Mindfulness Therapy

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Mindfulness therapy –

The faculty of bringing back a wandering attention over and over again is the very root of judgment, character, and will. No one is composure if he have it not. An education which should improve this faculty would be the education par excellence.

(James 1927: 95)

The traditional aims and methods of mindfulness practice have been introduced earlier (Read Mindfulness – Origins and Concepts). Its application to the whole field of mental health has depended upon the use of mindfulness within psycho-logical treatments used to alleviate mental suffering (Read Science of Mindfulness). These take a variety of forms, in which the contribution of mindfulness may be covert as well as explicit. This chapter surveys the growing range of therapeutic approaches that are bringing mindfulness to bear on emotional difficulties. The scope of these is potentially vast, and where it is necessary to give greater priority to some than others, this will reflect their availability (particularly within public mental health services) and theoretical significance.

Mindfulness in psychodynamic therapies

Incorporation of mindfulness into psychotherapeutic techniques moves attention to the heart of psychotherapy. Given that psycho-therapy depends so heavily upon the interaction between therapist and patient, it is remarkable how little prominence attention has received in its clinical literature. Notable exceptions have included Freud, who believed psychoanalysts’ attention was essential to their practice. According to him, the psychoanalyst should maintain

evenly hovering attention . . . all conscious exertion is to be withheld from the capacity for attention, and one’s ‘unconscious memory’ is to be given full play; or to express it in terms of technique, pure and simple: one has simply to listen and not to trouble to keep in mind anything in particular. [Failure to do this risks] never finding anything but what he already knows.

(Freud 1912: 111-12)

There is a nuance in the German gleichshwebende Aufmerksamkeit that makes it important that the translation is ‘evenly hovering’ attention, rather than ‘evenly suspended’ attention. Not only is attention being kept back in a very alert condition, but it is being evenly spread as it hovers across the field of experience. While Freud’s injunction is deceptively simple, it is very hard to realise in practice. The temptation to leap from quietly gathering clarity to an interpretative declaration that has the effect of dispelling it again can be irresistible. The subsequent history of ‘evenly hovering attention’ was for the concept to become distorted in the hands of Freud’s immediate successors. As Epstein (1984) relates, instructions to suspend judgement and theorisation were transformed into a justification for partial if apparently spontaneous interpretations on the part of the analyst.

Possibly in reaction to this, an equally famous call for psychoanalysts to refine their own attentive processes came from the British psychoanalyst Wilfred Bion in his Attention and Interpretation:

The capacity to forget, the ability to eschew desire and understanding, must be regarded as essential discipline for the psycho-analyst. Failure to practise this discipline will lead to a steady deterioration in the powers of observation whose maintenance is essential. The vigilant submission to such discipline will by degrees strengthen the analyst’s mental powers just in proportion as lapses in this discipline will debilitate them.

(Bion 1970: 51-2)

Bion’s concern was that the analyst does not squander his or her attention in the observation of phenomena that, for Bion, are ultimately only distractions. The point of the essential discipline he refers to is that consciousness does not become what he terms ‘saturated’:

If the psycho-analyst has allowed himself the unfettered play of memory, desire, and understanding, his pre-conceptions will be habitually saturated and his ‘habits’ will lead him to resort to instantaneous and well-practiced saturation from ‘meaning’ rather than from O.

(Bion 1970: 51)

Whereas Freud’s instructions seem compatible with traditional methods for attaining ‘bare attention’, this is less clear with Bion. For instance, Bion insisted that attention be withdrawn from not only ‘memory, desire and understanding’ but also sense perceptions:

Freud . . . speaks of blinding himself artificially. As a method of achieving this artificial blinding I have indicated the importance of eschewing memory and desire. Continuing and extending the process, I include understanding and sense perception with the properties to be eschewed. The suspension of memory, desire, understanding, and sense impressions may seem to be impossible without a complete denial of reality; but the psycho-analyst is seeking something that differs from what is normally known as reality.

(Bion 1970: 43)

In fact, Bion wishes to develop a faculty he calls ‘intuition’ to arrive at extrasensory apprehensions of a psychic reality that is beyond words and that he refers to as ‘O’. He often refers to this process as F or ‘faith’, while insisting it is just as dependable as logic or sensory evidence once it is familiar. With the suspension of memory, desire and understanding, the analyst will be exposed to undifferentiated feelings that are usually concealed, as part of the direct experience of psychic reality.

While this is commonly reported in meditative experiences, Bion draws no such parallel. He mentions other attentive practices, apart from this total suspension:

There is the possibility of suppressing one or all of these functions of memory, desire, understanding, and sense either together or in turn. Practice in suppression of these faculties may lead to an ability to suppress one or other according to need, so that suspension of one might enhance the effect of domination by the other in a manner analogous to the use of alternate eyes.

(Bion 1970: 44)

However, he is consistent in championing an intuited reality that is quite independent of sense impressions and the thinking he believes they feed:

I would say that the more ