Body-affective mindfulness intervention

1. Introduction

Version followed: the Turin group programme of Carletto, Ostacoli and colleagues (University of Turin), as given in the 2016 BMC Neurology trial protocol, where it is called a "Mindfulness Based Intervention (MBI)", and in the 2017 Frontiers in Psychology RCT report, which names it "body-affective mindfulness (BAM)". Where these papers name a practice without describing it, the guide fills in from the sources BAM says it is built on: the MBSR Authorized Curriculum Guide (2017) and Sensorimotor Psychotherapy (Ogden). Every such fill-in is tagged.

What it is. BAM is a manualised 8-week group programme. It was designed for adults with multiple sclerosis (MS) who have depressive symptoms, and in the protocol version for their caregivers too. It combines three things [source: Carletto et al. 2016; Carletto et al. 2017]:

MBSR/MBCT awareness practices: body scan, breath meditation, walking meditation and yoga.
"Mindfulness in relationship" practices: loving-kindness, "enriching listening to nature and persons", and self-compassion.
Five Sensorimotor Psychotherapy (SP) elements: somatic resources (grounding, centering, boundaries, lengthening the spine, body self-soothing); the window of tolerance as a model of the stress response; attention training; interpersonal mindful listening; and acceptance/self-compassion using decentering and mindful body self-touch.

BAM is not a treatment for MS itself. Its target is depressive symptoms and how people cope with a chronic illness.

How change happens (authors' model). Present-moment awareness with a non-judgmental, accepting attitude interrupts two habits: avoiding physical sensations, emotions and thoughts, and over-engaging with them. Patients can then "relate to their physical and psychological symptoms in a different way", which supports coping and adaptation. The SP elements add body-based resources that keep arousal within the window of tolerance, so a mindful stance can be reached and kept even when symptoms are distressing [source: Carletto et al. 2017; Carletto et al. 2016]. The papers do not spell out mechanisms beyond this [uncertain].

The manual. No full BAM manual or session-by-session plan is publicly available. The 2017 paper refers readers to the 2016 protocol, and the protocol gives only components and format [uncertain]. The 2016 protocol also traces SP's lineage to Kurtz's Hakomi method.

2. Framework

Format (from sources) [source: Carletto et al. 2016; Carletto et al. 2017]

Groups. 8 weekly group sessions of 3 hours, plus one all-day session of 7 hours. Group size is not reported [uncertain].
Home practice. About 45 minutes a day of mindfulness exercises and applications of mindfulness to everyday life, logged in a clinical diary.
Caregivers. In the protocol, one family member or caregiver per patient joins the patient's group. The 2017 outcome report describes patients only, so whether caregivers attended in the delivered version is [uncertain].
Facilitators. In the trial, BAM was led by clinical psychologists or psychotherapists trained in mindfulness and experienced with MS. The active control was psycho-education plus relaxation and stretching, with the same weekly format and no all-day session.

Who it was designed for (trial criteria; adapt clinically) [source: Carletto et al. 2016]

Included. Adults aged 18–65 with definite MS diagnosed at least 6 months earlier, relapsing-remitting or secondary progressive. Disease clinically inactive. EDSS below 6.5, because the programme needs at least partly preserved mobility. BDI-II above 13. Psychotropic medication stable or stopped. Concurrent psychotherapy suspended.
Excluded. Current severe major depression, severe suicidality, psychotic, bipolar or active substance-use disorders, overt dementia, corticosteroids in the last 30 days, other serious medical disorders, and pregnancy. These are trial criteria. For clinical use, treat them as a minimum screening list. Pregnancy was a research exclusion, not a stated clinical contraindication [synthesis].

Phases

The BAM papers give no per-session themes and no criteria for moving between phases [uncertain]. The sequence below is modelled on the MBSR 2017 class order, which BAM says it is based on, with the SP elements placed where SP's "resources before processing" logic puts them [synthesis; source: MBSR Curriculum Guide 2017; Ogden & Goldstein chapter]:

Screening and orientation (individual interview, before week 1).
- Goals: check the criteria above, informed consent, risks and benefits, practice commitment and attendance. MBSR flags addiction, untreated psychosis, acute depression, suicidality, PTSD, social anxiety and recent loss for discussion, not automatic exclusion [source: MBSR Guide 2017].
- Add an MS-specific mobility, fatigue and heat-sensitivity check [synthesis].
Foundations: stabilisation and attention (weeks 1–2).
- Body scan, awareness of breathing, short attention-training practices.
- Window-of-tolerance psychoeducation; first somatic resources (grounding, alignment).
- Goal: participants can name signs of hyper- and hypo-arousal and have at least one body resource that steadies them [synthesis].
Body in movement and stress reactivity (weeks 3–5).
- Adapted mindful yoga, walking meditation, centering, self-soothing.
- Working with unpleasant sensations and MS symptoms; reacting versus responding; decentering from depressive thoughts.
- MBSR places walking from class 3 and the reactivity themes in classes 4–5 [source: MBSR Guide 2017].
Mindfulness in relationship (weeks 5–7).
- Mindful listening in dyads, boundaries, listening to nature, loving-kindness.
- All-day session (7 h), placed between weeks 6 and 7 as in MBSR [synthesis; source: MBSR Guide 2017].
Acceptance, self-compassion and everyday life (weeks 7–8).
- Self-compassion with mindful self-touch; a personal daily practice plan; informal practice; ending.

