Commentary on Mind Stimulation Therapy

Mind Stimulation Therapy (based on earlier published model: Multimodal Integrative Cognitive Stimulation Therapy-MICST)

Mind Stimulation Therapy (MST) , the earlier acronym was MICST (Multimodal Integrative Cognitive Stimulating Therapy) was pioneered in the course of my clinical practice over a 40-year period working with varied client populations across ages in varied settings: Outpatient therapy with “behaviorally challenged” children and adolescents; general outpatient adult clients; developmentally disabled adults; persons with schizophrenia in inpatient and Community Support Programs of CMHCS; dual diagnosed substance abuse clients; physically and psychiatrically compromised adults in nursing home settings. The MST model was further refined and developed through my years of collaboration with a former student of mine, Dr. Charles Boisvert, Professor of Counseling, and Education Leadership at Rhode Island College, and through our many collaborative publications with him, (see our publications in the bottom of Psychology and mental health resource links by Mohidudin ahmed

Below is my write-up explaining the MST model as well as a commentary by a Yoga therapist working in a community mental health center (with whom we have had no contact or association) that captures the essence of the model very well.

Mind Stimulation Therapy (MST) promotes awareness of the present moment of existence to maximize concentration to the immediate present reality of living experiences, physical and social surrounding, and one’s inner body cues through a practice of what we describe as Body Movement Relaxation (BMR) exercise. This exercise promotes the notion that seeing and experiencing one’s movement of body, one becomes acutely aware of one’s living existence, and a sense of affirmation of being alive, and one then can try to reflect on one’s personal connection to “others.” This simple series of exercises can be used to highlight the need for goal setting, identifying steps to goal, and the experience of goal attainment, which cuts across one’s daily life domains, including understanding of “Individual Treatment Plans” that many clients have in various program settings.

MST highlights that information processing is basic to all living beings. Having a sense of awareness of how we process “information’ in ways that are “adaptive,” can promote therapeutic dialogue to increase one’s adaptive thinking, feeling, and behaving, minimizing social and personal distress, and help best deal with one’s current life circumstances, and coping with whatever psychiatric difficulties that one may have. This processing of information is collaboratively discussed in the context of “here and now approach” of present “Reality of Living Experience.” It is grounded on the belief that all have some degree of capacity for adaptation to our life circumstances optimizing our functioning.

Psychotherapy interaction is often characterized by focusing on “so called clinical symptoms” or negative behavior traits client present that need “fixing” or “remediation.” This approach for many with long-term history of psychological problems and prior of history of many years of involvement in psychiatric treatment, and their own years of struggles in coping with these behavioral issues, may generate a covert negative relationship framework between the therapist and the client. Instead, MST model focuses on what the clients can do, and tries to stimulate activities and discussions that may involve general knowledge, science, mental health issues, religion or philosophy, or any other topic that client’s spontaneous utterances indicate interests and in which the client seems to have some knowledge base. This is supplanted with the use of paper and pencil cognitive stimulating exercises to access and stimulate client’s intact “cognitive skills” and “interests” to promote “reality based thinking,” and thereby strengthening clients’ ability to engage in “positive redirection activities” in presence of whatever clinical symptoms client may be presenting as per the clinical record. The goal is to approach management and reduction of “clinical symptoms” through the use of positive redirection (analogous to counter-conditioning)- a practice that we all normally do in our own coping with emergence of ego-dystonic thoughts and feelings in our daily life.

MST promotes reflection on existential perspectives (existential uncertainty, existential anxiety, and existential mystery) to help us see the time flow of our life as series of momentary living experiences, and to give us a sense of connection to living and non-living things around us, and help us see the World around as expression of an underlying universal “spiritual’ force, without necessarily contradicting one’s religious faith or science based knowledge. (We are all created from one God or are manifestations of one Whole- a Point of Singularity from the Big Bang: symbolically they represent the same concept). Past is important, if we choose to bring in to impact the present in the context of positive mental health and well being, or in the investigation of research on causative factors or to promote social action change. This will be a judgment call in clinical service setting and his orientation of therapy model that one chooses to practice.

Mind Stimulation Therapy believes that independent of any level of “disability” or psychological problems that one may present, everyone has functions and capacities that may be dormant but not readily evident to others, but with active exploration these capacities can be enhanced to contribute to one’s sense of well being. In the process, through involvement in these positively valued activities, they can help displace or “limit” the effects of “negative traits” or “atypical traits that cause personal or social distress.” The feeling of empowerment that may arise from this process of engaging in mind stimulation and positive redirection activities can spiral itself into promoting “recovery” or “enhancing functioning” in one’s own life.

