each participant was given the opportunity to clarify any points.Participants were informed as part of the consent process that if risk or distress were evident in the interview that the researcher would contact the gatekeeper to follow up.They were also informed that they could withdraw at any time from the research.No risk or distress was highlighted by service user participants during the interviews and no request for follow up made.None of the participants withdrew from the research.

Data collection
A semi-structured interview schedule (Table 1) was developed in consultation with two practitioners to strike a balance between directing the participant, supporting the interviewer to keep on topic and allowing exploration of the thoughts that were expressed during the interview [11,12].A short video clip example of a mindfulness exercise typical in DBT was shown to the participant after the first few questions to stimulate them most of the research investigating the use of mindfulness for mental disorders has been carried out with adult participants and therefore the impact of introducing mindfulness to programmes of treatment aimed at adolescents diagnosed with a mental disorder lacks an evidence base.
Studies that have focussed on adolescents with mental disorder have reported mindfulness to be useful to adolescents in the following ways: shifting perspectives on self and life [3]; reducing distress in the moment [4]; increasing self-awareness and selfregulation [5]; facilitating adolescents moving from a state of distress and reactivity to a state of insight and application [6]; and self-distraction from distress [7].Empirical research has also highlighted difficulties that adolescents with mental disorders experience with mindfulness, including: Self-criticism [8]; doubting mindfulness would work when distressed [4] and that increasing focus on emotion becomes counterproductive [7].
The mindfulness element of DBT has been studied to a limited extent, the findings of which suggest that mindfulness is a useful part of the treatment through increasing the ability to act with awareness and to be non-judgemental [9].However, the body of research relating to mindfulness in DBT has not considered the application of DBT with adolescents.
At present, the body of evidence relating to mindfulness as an intervention indicates that although the adaptation of mindfulness as an intervention for adolescents with mental disorder diagnoses seems appropriate, there are significant gaps in the understanding of whether there are specific features of adolescence which may inhibit the effectiveness of mindfulness and if, or how, specific modifications to mindfulness-based need to be made to increase the effectiveness for adolescents.In view of the gaps in understanding with regards to the use of mindfulness with adolescents and in particular as part of DBT, the study presented in this paper was undertaken with the aim of answering the research question: What is the lived experience of adolescent service users engaging with mindfulness in DBT?

Methodology
The study was conducted using Interpretative Phenomenological Analysis (IPA) as it focusses researchers on the lived experience of a certain phenomenon [10].

Research context and researcher orientation
The research presented in this paper is an outcome of the first author's PhD.The first author is trained in DBT and practices DBT with adolescents.

Recruitment and participants
The study recruited adolescents from participants were used to define the interpretation made of the meaning of each part of the transcript.Themes were generated by grouping codes through clustering, subsumption; polarization; contextualization; numeration and function.The themes generated from all of the transcripts were analysed using the same clustering processes to generate superordinate themes across the data.
The validity of this research was checked against criteria suggested by Yardley (2000) including the following: use of salient up to date literature to provide the context of the research; description of the context of the research services and participants; in depth analysis of the data; use of data extracts to demonstrate findings; description of negative cases; demonstration of reflexivity throughout the research project; situating findings within the current research context.

Findings
Seven adolescents -all female and aged between to focus on mindfulness in DBT [13].After questions to establish the length of time in the programme and time since their programme ended, participants were asked to think back to specific experiences of mindfulness in DBT.Smith [14] suggested that adolescents need a greater level of structuring to allow them to access their thoughts about an experience.Therefore, additional prompts were used to elicit specific parts of the experience -how did you feel?What did you think?
Each participant was interviewed by the first author on one occasion at the clinical site from which they had been recruited between August 2015 and August 2016.The interviews, which were audio recorded, lasted between 31.49and 52.06 minutes.

Data Analysis
Verbatim transcripts, transcribed by a professional transcriber, were analysed following the process outlined in Interpretative Phenomenological Analysis (IPA) [10].Each transcript was analysed in turn.Codes  16 and 22 from four were recruited and interviewed (Table 2).There were differences between the DBT programmes offered by each service also outlined in the table.
The analysis of the interview transcripts led to the development of four superordinate themes and 16 subordinate themes as outlined in Table 3.
The findings of this IPA study are described and discussed, having been grouped into the superordinate themes.
The findings are illustrated by exemplar quotes from the interview transcripts -indicated in italics and ascribed a pseudonym to protect confidentiality.