Moving on. This is a fixed-length group, so the group moves on by calendar week. For an individual participant, use these markers [synthesis]:

Doing home practice most days (diary).
Can come back from distraction without self-criticism.
Can use a somatic resource when arousal rises.
No sustained arousal outside the window during practice.

If a participant is regularly outside the window, give more resourcing time and an individual check-in before relational or compassion work.

3. Guiding principles

Sources: [source: Carletto et al. 2016, 2017; MBSR Guide 2017; Ogden & Goldstein chapter; Ogden & Goldstein 2018 handout]. Lines marked [synthesis] are this guide's translation into practice.

Core mindfulness stance

Non-judgmental awareness and acceptance of the present moment. Invite participants to notice symptoms (fatigue, numbness, pain, low mood) as they are, without fixing or judging them.
Neither escape nor over-engagement. Watch each participant for avoidance (numbing, skipping practices) and for absorption (rumination, catastrophising about the body), and steer toward steady contact [synthesis].
Relate differently to symptoms. Success means a changed relationship to symptoms, not their disappearance. Say this at orientation [synthesis].
Non-striving. Don't try to make anyone relax. MBSR warns against striving even to relax.
Non-repression. Thoughts and feelings are neither suppressed nor forced away.

Body and arousal

Stay within the window of tolerance. Hyperarousal shows as tension, trembling, alert immobility. Hypoarousal shows as flat affect, collapse, slowed movement, reduced sensation. When you see either, pause content and use a resource [source: Ogden & Goldstein 2018 handout].
Resources first. SP builds self-regulation through somatic resources before deeper emotional material. Teach grounding and alignment early and return to them whenever needed.
Titration. Offer intensity in small, chosen doses (eyes open, shorter practice, a less loaded body area) and widen the window gradually [synthesis, from the SP modulation idea].
Honour the body's limits. In movement, explore the edge without going past it. Modify, rest, or rehearse a pose in imagination if it hurts [source: MBSR Guide 2017]. In MS this is a safety rule, not just an attitude [synthesis].

Teaching approach

Attention training adapted to cognition. MS and depression can impair attention, so use short, repeated, well-cued practices and brief instructions [source: Carletto et al. 2016; practical detail synthesis].
Inquiry over lecture. Teach concepts such as stress, reactivity and the window of tolerance through participants' reported experience, not slides.
Teacher embodiment. The facilitator practises alongside the group and models postures and self-touch. SP also uses modelling and state-sharing.
"there is more right with you than wrong with you" (MBSR class 1 theme). Direct attention to what still works in the body as well as to what is lost [source: MBSR Guide 2017].
Collaboration and choice (SP). Offer options ("perhaps you'd like to…") rather than commands, and let participants choose resources and pacing.

Relationship and group

Relational mindfulness. Present-moment experience is noticed and shared inside the relationship and the group; this is the base of the mindful-listening work.
Compassion and decentering. Treat depressive thoughts as mental events, not facts, and meet suffering with kindness, including through soothing self-touch.
Group safety. No one has to speak; no advice-giving, fixing or cross-talk; the facilitator keeps time and may interrupt [source: MBSR Guide 2017].
Patient and caregiver together. When caregivers attend, each member practises for themselves. The caregiver is not a co-therapist or monitor of the patient's practice [synthesis].

Practice

Daily practice is the treatment. The 45 minutes a day and the diary are central; review them every session [source: Carletto et al. 2016].

4. Intervention inventory

Scope of this inventory.

Named in the BAM papers. Every practice named in the BAM sources is listed below.
Steps. BAM publishes no step-by-step scripts. Steps come from the MBSR 2017 curriculum and SP sources where these give them, and are tagged. Steps that come from neither are [synthesis].
MS adaptations. These are mostly [synthesis], apart from the stated need for partly preserved mobility and attention training.
Touch. No BAM source describes therapist-to-client touch. All touch in BAM is self-touch.
Physical assistance. If you give any hands-on help (for example a steadying hand in standing yoga or walking), follow the consent steps under 4.19. MBSR teachers ask permission before physical contact [source: MBSR Guide 2017]. Touch of any kind needs specific training, supervision, and a check of what your licence and jurisdiction allow.

