Mindfulness-Based

Psychotherapy 4
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Look deeply at life as it is in the very here and now

—Buddha (Samyutta Nikaya, p. 326)

I
n chapters 2 and 3, we reviewed Germer et al.’s (2005) classi-
fication of mindfulness-oriented psychotherapy into three
types: the mindful therapist (chap. 2), mindfulness-informed
therapy (chap. 3), and mindfulness-based therapy, which is
the focus of this chapter. In this chapter, we address the defi-
nition and scope of mindfulness-based therapies and describe
the therapies that have the most empirical backing. For each
mindfulness-based therapy, we illustrate the central mindful-
ness practices as well as similarities and differences among
therapies. Issues of who is qualified to provide mindfulness-
based therapies are also briefly addressed. Research into the
efficacy of mindfulness-based therapies is summarized in
chapters 5 (mental health) and 6 (physical health).
Mindfulness-based therapy involves those therapies in
which mindfulness meditation practices are explicitly taught
as a key ingredient in the treatment protocol. A variety of
approaches incorporate both formal and informal mindfulness
practices into the therapy treatment protocol. The best known
of these are mindfulness-based stress reduction (MBSR;
J. Kabat-Zinn, 1990), mindfulness-based cognitive therapy
(MBCT; Segal, Williams, & Teasdale, 2002), dialectal behavior
therapy (DBT; Linehan, 1993a, 1993b), and acceptance and
commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999).
Before we review the specifics of these and other mind-
fulness-based therapies, it is useful to scan the research and

http://dx.doi.org/10.1037/11885-004 45
The Art and Science of Mindfulness: Integrating Mindfulness Into Psychology and the Helping
Professions, by S. L. Shapiro and L. E. Carlson
Copyright © 2009 American Psychological Association. All rights reserved.
 46 THE ART AND SCIENCE OF MINDFULNESS

clinical environment to get a sense of the growing popularity of

mindfulness-based approaches. For example, a cursory Internet search
for the term mindfulness-based yielded over 134,000 hits. Most of these
links appear to relate directly to mindfulness-based therapy program
information, although some are more peripheral. Reflecting the inroads
mindfulness-based therapies have made into mainstream psychology
and medicine, searches of the scientific literature on PsycINFO and
PubMed in February 2008 using the same term, mindfulness-based, yielded
260 and 115 published scientific articles, respectively. Many of these
articles appear in both databases, but it is safe to say that there are well
over 300 different published scientific articles regarding various theo-
retical and empirical perspectives on mindfulness-based interventions,
with many more studies under way.
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To assess the enthusiasm of funders, grant peer reviewers, and the

scientific community for these types of approaches, we searched the
CRISP (Computer Retrieval of Information on Scientific Projects) data-
base for all studies receiving funding through the National Institutes of
Health (NIH). When funded studies with the term mindfulness-based are
plotted year-by-year across all institutions (see Figure 4.1), the trend for
increasing research support is clear. In 2008, 44 funded studies were in
progress; this number had increased from 0 in 1998 and only 3 in 1999.
As can easily be seen from the graph, funding spiked between 2003 and
2005, when funded grant numbers jumped from 5 to 32. The total num-
ber of funded studies over the years cannot be surmised from this graph,
however, as some multiyear grants are represented in more than 1 year,
so total numbers are less than the sum of all years combined. Nonethe-
less, this growth curve is impressive, especially given that funding levels
and success rates overall dropped across these years. Indeed, this assess-
ment of funded studies is the most stringent measure of the caliber of
mindfulness-based research, given that funding success rates at NIH
have been dropping over the years and currently hover around 10% to
15% of all submitted applications.
What types of studies are being conducted given this influx of funds
and interest in mindfulness-based interventions? The range is quite stag-
gering. A list of mindfulness-based therapies funded by NIH (see Exhibit 4.1)
and types of problems and populations being studied (see Table 4.1) tell the
tale. Clinical groups being trained in mindfulness techniques range from
people with common mental health problems such as mood and anxiety
disorders to those with a range of physical health conditions from asthma
to organ transplant. A growing number of mindfulness-training studies
are also looking at such outcomes as immune system function, cognition,
and attention in healthy or aging populations. In summary, there is great
public and scientific interest in mindfulness-based interventions, which
are being applied to a very wide range of problems and clinical popula-
tions. In addition, the quantity of scientific studies of mindfulness-based
 Mindfulness-Based Psychotherapy 47

FIGURE 4.1

50

40
Number of grants

30
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20

10

0
98

99

00

01

02

03

04

05

06

07

08
19

19

20

20

20

20

20

20

20

20

20
Year
Note. National Institutes of Health (NIH)-funded mindfulness-based studies
from 1998 to 2008.

EXHIBIT 4.1

Types of Published Mindfulness-Based Therapies

Mindfulness-based stress reduction (MBSR)

Mindfulness-based cognitive therapy (MBCT)
Mindfulness-based eating awareness training (MB-EAT)
Mindfulness-based art therapy (MBAT)
Mindfulness-based relapse prevention (MBRP)
Mindfulness-based relationship enhancement (MBRE)
Acceptance and commitment therapy (ACT)
Dialectal behavior therapy (DBT)
 48 THE ART AND SCIENCE OF MINDFULNESS

TABLE 4.1

NIH-Funded Studies Underway on Mindfulness-Based Therapies

Populations being studied

Mental health Physical health Outcomes in healthy populations

Depression Coronary heart Inflammation/immune function

Anxiety disease/hypertension Attention
Posttraumatic stress HIV/AIDS Stress (acute/chronic)
disorder/trauma Cancer Cognition (in seniors)
Social phobia Bone marrow transplant Health status (in seniors)
Eating disorders Hot flashes/menopause
Obesity Irritable bowel syndrome
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Personality disorders Solid organ transplant

Substance abuse/smoking Chronic pain
cessation Asthma
Insomnia

interventions is steadily growing, and the caliber of these studies is consis-

tently improving.

Common Mindfulness-Based
Therapies

Ruth Baer, in the first chapter of the book Mindfulness-Based Treatment

Mindful Approaches, provided an overview of a number of common mindfulness
Reminder: Are and acceptance-based therapy approaches (Baer & Krietemeyer, 2006;
there ways you this book is also a good resource for more detail on these therapies). In
this section we focus on MBSR as the basic model for mindfulness-based
could routinely
approaches and then summarize some of the similarities and differences
apply mindful-
between several other approaches. We cover MBSR and MBCT in some
ness in the detail and briefly discuss other therapies emerging from the tradition of
moments of MBSR, which we refer to as mindfulness-based (MB) therapies. Finally we
your everyday discuss DBT and ACT as modalities that stem from other therapeutic tra-
life? ditions but incorporate mindfulness.

MINDFULNESS-BASED STRESS REDUCTION

The first and still most popular form of mindfulness-based therapy is
MBSR. Developed by Jon Kabat-Zinn and colleagues at the University
of Massachusetts Medical Center in 1979, MBSR takes the form of an
8-week group program of up to 35 participants who meet weekly for
 Mindfulness-Based Psychotherapy 49

21⁄2 to 3 hours, with a 6-hour silent retreat occurring on a weekend

between classes 6 and 7. MBSR is described in the book Full Catastrophe
Living: Using the Wisdom of Your Body and Mind to Overcome Pain, Stress and
Illness (J. Kabat-Zinn, 1990). It was developed in response to a perceived
need for alternative treatment for patients who were falling through the
cracks of the traditional medical system. Often difficult to treat, patients
with refractory pain or anxiety disorders who attended early MBSR
classes began to report remarkable improvements. With the publication
of the book and the emergence of empirical reports of the benefits of
MBSR, it began to increase in popularity, and many health profession-
als sought training in this modality.
MBSR is an intensive training program in a variety of mindfulness
practices, both formal and informal. Participants are required to prac-
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tice meditation and gentle yoga at home for a total of 45 minutes, 6 days
each week during the course of the program. The primary mindfulness
techniques taught include the body scan, sitting meditation, walking med-
itation, gentle yoga, and informal daily mindfulness practice. Didactic
teaching of mindfulness occurs each week, with time for participant
processing of their experience, feedback from facilitators, and group dis-
cussion of challenges to practice and other insights that may arise. The
atmosphere is collaborative and encouraging, with group facilitators
implicitly embodying and outwardly encouraging the application of
mindfulness attitudes of nonjudging, patience, acceptance, beginner’s
mind, nonstriving, letting go, nonattachment, and trust.
The program typically begins with eating one raisin mindfully; then
shifts focus to the body scan, a guided somatic sensory awareness exercise
in which the facilitator slowly directs participants’ attention through
body parts, usually from the feet to the head, encouraging them to pay
close attention to whatever arises in each area moment to moment,
without trying to change the experience or achieve any particular out-
come (see Appendix A for guided body scan instruction). Attitudes of
reverence, awe, and love are sometimes suggested, but participants are
primarily encouraged to simply notice whatever arises in the practice.
This can take up to 45 minutes. This practice encourages the develop-
ment of several core mindfulness skills: paying close and sustained
moment-by-moment attention to a specific object of awareness; flexi-
bility of attention in moving from one body region to the next; noticing
whatever sensations, thoughts, or feelings arise without trying to change
them; returning to the intended focus of awareness when the mind
inevitably wanders; and applying mindfulness attitudes of kindness,
acceptance, and nonjudging to the experience.
Mindful yoga is also introduced within the first few sessions (this
varies from program to program). The purpose of the yoga movements
is to cultivate kindness for the body within the context of gentle mind-
ful movement. It is not an athletic endeavor; rather, participants are
 50 THE ART AND SCIENCE OF MINDFULNESS