Superordinate Themes Being uncertain of how mindfulness will help
Participants engaged with mindfulness because it was part of the DBT programme not because they had specifically chosen to practise mindfulness.The experience of being directed towards mindfulness led to uncertainty because the first experiences of mindfulness did not fit with the participant's expectations of what would be helpful.
'So I'm just like looking around the room at different things.And I was just sitting there, I was just like, why?What, What's the point in this?We're just sitting here doing nothing, listening to some recording that just makes me laugh a little bit.' Philippa The instruction participants were given with regard to mindfulness did not connect with their ideas about what would help them with their problems; highlighted in the recurrent refrain -what's the point?As a result, participants experienced doubts and became sceptical of mindfulness only engaging because they deferred to the expertise of professionals, without any personal conviction that mindfulness would be helpful.
'Yeah, you're like, well they've told me to do this thing so I'm gonna do it 'cos they know what they're talking about I guess [giggles], um, but it still seems a bit, like … yeah.' Louise

The challenge of mindfulness
Participants questioned whether everyone had the ability to be mindful.Engaging in mindfulness was difficult because service users found themselves unable to partake comfortably in the exercises.
'We were meant to, like, not judge when we're judging other people, like not judging ourselves when we're judging other people.And, like, that's actually really hard, because like, obviously, like, everyone judges everyone else, like that's just, like, a normal society.'Kirsty Some Participants believed mindfulness was beyond their capability.• The experience of 'zoning out' from the painful thoughts or emotions • The experience of becoming more aware of a painful thought or feeling being self-aware.Activity-based mindfulness seemed to be blurred with the DBT teaching around distraction and it may be that mindful distraction is useful in order to prevent rumination.

'I just … I just stay in emotional mind. I don't … I, like, I can, I don't … wise mind just doesn't exist within me, like, I just, I can't do it. Yeah. I don't know. I'm not … yeah, I don't know, I, I'm not a very logical person anyway, so no. I don't know. Oh well.' Sam
'I would say that to be mindful you have to think about one … you have to focus on one thing; um, completely clear your mind; forget about your life at that ti-, at that time, um, just, just don't think really.' Tara Difficulties with choosing where to put one's attention could be the cause of difficulties with intrusive thoughts/memories and rumination.Therefore, by developing the ability to choose where to put their focus some participants demonstrated that they could reduce the effects of rumination.
Participants avoided internal awareness which they feared would lead to ruminative thoughts rather than cultivating an ability to tolerate the experience.There was one exception to this within the interviews -a description of using mindfulness to manage an anxiety provoking trip to the dentist where observing the experience led to a feeling of awareness and control.

A tension between being aware of painful thoughts or emotions or zoning out
Throughout the participant accounts, mindfulness was used as a kind of emotional first aid to deal with peaks in negative emotion and distressing thoughts, thereby helping participants to function again.Participants engaged in mindfulness in response to experiencing the most severe emotions and thoughts; 'I personally use it (mindfulness) as a way to, like, calm myself down in, like, drastic situations.And yeah, it was a bit difficult it in those, but it did help a lot.' Philippa Engaging in mindfulness in distressing situations was described as preventative of self-harm, arguing and being violent.The DBT approach of skills-based mindfulness lends itself to mindfulness being used in discrete moments of distress to deal with unwanted feelings and urges.This was valuable to many of the participants -to have a way of calming themselves and taking a step back from their situation, which led to change in their behavioural response.
'I argue a lot with my Mum.......... I'm just like, no, I'm just gonna, I'm just gonna leave it, I'm just gonna take a breather, and, and do some colouring, and that.That's, it's basically arguments 'cos I'm not very good at arguments, that I use it (mindfulness) in.' Rachel Participants were unsure whether to practice more in an effort to overcome the difficulties with mindfulness or whether to stick with the things that came more naturally.Participants use of words such as 'should' and 'not enough' (imaginative, calm, logical, clever) indicated an idea of being deficient and unable to develop mindfulness.Such a response could undermine attempts to engage with mindfulness.

Experiencing a new perspective
The most universal outcome of practising mindfulness described by participants was that of being calm and composed.Many of the participants described living in stressful and emotionally chaotic worlds from which they were seeking refuge and that mindfulness calmed the effects of their emotions.Mindfulness calmed service users both physically as well as psychologically and led to a change in behaviour.

'I think of it like when you're in crisis your brain is shaking; -well this is just a personal thing -like your brain is shaking, your thoughts are everywhere, you don't know what to do. Mindfulness lets your brain calm down,' Philippa
Participants felt dragged off course by their painful emotional worlds and destructive thinking patterns and through being calm they were able to reconnect to what was important to them.

'It brings you back to yourself, instead of thinking about everything else going on, like daily stresses and whatnot. It just brings you back to you, and just … your mind, and just letting everything calm down for a moment before whizzing back up into real life again.' Philippa
Participants used mindfulness to distract from unwanted emotions or sensations.They entered a world protected from thinking about their problems or experiencing their distress.Mindfulness acted like a cushion between the person and the reality in which they were living, giving some temporary space from their hectic, chaotic worlds.