Awareness practices (MBSR/MBCT strand)

4.1 Body scan

Purpose. Train sustained, non-judgmental attention to body sensation, including symptomatic areas, and practise neither escaping from sensation nor over-engaging with it. It is the foundation practice [source: Carletto et al. 2016; MBSR Guide 2017].
When to use. From session 1. It is the main home practice in early weeks: MBSR sets it on at least 6 days in weeks 1–2, then alternates it with lying yoga.
Steps.
1. Starting position: lying on the back on a mat, or seated in a chair with feet on the floor. Offer the chair whenever lying down or getting up from the floor is hard [synthesis for MS].
2. Settle with a few moments of awareness of breathing in the abdomen. Don't control the breath.
3. Guide attention slowly through the body in sequence. In MBSR this is typically from the toes of one foot up the leg, then the other leg, pelvis, back, abdomen, chest, hands and arms, shoulders, neck, face and head. At each region the participant notices whatever is there, including absence of sensation, tingling or numbness.
4. At each region, breathe "into" and "out of" it in imagination, then let it go before moving on (classic MBSR form; wording here is paraphrased).
5. When the mind wanders, notice where it went and return to the current region without criticism.
6. End with a sense of the body as a whole, breathing. Then move gently, roll to the side, and sit up slowly.
7. Inquiry: ask what participants noticed (sensation, thought, emotion), how they related to it, and what happened in areas of discomfort or numbness.
Duration. MBSR uses about 45 minutes. For MS groups with fatigue or attention problems, start with 15–20 minutes and lengthen over the weeks [synthesis].
Example language (illustrative).
- "Let your attention rest on your left foot — whatever is there: warmth, pressure, tingling, or nothing at all. Nothing is the right or wrong sensation."
- "If you notice the mind has gone off to tomorrow, or to the illness, that's simply what minds do. Note where it went and come back to the knee."
Watch for.
- Grief or distress when attention reaches areas affected by MS (weakness, numbness, pain).
- Signs of leaving the window of tolerance (see 4.16).
- Falling asleep. MBSR treats this as common: suggest eyes open, sitting, or a different time of day.
How you know it's working. Participants can describe sensations more precisely, report less fighting with symptoms, and come back from distraction with less self-blame [synthesis].

4.2 Breath meditation (awareness of breathing, sitting meditation)

Purpose. Give a portable anchor for attention and a way to steady oneself, and train decentering from thoughts [source: Carletto et al. 2016; MBSR Guide 2017].
When to use. Introduce in session 2 and extend through the course. In MBSR, daily unguided practice runs 10–15 minutes in week 2, rising to about 20 minutes by week 4. The sitting later widens to body, sounds, thoughts and emotions as events, then open ("choiceless") awareness.
Steps.
1. Sit upright but at ease on a chair or cushion, with feet grounded and hands resting. The aim is a posture that is dignified and balanced; back support is fine for fatigue [synthesis].
2. Choose where to feel the breath (nostrils, chest or abdomen) and rest attention there, observing without controlling.
3. Each time the mind wanders, note it briefly ("thinking") and return to the breath. The returning is the practice.
4. In later weeks, widen awareness: from breath to the whole body sitting; then sounds; then thoughts and emotions as passing events; then open awareness. Come back to the breath to finish.
5. If discomfort arises, choose either to move mindfully or to stay and explore the sensation. If overwhelmed, return to the breath or open the eyes [source: MBSR Guide 2017].
6. Close and inquire.
Example language (illustrative). "There is no need to breathe in any special way. Let the body breathe itself, and simply feel the next breath arrive."
Watch for.
- Breath focus can raise anxiety for some people. Offer feet, hands or sounds as alternative anchors [synthesis].
- Rumination dressed up as "meditation".
How you know it's working. The participant notices wandering sooner and can label thoughts as thoughts.

4.3 Attention training (adapted for MS-related cognitive difficulties)

Purpose. Strengthen attentional control, given possible neuropsychological deficits in MS and depression-related attention problems [source: Carletto et al. 2016].
What the source says. The protocol names this element but does not describe the exercises [uncertain]. The steps below are [synthesis] built from the MBSR practices above.
Steps.
1. Use short anchored practices of 3–5 minutes, repeated several times within a session rather than one long practice.
2. Use single, concrete objects of attention: breath at the nostrils, contact of the feet, or a single sound.
3. Give frequent, brief, spoken re-orienting cues, with silences that lengthen across weeks.
4. Have participants count their returns, as a measure of practice rather than failure.
5. Repeat the same short practice at home, attached to a daily routine (for example before a meal), and log it in the diary.
Example language (illustrative). "For the next three minutes, just the feeling of the feet on the floor. Each time you notice you've drifted, that noticing is one repetition — well done."
Watch for.
- Cognitive fatigue: get shorter, glazed, more frequent drifts. Stop before exhaustion.
- Shame about forgetfulness.

4.4 Walking meditation

Purpose. Carry mindfulness into movement and give an alternative for those who find stillness hard [source: Carletto et al. 2016; MBSR Guide 2017].
When to use. From around week 3; strongly recommended before the all-day session [source: MBSR Guide 2017].
Steps.
1. Standing, feet hip-width apart, feel the whole body standing and the weight in the feet.
2. Walk very slowly along a short, clear path, back and forth. Attend to lifting, moving and placing each foot, and the shift of weight. Pause at the turn.
3. When attention wanders, return it to the soles of the feet.
4. MS safety [synthesis]: use a path beside a wall or rail; allow mobility aids; let participants walk at their own speed. Offer a seated version (alternately pressing and lifting each foot, or attending to the breath while seated) for anyone with balance impairment. Have a second facilitator or assistant available, as MBSR advises for faster walking variants.
5. End standing still, then inquire.
Example language (illustrative). "Slow enough that you can feel the moment the heel leaves the floor. If you need the wall or your stick, they are part of the practice."
Watch for.
- Falls, dizziness and heat-related symptom worsening [synthesis].
- Self-criticism about gait.