encouraged to pay close attention to their experience and gently explore

their edges in various positions while applying the same mindfulness
attitudes as they did in the body scan. They are instructed not to com-
pare themselves with others or with their own performance from one
day to the next but simply to practice being fully aware of the body’s
capabilities in every moment as if for the first time. This mindful yoga
is a way to become familiar with and “make friends” with the body,
which in many cases has been the cause of a great deal of frustration,
disappointment, and pain. Although not a goal of mindful yoga, many
participants find themselves becoming physically stronger, more flexi-
ble, and with improved balance with regular practice of these gentle
exercises.
Sitting meditation may be considered the core of the program, with
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practice emphasizing a constant turning toward and remembering the

focus of the exercise, which usually begins with breath awareness (see
Appendix B for guided sitting meditation instructions). Participants are
instructed to feel the in-and-out flow of breath and notice whenever
their attention strays from that focus. This point of noticing can give rise
to many “aha” moments, when the participant has an opportunity to
refocus on the breath and begin again. Beginning again is seen as the
heart of the practice, and attitudes of curiosity, patience, and lightheart-
edness are encouraged. Over the course of the program, the focus of sit-
ting will broaden from always the breath to a greater mindfulness of
other aspects of moment-by-moment experience, including sounds,
bodily sensations, emotions felt in the body, and passing thoughts. The
practice of “bare awareness” or “choiceless awareness” is introduced
through the weeks with an emphasis on accepting whatever arises as it
is, learning to breathe with whatever comes up, and becoming a larger
container for potentially difficult experiences. The potential for the
acquisition of insight through mindful awareness is introduced, not as
a goal to strive toward but as an inevitable outcome of consistent practice.
Walking meditation is also incorporated into the curriculum, with
the awareness typically directed toward the bodily sensations of walk-
ing (see Appendix C for guided walking meditation instructions). The
speed can be normal or fast, and often it is slowed down to allow full
awareness of different parts of the step, for example, the meditator
notes lifting the foot, moving it through space, lowering it toward the
floor, placing it down, shifting the weight onto that foot, and subse-
quently lifting the opposite heel. All of this is done with the same atti-
tude of openness and curiosity, always returning focus when the mind
wanders. This practice is sometimes easier for new practitioners, who
may find sitting still for extended periods to cause discomfort and rest-
lessness. (However, in general, the core instruction in mindfulness is to
face whatever is aversive and observe the shifting nature of aversions
themselves.)
 Mindfulness-Based Psychotherapy 51

A final formal meditation practice included during the MBSR day-

long class and throughout the concluding sessions is loving-kindness
(metta) meditation (see chap. 8, this volume). Loving-kindness medita-
tion is a type of practice that purposefully cultivates feelings of kindness
and compassion toward different objects of attention. This traditionally
begins with oneself or a benefactor and gradually expands to others in
one’s life and eventually to all beings.
Finally, informal mindfulness practices are encouraged throughout
the day as ways to begin incorporating mindfulness as a way of life, rather
than as an isolated formal practice. Hence, mindfulness of everyday tasks
such as eating, grooming, washing the dishes, and communicating with
others is encouraged. Informal practice involves intentionally attending to
whatever one is doing with care and kindness. Mini meditation exercises
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are prescribed that can be done at any time, such as at stoplights, when
waiting in line or for appointments, in traffic, or while on hold. These
informal practices simply involve intentionally tuning in to the body and
breath for a short time as one carries out activities of daily living.

MINDFULNESS-BASED COGNITIVE THERAPY

A newer twist on MBSR came about with the development of MBCT in
the late 1990s. Cognitive therapists John Teasdale, Mark Williams, and
Zindel Segal were experts on the treatment of depression using cognitive–
behavioral therapy (CBT), the current gold standard. The main challenge
facing clinicians and researchers in the area of depression was prevent-
ing relapse. Although there were effective treatments for acute episodes
of depression, no therapy had been especially effective at preventing
relapse. Most people who recovered from a major depressive episode
were likely over time to have more. Segal and colleagues were interested
in understanding the psychological underpinnings of depression relapse
in order to design effective therapies for this problem. With the surge
of interest and research into MBSR, they became familiar with the model
and believed aspects of mindfulness could help recovered depressed
patients steer clear of relapse. Over time, and with the help and encour-
agement of Dr. Kabat-Zinn and his colleagues, they developed and man-
ualized MBCT, a formal therapy integrating MBSR and CBT (Segal et al.,
2002). This therapists’ manual was supplemented recently with a patient
self-help book that comes with a guided meditation CD (J. M. Williams,
Teasdale, Segal, & Kabat-Zinn, 2007).
MBCT is typically conducted over 8 weeks with smaller groups than
in MBSR, up to about 12 participants. In terms of practices, MBCT is sim-
ilar to MBSR, using the body scan, sitting meditation, walking medita-
tion, and informal daily mindfulness. However, MBCT does not include
the formal loving-kindness meditation instructions, although kindness
toward oneself and one’s experience is emphasized throughout MSCT.
 52 THE ART AND SCIENCE OF MINDFULNESS

The didactic material is focused more on understanding depression than

on stress and the stress response, as in the original MBSR program. A
model of understanding depression as a vicious downward spiral trig-
gered by futile efforts to logically argue away negative thoughts is pre-
sented to participants, and an alternative way to deal with negative
thoughts is offered. Participants are invited to become aware of the per-
sistent and familiar negative patterns of thought as they begin to arise,
and to change their relationship to the thoughts. Instead of ruminating
over any particular thoughts of unworthiness or hopelessness, people
learn to see these thoughts just as thoughts, which will come and go in
their own time. They recognize that thoughts and emotions arise and
pass if they are not “fed” or believed as a static reality that represents
the way things are and always will be. Hence the meditation practices
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are directed toward noticing and allowing these types of experiences to

come and go, with the same mindfulness attitudes of kindness, curiosity,
and patience.
Specific techniques unique to MBCT include the “3-minute breath-
ing space.” This exercise is similar to the mini meditations practiced in
MBSR, but more formalized into three distinct steps:
1. Focus on the range of internal experience, addressing the ques-
tion, What is my experience right now? For this first minute no
attempt is made to change the experience, just to note with
acceptance what it consists of;
2. focus full attention on the movement and sensations associated
with the breath, breathing in and out for a full minute; and
3. expand awareness once again to the body as a whole, including
posture, facial expression, and emotions, again with acceptance
and without judgment.
This process is sometimes described as an “hourglass” wherein the atten-
tion is broad at first, then narrows to the breath at the waist of the
hourglass, and finally expands again. It is meant to be practiced anytime
throughout the day, especially when participants begin to feel over-
whelmed.
Other elements of cognitive therapy are added to the MBSR curricu-
lum, including discussion of how one’s current mood affects the auto-
matic thoughts that arise; for example, a person in a depressed mood
tends to have more depressed thoughts and is also more likely to believe
these depressed thoughts are true. Participants are encouraged to see that
thoughts are not truth or reality, and that they change moment to
moment and day to day depending on current mood and situations. They
begin to see thoughts as impermanent, as passing mind-moments that are
not necessarily true. Unlike with traditional CBT, they are taught not to
purposefully change any thoughts or replace distorted thoughts with
 Mindfulness-Based Psychotherapy 53

healthier alternatives but just to see them for what they are. In addition,
participants are encouraged to practice activities that generate feelings of
mastery and pleasure, as these types of activities are known to help pre-
vent relapse. In the last two sessions, plans for relapse prevention are dis-
cussed. Participants reflect on what they have learned in the MBCT
course as well as their past experiences to determine an effective plan for
how to continue to prevent relapse.

OTHER EMERGING MINDFULNESS-BASED

THERAPIES
Many other therapies modeled after MBSR are emerging. These thera-
pies have modified the MBSR curriculum in response to the needs of
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specific clinical groups. These pioneering therapies have appeared only

recently in the published literature and an evidence base for their use-
fulness is just beginning to be developed. Next, we review the four most
researched of these newer mindfulness-based therapies.

Mindfulness-Based Eating Awareness Training

Quite a bit of work has been conducted in the modification of the tra-
ditional MBSR curriculum to treat individuals with binge eating dis-
order and, more recently, obesity. First developed by Jean Kristeller
(Kristeller, Baer, & Quillian-Wolever, 2006), mindfulness-based eating
awareness training integrates elements of MBSR and CBT with guided
eating meditations. The eating-relevant guided meditations address
issues around body shape, weight, and eating-related processes such as
appetite and satiety. Overeating is seen as symptomatic of larger sys-
temic dysregulations involving disturbances of affect, cognitions, and
behavioral regulation. Mindfulness training is seen as a way to increase
awareness of automatic patterns and then to disengage from undesir-
able behaviors and reactivity. Many of the meditations use food in the
group sessions, beginning with the raisin exercise, a simple exercise of
mindfully eating one raisin and building up to more challenging foods
such as cookies, cakes, and finally a full buffet around which the prac-
tice of making mindful food choices is incorporated. There is some body
work, but the use of yoga is limited compared with traditional MBSR.

Mindfulness-Based Relationship Enhancement

Another emerging mindfulness-based therapy described by Carson and
colleagues (Carson, Carson, Gil, & Baucom, 2006) is mindfulness-based
relationship enhancement (MBRE), developed to enhance the relation-
ships of couples who are relatively happy. It is closely modeled on
MBSR in terms of format, techniques, and homework topics; however,
 54 THE ART AND SCIENCE OF MINDFULNESS

several of the elements have been modified into dyadic exercises rather
than individual ones. For example, in MBRE the loving-kindness med-
itation practice focuses on generating feelings of kindness and care
toward the partner. There is a greater emphasis on loving-kindness
meditation in general in MBRE than in MBSR. In MBRE, it is intro-
duced in the first session and continued throughout the intervention,
as opposed to in MBSR, where it is only formally introduced during the
daylong retreat. There is also emphasis on practicing mindful commu-
nication and listening skills within the sessions that may transfer into
daily life for the couples. Yoga exercises are modified to allow for more
partner involvement, referred to as a “dyadic dance” wherein partners
physically support and facilitate one another in the postures. Other
mindful couples’ exercises include a mindful touch exercise and back
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rub, and discussion of how mindfulness can enhance sensual intimacy.

Overall, the focus is on bringing mindfulness to the relationship both
during the class sessions and in daily life.

Mindfulness-Based Art Therapy

Another example of mindfulness-based therapies is mindfulness-based
art therapy (Monti et al., 2005), which has been developed for use in
medical populations and piloted specifically in women with breast
cancer. It incorporates elements of the creative process as a means for
expressing emotions around the meaning of the illness, health, and
healing. It incorporates art-making with traditional elements of MBSR,
with the goal of enhancing both the supportive and expressive aspects
of treatment. Participants use multiple artistic modalities and exercises
designed to help outwardly express feelings identified through mindful
awareness practices, including pain and fear.

Mindfulness-Based Relapse Prevention

Other mindfulness-based therapies gaining a foothold in addiction research
and treatment circles are collectively known as mindfulness-based
relapse prevention (Marlatt & Gordon, 1985; Marlatt & Witkiewitz,
2005), which is patterned after MBCT. Mindfulness-based relapse pre-
vention integrates mindfulness with the principles of a well-established
therapy for prevention of relapses to substance abuse based on cognitive
and behavioral theories of risk avoidance (Daley & Marlatt, 1997). The
authors hypothesized that improvements made in preventing relapses to
alcohol and drug abuse may be due to changes in metacognitive processes
(i.e., the ability to act as the observing witness) as well as the acquisition
of specific skills to cope with urges, cravings, and negative affect. It has
been applied not only to alcohol and drug abuse but also to smoking ces-
sation (Wetter, 2008).
 Mindfulness-Based Psychotherapy 55

These are some examples of MB therapies that have been published

and are the subject of funded research activity investigating their effi-
cacy. Many more, emerging on a regular basis, will require similar
investigation.

DIALECTICAL BEHAVIOR THERAPY

Turning to other therapies that incorporate mindfulness but stem from
different theoretical roots, we first address DBT, then ACT. DBT was
developed by Marsha Linehan (Linehan, 1993a, 1993b) specifically as
a treatment modality for borderline personality disorder, although more
recently it has been adapted to various other disorders. The central tenet
of DBT is the balance and integration of opposing ideas: the dialectic. As
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an example, DBT incorporates elements of both acceptance and change.