Mind Stimulation Therapy does not actively review personal historical events to promote “insight and understanding” in people with long-term psychological problems or “limitations.” Exploration of “painful past” or “unusual behavior experiences” one’s life (e.g., reflection of our unique personal autistic and ego-dystonic thinking process, or habits of hallucination or delusions) may promote strengthening of these behaviors by reinforcing repeated visitations through a simple Law of Exercise, may impede practice of positive redirection, necessary for adaptive living, which we all practice in our daily lives.
In many persons with long-standing psychological problems, people do show or able to express “insights” in therapeutic dialogues, but it is the difficulty in translating these insights into behavior poses a stumbling block to recovery or toward movement to one’s own well being. (This may not be case for many with a high degree of intelligence and education and/ or motivation for self-reflection, and with transient experience of “psychosis” who may profit very well from such a psychodyanamic therapy approach.)

MST actively uses a multi-modal approach in therapeutic interaction, use of blackboard, computer screen, to maximize communication. It takes the position that auditory based conversational model of communication may not always be appropriate mode for these groups of clients who exhibit difficulties in working memory, control of repeated “intrusion of other thoughts” in the conversation flow, and in the practice of “redirection strategies,” that we all use to make our social or teaching communications effective. Therapy process need not rely solely on auditory based conversational modality: visual presentation of spoken words via computer screen, as we have had several publications using computer facilitated therapy, could be helpful. MST model assumes for these clients with long-standing psychological problems of developmental and or experiential origin may not have the capacity to internalized dialogue themes in therapy interactions and translate them into behavior change outside the therapy sessions. As such printed hand outs from sessions, follow-up practice in mind stimulating exercises, and active collaboration with client’s therapeutic milieu to ensure building prompts and support in the practice of positive redirection may be necessary to ensure maximal benefit from therapeutic encounters.

MST does not use a sequential training model, realizing many of these clients may exhibit variable emotional status or functioning on a day to day basis, so different element of the MST model may be highlighted or repeated in different sessions. Different elements of the MST model can be use or incorporated in practice of any therapeutic modality that clinician prefers to use, as MST model can be viewed as adjunct to any current practice of therapy.

The following review was written by yoga therapist who articulated very well the elements of mind stimulation therapy and its application to clinical population of Community Support Program where she has been working currently.

Mind Stimulation Therapy for Persons with Schizophrenia : Comment on Amazon website:Posted on April 25, 2014by OMpowermentYoga

“Before getting into the meat of this post, I feel like I need to touch base briefly on Schizophrenia. Schizophrenia is a mental illness that I think most people are familiar with, but know little about. Our stereotypes of people with Schizophrenia are largely shaped by the interactions we have with people affected by the illness. In the general public this may be limited to encounters we have with people in public forums – parks, malls, on buses or trains – and often are marked by their brevity. I remember the first time I ever encountered someone with Schizophrenia. I was taking the commuter rail back from an evening in Boston and a disheveled looking man entered the car I was on. He was exuberant, slightly raucous, and yelling at one of his pointer fingers because he thought it was talking to him. As he engaged in this conversation it was apparent that, at least in his mind, the conversation was a two-way one (although on my end that pointer finger never did reply!) In retrospect, there’s no way of knowing this man actually did have Schizophrenia. Any number of things can account for hallucinations – medical issues, drug use, etc – but as a younger person with limited knowledge of this mental illness my brain immediately associated talking to oneself with Schizophrenia.