4.5 Mindful yoga (gentle mindful movement)

Purpose. Awareness of the body in motion, exploring limits kindly. In MBSR these are awareness practices, not exercise or alignment training [source: Carletto et al. 2016; MBSR Guide 2017].
When to use. Standing poses from session 1 (MBSR starts with Mountain Pose); lying sequences from week 3. In MBSR these alternate with the body scan at home.
Steps.
1. Offer floor, chair and standing options for every movement, and demonstrate.
2. Move slowly in coordination with breath, staying with sensation throughout.
3. Approach the edge of a stretch without going beyond it. Rest, modify, or do the movement only in imagination if it is painful or unsafe [source: MBSR Guide 2017].
4. Pause between movements to notice after-effects.
5. Participants with medical conditions should ask their own clinician which postures suit them [source: MBSR Guide 2017]. In MS, spasticity, weakness, balance, fatigue and heat sensitivity make chair-based options standard [synthesis].
6. Close lying or seated, then inquire.
Example language (illustrative). "Lift the arms only as far as is kind today. Different days, different edges — and noticing today's edge is the practice."
Watch for.
- Striving, competing with others, or pushing through pain.
- Overheating, and fatigue rebound later in the day (ask about it the next week) [synthesis].

4.6 Mindfulness in everyday life (informal practice)

Purpose. Generalise mindful awareness to daily activities; it is part of the 45-minute daily homework [source: Carletto et al. 2016].
Steps [synthesis from MBSR home practice].
1. Each week, choose one routine activity to do with full attention: eating a meal, showering, transfers, taking medication.
2. Add the 'mindful meal' from MBSR week 1.
3. Note in the diary what was noticed.
Example language (illustrative). "This week, choose one thing you do every day anyway, and do it as if for the first time."

Mindfulness-in-relationship practices

4.7 Loving-kindness meditation

Purpose. Cultivate friendliness and warmth toward oneself and others, as an antidote to the self-criticism and isolation of depression [source: Carletto et al. 2017; MBSR Guide 2017].
When to use. In MBSR, during the all-day session and then week 7. Place it after participants have stable anchors [synthesis].
Steps.
1. Sit comfortably and settle with the breath.
2. Bring to mind someone who easily evokes warmth, and let the wish for their well-being form. MBSR treats the classical phrases as optional, and keeps talking to a minimum with plenty of silence.
3. Extend the wish to oneself.
4. Then extend it in widening circles: a neutral person, a difficult person, and all beings. Participants can stop at any step [synthesis on the step order, which follows common practice; the MBSR guide extract gives only aims].
5. If the wish feels empty or provokes grief, simply notice that, with kindness.
6. Close and inquire.
Example language (illustrative). "You might silently offer: may I be safe, may I be at ease. If the words feel hollow, the intention is enough."
Watch for. "Backdraft": grief, unworthiness or anger when warmth is turned toward oneself. Return to the breath or to a somatic resource [synthesis].

4.8 Enriching listening to nature

Purpose. Open, receptive attention to the natural world as a nourishing, non-self-focused anchor [source: Carletto et al. 2017, practice named only].
What the sources say. No instructions are published [uncertain]. The steps below are [synthesis].
Steps.
1. Go outdoors, or sit by an open window if mobility or heat make that difficult.
2. Spend 10–15 minutes listening to sounds as they arise and fade, without naming or judging them. Optionally widen to sight, air on the skin, and smell.
3. Notice what in the body responds.
4. Share in pairs or with the group.
Example language (illustrative). "Let sounds come to you, as if the ears were simply open windows."
Watch for. Heat exposure, fatigue, and accessibility of the outdoor space.

4.9 Interpersonal mindful listening ("listening to persons")

Purpose. Bring present-moment awareness into relationship: noticing one's own body, reactions and urges while listening, and being fully heard. This is one of SP's five tailoring elements [source: Carletto et al. 2016, 2017]. It relates to SP's embedded relational mindfulness [source: Ogden & Goldstein chapter] and to MBSR's dyadic speaking and listening exercises [source: MBSR Guide 2017].
Steps.
1. Form dyads. In patient–caregiver groups, consider pairing people with someone other than their own partner at first [synthesis].
2. Speaker A talks for 3–5 minutes on a given prompt, for example "how the illness shows up in my day" or "something that nourishes me".
3. Listener B listens without interrupting, advising or reassuring, and keeps part of their attention on their own breath, posture and reactions.
4. B briefly reflects what was heard, then the pair swaps.
5. Both share what they noticed in the body while speaking and while listening.
6. Durations and prompts are [synthesis]; the structure follows MBSR's dyad work.
Example language (illustrative). "As you listen, notice any urge to fix or reassure. Let it be there, and keep listening."
Watch for.
- Caregiver–patient tensions surfacing.
- Advice-giving.
- A speaker overwhelmed by their own story: cue a resource and shorten the turn.