'It kind of, like, when I cancel everything out it feels like that, I'm in my own little world, and, like, I'm in, like, my own little world where I can just like relax, and, like, I'm just free really.' Kirsty
Stepping back from the intensity of the situation prevented ruminative introspection, although it is not clear whether there was a distinction between taking a step back from ruminating and stepping away from mindfulness as a distraction echoes the experience of the adolescents in the study by Ames, Richardson, Payne, Smith, & Leigh [4] who used mindfulness in times of distress but were also concerned that mindfulness would be difficult to use if they were very distressed.The practice of decentering from thoughts is central to mindfulness [15], and therefore being able to do this may reduce the impact of any judgements the adolescent has about their engagement with mindfulness.
There may be limits to the use of mindfulness as a distraction.Distracting away from experience consistently may lead to thought suppression [17] which is associated with increased psychopathology [18].Therefore, alternative ways of decreasing distress through mindfulness may be needed to avoid helpful mindful distraction (choosing the focus of attention) becoming unhelpful thought suppression.There are many more potential mechanisms of change which may be helpful to adolescents [19]; Shonin and van Gordon, 2016) and so it seems that the adolescents in this study had a somewhat narrow understanding of how mindfulness could help.For example, research into mindfulness as taught in DBT has suggested that accepting without judgement and acting with awareness are instrumental in changing clinical outcomes [9], however these facets of mindfulness were not consistently spoken about in the adolescents' accounts and may therefore be particular areas for development in the DBT curriculum.
Ciarrochi [20] found that an increase in emotional awareness and experiential acceptance led to greater wellbeing in adolescents, however, the adolescents in the current study did not regularly speak of experiential acceptance.The adolescents in the study found introspective mindfulness exercises that connected them to their internal experiences particularly challenging, frequently describing an aversion of being aware of the body and emotions.
What is not clear from our findings is how the differences between being able to tolerate emotion, be non-reactive to emotion and develop emotional awareness, effect the clinical outcomes for adolescents.Previous qualitative studies have proposed models of phases or stages in the development of mindfulness in adults.Malpass, et al. [21] proposed a staged model which noted that a transformation from a maladaptive state of limited insight to one which observed and developed insight into internal experiences.The adolescents in the current study described a shifting perspective on their reaction to emotion (through decentering) but did not speak of increased insight into their experiences.This may be associated with the specific difficulties that they described with acceptance of and non-judgementally describing their experiences, meaning that found focusing on internal experiences challenging.This may have been exacerbated by Overall, there was little sense of mindfulness being useful to the participants outside of stressful, upsetting situations.Everyday mindfulness was not present in accounts as a way of reducing propensity to emotional dysregulation.
Participants were cautious about connecting to emotions rather than using mindfulness to focus away from painful emotions and urges.

Discussion
The findings of this study suggest that adolescents, who have been taught mindfulness as part of DBT interventions, experience difficulty with negotiating seemingly opposing uses of mindfulness, for example to move attention away from distressing thoughts and to increase awareness of their experiences, and therefore these adolescents experienced difficulty at times in how to apply mindfulness as an intervention for their mental health difficulties.
The adolescents in the study were sceptical about the place of mindfulness in helping them with their problems.Often, they did not find the exercises that they did related to their experience of distress.Studies on mechanisms of change in mindfulness suggest that mindfulness can reduce distress through decentring from thoughts to reduce harmful rumination [15] and can reduce harmful behaviours by decoupling actions from urges [16].When the participants talked about using mindfulness despite their reservations they talked about both of these mechanisms, using distraction activities to decentre and calm -leading to fewer urges to act on their emotions.It seems that the adolescents in the study intuitively found that focusing on their difficulties was detrimental and therefore opted to use mindfulness as a way of re-directing their attention, similar to the participants in the study by Tharaldsen [7] who noted that adolescents found over focussing on their difficulties counter-productive.Focussing on question about whether emotional tolerance is equal to emotional experiencing in their effects.
More emphasis on compassion focused practices that reduce self-criticism and increase curiosity may help adolescents with the caution and barriers they experience when introduced to mindfulness.Ensuring practitioner understanding of the helpful mechanisms of awareness and non-judgement so this can be conveyed in full also seems important.

Conclusion
The findings of this study suggest that adolescents find that it is not straight forward to learn mindfulness in DBT.The adolescents in this study described a challenge in knowing how mindfulness could be helpful to themfinding a dialectic between focussing away from their experiences and focusing in on their experiences.Many of the adolescents found learning mindfulness difficult leading to both self-criticism and criticism of mindfulness.However, the times that the participants did engage with mindfulness they noted the cultivation of calm in their lives for a time.
The role of the DBT practitioner therefore should be to assist adolescents to more fully understand the role of mindfulness in the recovery from mental disorder and to support the non-judgemental awareness needed for self-compassion when adolescents face difficulties.