Despite this very limited interaction in my earlier life, I feel fortunate that I have encountered people who experience mental illness in real and tangible settings, though growing up they were few. While many of us may know people who struggle with depression, anxiety, or substance abuse, Schizophrenia affects only 1% of the population. This means that most people will never knowingly encounter a person with Schizophrenia. Thus, many people’s understanding of this illness is based on fictional representations they see in movies or tv, characters they may read about in books, or the horror stories they occasionally hear via the news or internet. In these instances, their mental illness often becomes the headline and inevitably Schizophrenia is paired in people’s minds with violence. If you don’t believe this, do a Google image search for Schizophrenia and see what comes up. This is the first image I got:
This is the first image I got when Googling “Schizophrenia”
I bring this up now because since starting work in a community mental health agency I have encountered people with Schizophrenia regularly. Currently I work with a number in personal therapy. And guess what? They’re actually very interesting, resilient people who happen to struggle with mental illness on a regular basis. As such, I have begun researching treatment approaches to use with these clients that don’t forcefully challenge their beliefs, reduce the likelihood they will engage in therapy, or cause greater stress than what they are already experiencing. For a long time treatment for Schizophrenia has been primarily focused on medicating the client and changing their beliefs. For example, trying to convince your client that his or her next-door neighbor ISN’T controlling his mind. However, as a longtime yoga practitioner I’ve always felt a little bit unnerved with approach, which I believe lacked some of the core components of my daily yoga practice: acceptance & non-judgment. Thankfully while completing my master’s degree I was introduced to a way of working with clients diagnosed with Schizophrenia steeped in a positive psychology framework. And that way now has a name: Multimodal Integrative Cognitive Stimulation Therapy (MICST).
MICST is an approach steeped in learning theory and positive psychology that emphasizes the role that our environment and interactions have in shaping who we are. With Schizophrenia, the creators of MICST (Ahmed & Boisvert, 2013) argue that portions of symptomology may actually be reinforced unintentionally by a person’s environment (friends, family, therapists, community interactions). So what does this mean? Basically, that Schizophrenia is an illness that can manifest itself in a number of symptoms. But by constantly pointing these symptoms out to clients and arguing against them (i.e. “These things aren’t real.” “You’re just sick.” “No your neighbor isn’t spying on you!) we may actually be reinforcing these symptoms and further entrenching them within our clients. Thus, MICST encourages practitioners to to emphasize reality-based behaviors and beliefs, and to focus on on what client’s do well rather than reinforcing their deficits.
Instead, the authors emphasize using a positive psychology framework “to enhance self-esteem and well-being,” by focusing on client strengths rather than their weaknesses and utilizing cognitive stimulation “to access areas of intact cognitive and memory functioning.” The authors who created MICST suggest three basic ways of doing this:
1. Body movement-Mindfulness-Relaxation (BMR) exercises
2. Group Discussions
3. Paper & Pencil exercises
As I read through this treatment approach, I can’t help but notice the similarities I see between the recommendations set forth in the MICST manual and components I find in a really great yoga class:
 Acceptance: Encouraging your students to accept themselves where they are at rather than emphasizing failures or unmet wants & desires
 Non-judgment: Role modeling your own personal acceptance as a teacher for your students and encouraging your students to engage in personal growth without harsh criticisms against themselves or others
 Asana: Engaging in physical exercise to provide a point of focus or “moving meditation”
 Mindfulness: Reminding your students over and over again to be in the present moment (often I hear this with a phrase like “be on your mat,” or “Notice what’s going on with you on your mat today.)
 Relaxation: Taking Savasana at the end of class to integrate everything that you experienced during class
 Cognitive Stimulation: I would argue that through the joint practice of mindfulness and movement, with the added component of education on yoga principles or mental health topics at the beginning of class that yoga is an excellent cognitive stimulation exercise
 Group Discussion: Who hasn’t gone to a yoga class and either engaged in conversation with their yoga buddy or with classmates? But I’d argue a really great class includes some discussion about the class theme, or a check-in with students, at the beginning of class (and is a two-way conversation)
Looking at that list and reflecting on the philosophy of MICST, it’s no question that components of yoga can be beneficial for patients with Schizophrenia (or that practicing yoga can help therapists acquire the skills necessary to serve their clients in the most effective way possible). Next week I’d like to follow-up on these similarities further, focusing specifically on the BMR component of MICST and how yoga can help to play this role in clients affected by Schizophrenia.”

Further Comment on Mind Stimulation Therapy:
” I do believe that there are different pathways to achieve positive results in therapy, as psychological profiles are unique and different from person to person, specifically for those considered to be having severe and persistent mental illness, which by definition means that this client group has not responded to any current standard psychiatric treatment protocol by history in a very positive manner. So there is need for use of innovative and creative approaches in working with this challenging population.

Success of therapy may also depend on what should be the target of intervention. It is a complex process, as you rightly pointed out, and a very evolving one too. What makes sense now, may be different later with more knowledge and understanding, and advancement of communication technology.

Mind Stimulation Therapy is viewed as adjunct to any ongoing clinical interventions that the client may be receiving from other service providers, , and one can choose to incorporate whatever elements of the model presented in the particular brand of therapy that one choose to practice or promote incorporation of the elements in the milieu intervention of the client.