4.10 Self-compassion with mindful body self-touch

Purpose. Meet one's suffering with kindness and give the body a direct soothing signal. In the protocol, self-compassion and acceptance are cultivated through decentering from negative cognitions and "mindful body self-touch" [source: Carletto et al. 2016].
What the sources say. The BAM papers do not describe the exact self-touch. The hand-on-heart form below comes from SP practice [source: Ogden & Goldstein chapter]; the other steps are [synthesis].
Steps.
1. Seated, recall a mildly difficult moment from the week (start with mild, not the worst).
2. Notice where it is felt in the body.
3. Invite, never instruct, participants to bring a hand gently to the heart, or to another place that feels soothing: cheek, upper arm, abdomen, or one hand holding the other. Notice the warmth and pressure and the effect over a few breaths.
4. Experiment: compare touch and no touch, firmer and lighter, and a different location. Keep whichever helps.
5. Optionally add a kind inner phrase in the participant's own words.
6. Close by noticing any change in breath, posture or mood.
Consent. It is self-touch, but still offer it as optional. Give a no-touch alternative (imagining the gesture, or resting the hands on the lap) and normalise choosing it [synthesis].
Example language (illustrative). "If it feels right, you might rest a hand over your heart — or anywhere else that feels kind — and just notice what happens. It's equally fine to keep the hands where they are."
Watch for.
- Self-touch evoking aversion, shame, or trauma-related responses. Stop and switch to a neutral resource.
- Sensory changes from MS (numbness, dysaesthesia) altering how touch feels: invite curiosity, and allow a different location.

4.11 Decentering from negative cognitions

Purpose. Relate to depressive thoughts as passing mental events, not facts, which is MBCT's core move. The BAM protocol uses it inside the acceptance and self-compassion element [source: Carletto et al. 2016].
What the sources say. No specific BAM exercise is described [uncertain]. The steps below are [synthesis], following the MBSR sitting practice of noticing thoughts as events.
Steps.
1. In sitting practice, after breath and body, make thoughts the object of attention.
2. Note them as they arrive ("planning", "judging", "the 'I'm a burden' thought").
3. Watch them pass, and return to the breath.
4. Notice the body correlates of a recurring depressive thought, and soften around them.
5. In inquiry, link this to daily life: "when this thought appears, what does the body do, and what helps?"
Example language (illustrative). "See if you can let 'I'm useless now' be a thought that's visiting, rather than a verdict."
Watch for. Hopelessness that does not shift, or thoughts of death. Move to a risk check (see section 5).

Sensorimotor Psychotherapy strand (somatic resources and arousal regulation)

Where the SP detail comes from. BAM lists five somatic resources: grounding, centering, boundaries, lengthening the spine, and body self-soothing [source: Carletto et al. 2016]. SP's own full instructions are in Ogden, Minton & Pain (2006) and Ogden & Fisher (2015). Those books are not drawn on; only SP Institute pages and Ogden & Goldstein materials are. Steps below are therefore partly [synthesis] and marked. In SP, as Ogden describes it, these resources are used to build regulation before trauma or attachment material is processed [source: Ogden & Goldstein chapter].

4.12 Grounding

Purpose. Build a felt base of support through the feet, legs and pelvis, and settle activation that feels like it is rising. The SP Institute uses the image of water settling to the bottom of a pitcher [source: SP Institute pages].
When to use. Teach early, then use whenever anxiety or hyperarousal rises in practice or inquiry.
Steps [synthesis beyond "focus on the feet" and "feet, legs and pelvis"].
1. Sitting with feet flat on the floor, or standing if balance allows, notice the contact of the soles with the floor.
2. Gently press the feet into the floor and release, a few times, sensing the legs engage.
3. Notice the weight of the pelvis on the chair, and the support of chair and floor.
4. Let the breath go down toward the belly.
5. Track any change in arousal, thoughts or mood for a minute or so.
6. Compare with how it felt before.
Example language (illustrative). "Feel your feet on the floor. Press down a little, as if gently pushing the floor away, and let go. What happens in your legs, your breathing?"
Watch for.
- Reduced sensation in the feet in MS: use the pelvis on the chair, or the hands on the thighs, as the contact point.
- Signs of settling: slower breath, dropped shoulders, steadier gaze.

4.13 Centering

Purpose. A felt sense of one's core or midline as a place of stability [source: Carletto et al. 2016, resource named only].
What the sources say. No centering instructions are given in the sources [uncertain]. The steps below are [synthesis].
Steps.
1. Seated and upright, bring attention to the midline of the torso: chest, abdomen, spine.
2. Optionally place one hand on the chest and one on the abdomen, as an invitation, with self-touch as in 4.10.
3. Sense the breath moving under the hands.
4. Notice any sense of "here I am" or inner steadiness.
5. Pair it with grounding.
Example language (illustrative). "Sense the line from the base of your spine to the top of your head, and the breath moving in the middle of you."
Watch for. Attention to the chest or belly increasing panic: switch to an external anchor.