DBT therapies teach formal mindfulness practices as one of four central
modules, although the exercises are typically shorter than those prac-
ticed in MBSR or MBCT and focus on specific targets of mindful aware-
ness in addition to the breath and body. The other three modules of
interpersonal effectiveness, emotion regulation, and distress tolerance
are influenced by the core mindfulness skills such that the four mod-
ules are intimately interconnected.
Within the mindfulness module, three “states of mind” and six
“mindfulness skills” are introduced. The states of mind are reasonable
mind, the logical rational part of the mind that makes intellectual deci-
sions; emotional mind, which is the reactive mind wherein emotions con-
trol thoughts and behaviors; and wise mind, the integration of the former
two modalities that balances the intellect with intuition and emotions.
These three states of mind can be seen as the balance between the
opposing dialectic of emotion and reason, and is developed through the
practice of mindfulness skills.
The six mindfulness skills are broken down into three “what” skills
and three “how” skills. The what skills specify just what one does during
mindfulness training, specifically: observing, describing, and participating.
Observing and describing are similar to the mindfulness practices in the
other MB therapies previously described; participating refers to attending
completely and immersing oneself in the present moment,as well as acting
with spontaneity and without self-consciousness. The three “how” skills—
nonjudgmentally, one-mindfully, and effectively—parallel the mindfulness atti-
tudes. One-mindfully typically refers to focusing undivided attention
on one thing at a time. This component as defined in DBT refers to a prac-
tical skill involving recognizing the limitations of a situation, identifying
one’s goals, and using skillful means to achieve them, rather than attend-
ing to one thing at a time as in other MB therapies. There is a very robust
body of studies (see Lynch, Trost, Salsman, & Linehan, 2007; Ost, 2008)
demonstrating clinical effectiveness with borderline personality disorder.
 56 THE ART AND SCIENCE OF MINDFULNESS

ACCEPTANCE AND COMMITMENT THERAPY

The roots of ACT are also different than those of MBSR and MBCT. ACT
stems from relational frame theory, a very broad theory that attempts
to account for all of human language and cognition by positing that
relationships within and between individuals are learned associations
reinforced through behavioral contingencies (Hayes et al., 1999). ACT
stems from this context and applies acceptance and mindfulness strate-
gies in conjunction with commitment to certain goals and values along
with behavior change strategies. The goal is to increase psychological
flexibility by learning how to contact the present moment fully and con-
sciously, based on demands of specific situational circumstances.
ACT is usually delivered in an individual rather than group format
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and can be applied to a broad range of psychological problems. A central

tenet of ACT is that clients often use language in futile attempts to con-
trol their inner lives; this is similar to the idea in MBCT of trying to argue
with or change dysfunctional thoughts, which tends to be counter-
productive. Through metaphor, paradox, and experiential mindfulness
exercises, clients learn how to contact and identify thoughts, feelings,
and sensations that have previously been feared and avoided. They learn
to accept these inner events, develop greater clarity about values, and
commit to changing behavior in service of these deeply held values.
Hence, the idea of experiential avoidance is a central concept, and many
of the therapy exercises are designed to facilitate exposure to feared
inner experiences through the use of various mindfulness practices.
A key concept in ACT that will be familiar to practitioners of mind-
fulness is termed cognitive fusion. This idea illustrates the belief that
thoughts are true and factual, and hence are signposts that dictate feelings,
reactions, and behaviors; in effect, the cognitive, affective, and behav-
ioral aspects of a person can become “fused.” In cognitive “defusion,”
the antidote to this problem, clients learn to observe passing thoughts
without assuming they are true or important and without having to
act on their content. They can be seen as just mind events that come and
go, no matter how aversive their content. Attempts to eliminate or change
these thoughts are not made, and a simple observational stance is
assumed. Hence, when a person is fused with cognitions, thoughts (e.g.,
“I’m going to screw this up and be so embarrassed”) become truth to the
person and are accompanied by bodily reactions (tension, flushing,
sweating) and feelings (dread) that lead to corresponding behaviors
(avoiding the situation, stammering). In cognitive defusion, the thought
can be recognized as just a thought and allowed to pass without trigger-
ing the associated feelings and behaviors, so the person can engage in
the feared behavior without mishap. The witness consciousness is used
in ACT as a way of helping to achieve cognitive defusion, so that instead
of noting the thought “I’m a failure” an individual would learn to say
 Mindfulness-Based Psychotherapy 57