My experience in working with people with schizophrenia (I am using this label until a newer and less stigmatizing name is adopted, but it does serve a denotative function for communication here. and you may have read a discussion thread sometimes ago whereby we presented a model of Atypical Thinking Psychosis as an alternative name for schizophrenia in a response letter to Bill George and A Klijn in the Lancet Psychiatry a year ago) has been primarily in state psychiatric and Community Support Programs of CMHC facilities. Almost all these patients/clients demonstrated varying degree of difficulties in 1) working memory (holding information on line (in head) to solve a problem), 2) episodic (personal) memory, and 3) semantic (knowledge based factual) memory. While for 1 and 3, one can provide objective feedback, but for #3, personal memory (analogous to belief as to what happened in the past, it is difficult to do so. As it can be compounded by objective experience of recall, subjective interpretation of the experience that is recalled (often in bits and pieces), and added with subjective feelings and personal imaginations or interpretations. While there is a value to explore these past memories objectively and symbolically for some, but not sure how productive will it be for the kind of population that I am referring who may have gone through this “recall phases” many times in their own personal life or induced by other care givers in the past. It may be very productive for other client populations, as many will testify. I don’t doubt it.

When I was working at a state inpatient psychiatric facility in the 80’s, many of the patients were described as not being suitable for any kind of psychotherapy, individual or group. Psychologists were the only designated provider of psychotherapy for the patients, and only a few who were highly verbal and reasonably stable were seen in individual psychotherapy. There was no provision for group therapy then. And there was of course the resource limitation and availability issue too.

I started the first group in that facility in a psycho-geriatric unit, the most disabled group in the hospital, enlisting a social worker as a co-leader, after formulating a group protocol similar to what would later evolve as Mind Stimulation Therapy with varied activities.

Initially we labeled it as cognitive skills training psychotherapy group. The model was partially based on several dimensions of my previous experiences: 1) Providing conjoint therapy/consultation (with casemanager present) with CSP clients in a CMHC, all diagnosed to have schizophrenia, incorporating visual modality rather than just verbal conversation, to make our session conversation more effective. For example, I would type and show the client on the computer screen the major themes discussed, and give print outs to the client and the casemanager. This technique would later be labeled as computer facilitated therapy, and we have published several articles in peer reviewed journals, see publications in my website: 2) Conducting ADHD children group in a CMHC, using paper and pencil cognitive stimulating and self-reflection exercises, a first of its kind to conduct a group at that facility then (early 80’s). 3) Managing a DMH research funded day and residential treatment programs for “mentally retarded and emotionally disturbed adults” living in the community on the grounds of a state inpatient facility (for the developmentally disabled populations).

So the MST model does incorporate all these different experiences of mine of working with challenging mental health clients in various settings. I have used elements of the MST model with dual diagnosed substance abuse clients in two residential programs, and presented our work at 23rd and 26th Cape Cod Symposium on Addictive Disorders, and last clinical was in two nursing homes where I used the model with geriatric clients. I am currently involved in providing consultation to Applied Behavior Analysis oriented Treatment Plans for the developmentally disabled adults (many with a concurrent dx of schizophrenia or other psychotic disorders) suggesting ways to incorporate elements of the MST model into milieu program and in the behavior training approaches. So Mind Stimulation Therapy has varied applications to diverse clinical populations.

But I do agree that one needs to be open to using different approaches in working with challenging mental health populations, as long as one is clear what outcome one is striving to achieve collectively with a client and with client’s significant others who may be involved in clients’ care or well being. There should be some kind of objective criteria to assess progress, however limited, they may be, rather than going by one’s commitment to a therapy model, without assessing whether it fits the client’s needs or functioning or not. I have often heard that “so and so patient is not ready or not been able to use therapy when offered” somehow implying the patient does not match a therapy model that the clinician has been trained in , and not exploring modification of a therapy approach to fit the particular patient needs.

Of course there are time constraints and resource commitment issues that professional and agencies serving this type of challenging mental health clients face, so there is less opportunity to engage in innovative practice or going beyond one’s expected defined roles.

But keeping an open mind does help to make some impact in a positive direction. After all, Reality is multifaceted, and there is validity to different perspectives, and there are many ways to reach desirable goals!”

2 thoughts on “Commentary on Mind Stimulation Therapy”

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