Study Limitations
The experiences generously shared by the adolescents in this study provide a small insight into the wider experience of mindfulness in DBT.Whilst this is in keeping with the IPA approach of using the particular to illuminate the whole, the findings cannot be said to be generalisable to every individual or indicative of specific causal relationships.
The sample size for this study was small and therefore does not represent an exhaustive account of the experience.The participants were recruited from a range of sites offering different DBT programmes and therefore what they were taught and how they were taught was not consistent.Further studies of the experience of mindfulness in DBT and adolescent mindfulness would be helpful in either supporting or challenging the findings of this study.
The data collected for the study relates to one time period and does not represent how the experience of engaging with mindfulness develops over time.Studies that track the development of mindfulness throughout and beyond mindfulness interventions are needed to understand the long-term experience of engaging with mindfulness.
A consideration needs to be given to the bias introduced when engaging in interpretation of other's experiences.The interpretations in this paper will have been influenced by the first author's gender (female), developmental stage, as mid to late adolescence is a time of great change with regards to the development of identity [22].
One of the findings of the study was that the participants felt incapable of developing mindfulness skills.Mindfulness can be a tricky skill to learn as evidenced research by Ames, et al., [4], with the authors reporting that mindfulness can potentially increase selfcriticism and shame when skills cannot be implemented by participants [8].A factor here is that adolescents being introduced to mindfulness will also need skills to engage self-compassion in order to acknowledge and accept the difficulties that come with learning mindfulness [8].Therefore, the teaching of mindfulness will need to navigate a balance between instilling expectation that mindfulness is worthwhile and offering gentle compassion that it can be hard to develop.
The most prominent finding of the study was that of the experience of mindfulness was cultivating a sense of calm for the participants who described chaotic and painful emotional experiences.It is in that that respect therefore, that despite the difficulties of engaging in mindfulness there continues to be evidence that supports its continued use with adolescents with mental disorders.

Implications for Practice and Recommendations
We have generated evidence that some adolescents state that they are unable to engage with mindfulness as it is currently being taught.It may be therefore that there need to be adjustments to the approach to teaching mindfulness in DBT.For example, the nuances of each adolescents' experience of mindfulness may be explored more fully and the adolescent supported with particular difficulties within a one to one interaction.Those adolescents who have access only to group skills training may not have opportunity or may feel too selfconscious to have these explorations as part of a group.However, we are not recommending that teaching mindfulness in a group should be abandoned as groupbased mindfulness have been shown to be helpful [23] and may be more economical.
Of importance in all therapeutic interventions is that adolescents need to be fully informed of the effects and potential benefits of the intervention.In the case of emotional experiencing as part of mindfulness these may include the possibility of increased physical, emotional or cognitive distress.
More clarity about expected outcomes and how these relate to mechanisms of change may help to reduce the uncertainty of how mindfulness relates to symptoms/difficulties.The uncertainty experienced by adolescents could be reduced by a greater knowledge of the outcomes that are expected through the use of mindfulness in DBT treatment.In particular the experiences of adolescents in this study have raised a

Table 1 :
Interview schedule Questions How long have you been doing DBT?What sort of things are you working on/learning?How is it going for you?I'm going to be asking you some questions about the mindfulness bit of the DBT programme.I thought we could do an activity to help you start to think about mindfulness.Here is a video clip of someone introducing a mindfulness exercise.Tell me about one of the times that you did some mindfulness in your group.Tell me about the first time that someone spoke to you about mindfulness in DBT.(If programme offered individual therapy) Has there ever been a time that you talked about mindfulness in individual therapy?(If programme offered telephone skills coaching)Has there ever been a time that someone suggested using mindfulness in skills coaching?Can you think of any times when you think you were mindful when you weren't at the DBT group?

Table 2 :
Summary of outcome of recruitment and participant demographics.

Table 3 :
Overview of themes developed during analysis.

Themes Subordinate Themes Being uncertain of how mindfulness will help •
Not seeking mindfulness but being told to engage with mindfulness • Experiencing mindfulness as weird • Suspending doubts • Not everyone is ready for mindfulness

tension between being aware of painful thoughts or emotions or zoning out
• Internal focus intensifies difficult thoughts and emotions • Focused on external focus.
'I was observing, like, the different um, sensations in my mouth as he used, like, the different sort of tools........It felt quite weird to start with, you know.It made me feel a bit more vulnerable.But I don't know, it felt a bit more like, but now I know what's going on, you know.It made me feel more aware and more in control.'Vicky I think when you just randomly zone out, you're, you're kind of, you're still thinking about the problems in your life, um, and stuff like that; whereas if you mindfully zone out you're kind of, you're, kind of thinking about nothing, so you're taking a step back from your life, and I think that's why it helped me so much' Tara '