to him- or herself, “I’m having the thought that I’m a failure.” This dis-
tancing aids the process of separating the self from passing thoughts and
feelings and frees the observer-self from being influenced by these pass-
ing mental events.
Finally, similar to DBT, ACT includes explicit attention to the client’s
values and goals in life, and seeks to promote committed action in areas
such as relationships, health, personal growth, career, and citizenship.
Goals relevant to the client’s values are set in therapy, and obstacles that
stand in the way of committing to these goals (which often result from
anxiety, avoidance, fear, etc.) are examined. Plans are made to help
overcome these obstacles and ultimately align actions with core beliefs
and values.
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Similarities and Differences

Among Therapies

As summarized throughout this chapter, many of the mindfulness-based

Mindful therapies share common theoretical underpinnings and specific exer-
Reminder: Stop cises. DBT and ACT use shorter, less formal, and more focused mindful-
for a moment ness exercises than do the MB therapies, and also include explicit focus
on both acceptance and change-based strategies, whereas the MB modal-
and scan your
ities mostly rely on acceptance. Most of the mindfulness-based interven-
body. Are there
tions are offered in group formats, whereas ACT is typically an individual
areas of ten- therapy and DBT contains both individual and group components.
sion, holding, Specific modifications of mindfulness-based modalities add exercises
tightness? Are relevant to the population being treated, whether these include focused
you able to eating exercises for binge eaters or awareness of cues for relapse in sub-
release some of stance abusers. The duration of the treatments also varies: The group
mindfulness-based techniques are usually about 8 weeks in duration,
this right now?
whereas ACT can be for a short or longer period, depending on the
client. DBT typically lasts for 1 year or longer.

ROLE OF MINDFUL MOVEMENT

Another difference among therapies is in the importance placed on the
role of mindful movement. Formal practice of mindful movement and
stretching is not included in DBT or ACT. In terms of the other MB ther-
apies, the role of mindful movement has not received much attention in
the literature. The originators of MBSR would argue that this component
is crucial to the program as a whole; however, the practitioners now
being trained in program delivery are largely health care professionals,
many of whom do not have extensive experience or training in mindful
 58 THE ART AND SCIENCE OF MINDFULNESS

movement and may be reluctant to risk teaching these movements for

fear of causing harm or injury. They may also not as readily see the ben-
efit of incorporating these mindful body movements and stretching into
the more cerebral practices of formal meditation. The benefit of mindful
movement versus sitting and body scan meditation practices in MB ther-
apies remains an empirical question, but our belief is that for certain
patient populations in particular, the mindful movement is a crucial ele-
ment of success. For example, in studies involving thousands of patients
with cancer over the last 10 years, patients reported equal benefit from
the mindful movement and from the formal meditation practices. Only
empirical investigation will be able to show the extent to which mindful
movement is helpful and for which populations it is most beneficial.
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THERAPIST QUALIFICATIONS
With the growing public interest in MB therapies, many professionals
wish to know how to become properly qualified to deliver these inter-
ventions in a safe and ethical manner, and potential program partici-
pants wish to determine how to find a qualified instructor. This issue of
who is qualified to deliver these types of therapies has been somewhat
controversial. The Center for Mindfulness in Medicine, Healthcare, and
Society is the only professional body that provides certification for MBSR
teachers, whereas other professional bodies provide professional licenses
to practice therapy in each jurisdiction. Practitioners and developers of
MBSR and MBCT strongly believe that in order to teach these modali-
ties instructors need to have their own daily practice of meditation. This
is not a requirement for other therapies developed outside this tradition,
such as DBT and ACT.
The guidelines suggested by the Center for Mindfulness for MBSR
teacher certification are quite stringent and include (a) professional
experience and graduate degree or equivalent in the fields of health care,
education, or social change; (b) ongoing daily meditation and body-
centered awareness practice and commitment to the integration of mind-
fulness into everyday life; (c) regular participation in 5- to 10-day silent,
teacher-led mindfulness meditation retreats; and (d) experience teach-
ing a minimum of four 8-week MBSR courses. In addition to these ele-
ments, they require specific training in MBSR as provided though a
series of professional development opportunities. The first exposure is
typically a 7-day professional retreat where professionals are introduced
to the theoretical foundations and curriculum of MBSR. This is followed
by participation in a full 8-week program with supervision; and partici-
pation in a longer practicum in MBSR with opportunities for coteaching
with feedback and individual supervision; and finally a teacher develop-
ment intensive during which a group of teachers practice teaching
one another with feedback. All of these courses are offered through the
 Mindfulness-Based Psychotherapy 59