4.14 Boundaries

Purpose. Develop a felt, bodily sense of one's preferences, wishes, rights and safety, as distinct from a cognitive idea of boundaries [source: Ogden & Goldstein 2018 handout]. This is relevant to patients managing intrusive help, medical procedures and changed roles, and to caregivers [synthesis].
Steps.
1. Notice a boundary. Standing or sitting, the participant imagines or sees someone approaching (in a group, a partner walks slowly toward them). The participant signals "stop" when the distance feels right, then notices what in the body told them.
2. Practise "no" with the body. Explore saying "no" with the body rather than in words: tensing, facial expression, and the arms extended with palms facing outward. Stomping the feet is a variant. The therapist models the action alongside the participant [source: Ogden & Goldstein chapter].
3. Pushing motions. SP group materials list pushing and push–pull dyad exercises among distance-seeking actions, without giving steps [source: Ogden & Goldstein 2018 handout]. If you use them, the participant pushes slowly against their own hands or against a wall, at low effort, with attention on sensation and on any shift in sense of self. Any partner pushing needs explicit consent and a stop signal (4.19) [synthesis; uncertain].
4. Close. Name the bodily sense of "my space", and how it might be used in a real situation.
Example language (illustrative). "Let your hands come up, palms out, slowly, as if saying 'that's close enough'. What happens in your spine, your breath, your belly?"
Watch for.
- Arousal spiking with trauma or memories of being overpowered: slow down, switch to grounding.
- Pain or spasticity with effortful pushing: keep effort minimal.
- Avoid forceful or cathartic versions [synthesis].

4.15 Lengthening the spine (alignment)

Purpose. Counter the slumped, collapsed posture linked to depression and stress, and explore how an aligned posture changes mood and thought [source: Carletto et al. 2016; SP Institute pages; Ogden & Goldstein chapter].
Steps.
1. The therapist models a slumped posture, then an upright one. Participants try each and compare emotions, thoughts and sense of self in each [source: Ogden & Goldstein chapter].
2. From sitting, sense the support of the pelvis.
3. Lengthen gently upward through the crown of the head, without stiffening, and let the shoulders soften [synthesis].
4. Stay a few breaths, noticing.
5. Optionally walk around the room keeping the aligned posture [source: Ogden & Goldstein chapter]. Only where mobility allows; a chair version is fine.
Example language (illustrative). "Let the spine grow a little longer, as if there's space between each vertebra. Is there any difference in how today looks from here?"
Watch for.
- Back pain and fatigue.
- Lengthening that turns into rigid "good posture". The aim is uplift, not effort.

4.16 Window of tolerance: psychoeducation and tracking

Purpose. Explain the stress response and give participants a map for recognising hyperarousal and hypoarousal in themselves, so they can choose a resource [source: Carletto et al. 2016; Ogden & Goldstein 2018 handout; Siegel 2015].
Steps.
1. Draw the window on a board: an optimal zone in the middle, hyperarousal above, hypoarousal below.
2. Describe the signs.
  - Hyperarousal (fight/flight): tension, trembling.
  - Freeze: alert immobility, constricted body.
  - Hypoarousal: flatness, reduced sensation, collapsed posture, slowed movement [source: Ogden & Goldstein 2018 handout].
3. Ask participants to identify their own signs. Separate MS fatigue from hypoarousal: ask whether it is "the body's battery" or "shutting down" [synthesis].
4. Practise tracking. During practices, ask participants to report changes such as tightness, tingling or small movements [source: Ogden & Goldstein chapter]. The facilitator watches posture, breath and face.
5. Match resources to state [synthesis].
  - Hyperarousal: grounding, slower exhalation, orienting to the room.
  - Hypoarousal: alignment, gentle movement, eyes open, contact with feet.
6. Homework: notice once a day where one is in the window, and record it in the diary.
Example language (illustrative). "When things get too much, some of us speed up and some of us switch off. Which one do you recognise in yourself?"
Watch for. Participants pathologising every fluctuation. The aim is to widen the window over time, not to stay calm always.

4.17 Body self-soothing

Purpose. Self-regulation through gentle self-touch and soothing movement [source: Carletto et al. 2016].
Steps.
1. Explore, by invitation, forms such as a hand on the heart [source: Ogden & Goldstein chapter], arms crossed holding the upper arms, a hand on the belly, slow rocking, or warming the hands and placing them on the face [synthesis for the forms beyond hand-on-heart].
2. Pick the form that works best and rehearse it so it is available in daily stress.
3. Same consent framing as 4.10.
Example language (illustrative). "Try a couple of these and notice which one your body says yes to."
Watch for. Paradoxical distress with self-touch.