teaching arm of the Center, Oasis. Equivalencies with proof of teaching

on videotapes or CDs are sometimes accepted (Santorelli, 2008).
Many professionals deliver MBSR programs without this certification,
as it is an informal requirement and not required by most professional
licensure bodies. Therapists practicing other forms of mindfulness-based
therapies generally have adopted these guidelines as the gold standard.
Specific training workshops for MBCT are routinely offered over the
course of a few days or a weekend, but no specific teacher requirements
are detailed. The philosophy of the ACT community is to foster
an open and responsible scientific culture that is non-
hierarchical, self-critical, and that makes it easy for everyone to
play a role. In furtherance of these values the ACT Community
has decided not to formally certify therapists, trusting an open
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process of development to weed out problems. (Hayes, 2005)

Hence, although many ACT training opportunities are provided, no cer-
tifying body exists. For DBT, which has been an established therapy
modality for a longer time, training is provided in many graduate pro-
grams but not actively certified by any central body.
The issue of teacher certification is likely to remain controversial as
practitioners attempt to find a balance between protecting the integrity
of the practice but not overly limiting opportunities to offer mindfulness-
based interventions to populations in need.

Conclusions and Future

Directions

This chapter highlighted the emerging field of mindfulness-based inter-

ventions, both the well-established MBSR and MBCT as well as the
newer MB therapies that are being developed and applied to a broad
array of disorders and populations. The development of MB therapies is
quite exciting, opening seemingly unlimited possibilities for the applica-
tions of mindfulness. The danger, however, is that as mindfulness gains
in popularity it faces possible harm through the potentially unskillful
application of its tenets. There is great debate in the field of mindfulness-
based psychotherapy regarding how to protect the sanctity and purity of
the modalities as they have been originally conceptualized and applied,
while at the same time remaining open to new and potentially very use-
ful applications. This debate is by no means closed, and it will likely con-
tinue as mindfulness continues to enter the mainstream of medicine and
mental health care.
Some purists are deeply concerned by the removal of the concept
of mindfulness from its traditional Buddhist roots, which are the implicit
 60 THE ART AND SCIENCE OF MINDFULNESS

basis of all the mindfulness-based interventions, including MBSR. These

purists suggest that the application of mindfulness in a secular treatment
has resulted in a watering down of its potential power and intended
applications. Others believe that if a “secularized mindfulness” can be
of benefit and is more accessible to a wide range of populations, then by
all means it should be used. Our belief is that a clear understanding and
some experience of the traditional context of mindfulness is helpful to
teachers and therapists applying its tenets. Reading of the original Bud-
dhist texts is useful to deepen one’s ability to convey important concepts
to clients, even if the traditional Buddhist vocabulary to describe the
concepts is not used. This does not imply that all mindfulness-based
therapists must spend years or even months at meditation retreats, but
it does seem essential to have a regular mindfulness practice and to read
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some translations of Buddhist psychology and basic philosophy regard-

ing the nature of suffering, its root causes, and recommended methods
to end suffering.
Our hope is that practitioners and researchers involved in the devel-
opment, investigation, and application of mindfulness-based interven-
tions will have a deep personal experience to inform their clinical work
and empirical investigations. As S. L. Shapiro, Walsh, and Britton (2003,
pp. 85–86) noted
Without direct experience, concepts (and especially
transpersonal concepts) remain what Immanuel Kant calls
“empty” and devoid of experiential grounding. Without this
grounding we lack adequatio: the capacity to comprehend the
deeper “grades of significance” of phenomena (Schumacher,
1977), which Aldous Huxley (1944) refers to in The Perennial
Philosophy as “knowledge is a function of being . . . .” Without
direct practice and experience we may be in part blind to the
deeper grades of significance of meditation experiences, and
blind to our blindness.
We believe that our direct experience with mindfulness will best inform
clinical interventions as well as research investigations. We also believe
that further, rigorous evaluation of all newly introduced MB therapies
is essential. As helping professionals, our ethical duties are to provide
the most appropriate form of intervention for each client who crosses
our threshold. We can do this only from a deeply informed position,
drawing from both personal experience and evidence-based science.