Programme structure components

4.18 All-day session (7 hours)

Purpose. Sustained practice that consolidates the skills and carries mindfulness across activities [source: Carletto et al. 2016]. In MBSR it is largely silent [source: MBSR Guide 2017].
Steps. These are modelled on MBSR. The BAM day content is not published [uncertain].
1. Arrival and brief orientation.
2. Alternate sitting, mindful movement, body scan, walking, and a mountain, lake or loving-kindness practice.
3. Mindful lunch.
4. A short seated closing practice.
5. Break silence gradually: dyads, then group sharing and a closing circle.
MS adaptations [synthesis]. Frequent rest periods, a cool room, lying-down options, an accessible layout, and explicit permission to rest or leave practices.
Watch for. Strong emotion in silence. Have a facilitator available for brief, quiet check-ins.

4.19 Consent protocol for any physical contact or partner exercise

The BAM sources describe no therapist touch. MBSR states only that teachers ask permission before physical contact [source: MBSR Guide 2017]. SP asks permission before body-focused enquiry and invites clients to say when something feels uncomfortable [source: Ogden & Goldstein chapter]. The steps below are [synthesis] and apply to any hands-on help or partner exercise (for example pushing).

Explain beforehand what the contact would be, where and why.
Ask, and accept a no without asking why.
Offer a no-touch alternative: verbal cueing, a wall or chair for support, self-pushing.
Agree a stop signal (word or gesture).
Check in during and after the contact.
Never touch the trunk, face or any intimate area. Steady only at forearm or shoulder, and only when needed for safety.
Record the consent.

Any touch requires specific training and supervision, and a check of what your licence and jurisdiction allow.

4.20 Daily home practice and clinical diary

Purpose. Consolidate skills; it is a central dose of the programme: about 45 minutes daily, recorded in a clinical diary [source: Carletto et al. 2016].
Steps [synthesis].
1. Give recordings and written guidance for each week's practices. Audio is not mentioned in BAM; MBSR uses recordings.
2. The diary records the date, the practice, its length, and what was noticed (body, emotion, thought), plus one informal practice.
3. Review the diaries in pairs or with the group at the start of each session.
4. Allow split sessions, for example 3 × 15 minutes, around fatigue cycles.
Example language (illustrative). "The diary isn't a test. Even 'didn't practise, felt guilty' is useful data."
How you know it's working. Consistent entries, and entries that become more descriptive.

4.21 Caregiver participation

Purpose. Address caregiver stress, and give the patient–caregiver pair shared language for symptoms and stress [source: Carletto et al. 2016, protocol version].
Steps [synthesis].
1. Interview the caregiver separately at screening.
2. Ask both members to practise for themselves.
3. Mix pairs in dyad work.
4. Explicitly invite caregivers' own experience into inquiry.
Watch for.
- Caregivers monitoring the patient's practice.
- Patients self-censoring in front of the caregiver.

4.22 MBSR elements not named in the BAM papers

BAM says it is based on MBSR/MBCT, but the papers do not say whether the following were included [uncertain]. If used, deliver them as in MBSR [source: MBSR Guide 2017]:

Raisin exercise (mindful eating, week 1). Slowly explore and eat one raisin with all the senses, then a second in silence. In inquiry, separate direct sensation from opinion.
Pleasant and Unpleasant Events Calendars (weeks 2–3). One event a day: what happened, body sensations, feelings, thoughts.
Difficult Communications Calendar (week 5).
Mountain and lake meditations. Imagery for stability and fluid steadiness.
Passive, aggressive and assertive postures (week 6). MBSR's communication work, which overlaps with SP boundaries.

5. Handling problems

The BAM papers give no troubleshooting guidance [uncertain]. Items tagged [source] come from the MBSR guide or SP materials; everything else is [synthesis].

Screening and safety

Before the group. Screen for:
- severe depression and suicidality;
- psychosis, bipolar disorder and active substance use;
- dementia;
- recent corticosteroids or relapse;
- EDSS 6.5 or above;
- severe dissociation or unprocessed trauma (PTSD was flagged for discussion in MBSR screening).
These follow the BAM exclusions and the MBSR screening list [source: Carletto et al. 2016; MBSR Guide 2017]. Severe dissociation and unprocessed trauma are added [synthesis]. Refer anyone excluded to individual care.
Suicidality during the course.
- Ask directly about suicidal thoughts when hopelessness, talk of being a burden, or withdrawal appear.
- Assess using your service's standard risk protocol.
- Agree a safety plan, including means-safety counselling (secure storage or removal, for example of stockpiled medication, coordinated with the prescriber).
- Involve the MS team and GP.
- Pause compassion and decentering homework until stable.
- Continuing in the group is a clinical decision. Individual sessions may be needed [synthesis].

Overwhelm and leaving the window of tolerance

Hyperarousal (trembling, rapid breathing, alert immobility).
- Stop the content and invite eyes open.
- Orient to the room, then grounding (4.12) and a longer exhale.
- Track until settled before going on [source for the signs: Ogden & Goldstein 2018 handout; responses synthesis].
Hypoarousal (flatness, collapse, unresponsiveness).
- Speak more, and use the person's name.
- Invite alignment (4.15), feet pressing, gentle movement or standing.
- Bring in sensory contact with the environment [synthesis].
During practice. MBSR advises shifting posture, opening the eyes or returning to the breath when overwhelmed, and modifying or pausing practice. Some participants may consider stopping the course [source: MBSR Guide 2017].
Body scan reaching MS-affected areas brings grief or panic. Allow the participant to skip or shorten that region, and to anchor elsewhere. Name grief as a legitimate response to loss, not a practice failure.

MS-specific difficulties [synthesis]

Fatigue.
- Use shorter practices, seated or lying options, and breaks within the 3-hour sessions.
- Let the diary record fatigue so practice can be scheduled at the person's best time.
- Distinguish fatigue from avoidance by asking, not assuming.
Heat sensitivity. Keep the room cool; avoid vigorous movement; allow cool drinks.
Balance and falls. Use chair or wall options for every standing practice, and an assistant during walking.
Pain and spasticity. Movement stays within limits; participants check postures with their own clinician [source: MBSR Guide 2017].
Cognitive difficulties. Give brief instructions, repetition and written summaries, and have the group re-teach key points. Use the attention-training format (4.3).
Relapse during the course.
- The participant should contact the neurologist.
- Offer a lighter home-practice plan and a catch-up check-in.
- Steroid treatment was an exclusion in the trial window; agree with the MS team whether to continue [source for exclusion: Carletto et al. 2016].

Stuck clients and "nothing is happening"

Normalise: MBSR treats early worsening and "nothing happening" as common and non-linear [source: MBSR Guide 2017].
Shift the goal from feeling better to noticing more precisely.
Use the midway check (MBSR's written midpoint assessment, in week 5) to surface doubts confidentially, and follow up individually.

Non-adherence to home practice

Explore barriers with curiosity, not judgment: fatigue, cognition, caregiving, shame, or a practice that doesn't suit.
Negotiate a minimum, such as 10–15 minutes plus one informal practice. Split sessions. Link practice to daily routines.
Use the diary to celebrate any practice.
MBSR guidance on attendance:
- people expecting to miss 2 or more classes are encouraged to take a later cycle;
- people who miss 3 or more are encouraged to stop and retake.
Apply this flexibly where absence is due to MS symptoms [source: MBSR Guide 2017; flexibility synthesis].

Resistance and doubt

Doubt about "lifestyle advice for a neurological illness". Be clear at orientation that BAM addresses depressive symptoms and coping, not the disease process. Invite experimenting rather than believing.
Aversion to the body ("my body has betrayed me").
- Start with neutral or strong areas.
- Use external anchors.
- Introduce self-compassion and self-touch gradually.

Ruptures and group difficulties

Group rules. No pressure to speak. No advice-giving, fixing or cross-talk. The facilitator may interrupt to keep time and safety [source: MBSR Guide 2017].
A participant feels unseen or criticised. Name it in the moment if safe, or check in afterwards. Acknowledge your part; adjust pacing or options.
Dominance, or comparison of disability levels.
- Return to each person's own experience.
- Remind the group that practices have no performance standard.

Patient–caregiver dynamics [synthesis]

Caregiver over-helping or monitoring: give caregivers their own focus; use separate dyads.
Conflict surfacing in listening exercises: contain it in the session and offer a separate couple or family referral. Don't turn the group into couple therapy.
Caregiver burnout: treat it as a primary target of their own participation.

Body-technique risks [synthesis]

Boundary and pushing exercises (4.14) can trigger memories of being overpowered, and effortful pushing may aggravate spasticity or pain. Keep effort low, go slowly, offer imaginal or self-only versions, and follow the consent protocol (4.19).
Self-touch (4.10, 4.17) can evoke shame or trauma responses, and altered sensation may make it unpleasant. It is always optional, with a no-touch alternative.
No cathartic discharge or breath intensification. BAM includes no hitting, kicking, screaming, hyperventilation-type breathwork, stress positions or deep-tissue work. Do not add them, especially given cardiovascular, respiratory and neurological vulnerability in this population.

When to refer out

Worsening depression or emerging suicidality despite adjustments.
Trauma memories that keep breaking through. Offer individual trauma-focused therapy with stabilisation, for example full Sensorimotor Psychotherapy with a trained clinician.
Cognitive decline. Seek neuropsychological assessment.

Sources

Sources

Books and papers cited by the BAM authors (not drawn on)

Kabat-Zinn, J. (2013). Full Catastrophe Living (rev. ed.).
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-Based Cognitive Therapy for Depression (2nd ed.).
Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy.
Ogden, P., & Fisher, J. (2015). Sensorimotor Psychotherapy: Interventions for Trauma and Attachment.
Siegel, D. J. (2015). The Developing Mind (2nd ed.).
Kurtz, R. (2007). Body-Centered Psychotherapy: The Hakomi Method.
Keng, S.-L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health. Clinical Psychology Review.
Grossman, P., et al. (2007). Mindfulness training as an intervention for fibromyalgia. Psychotherapy and Psychosomatics (source of the control condition).

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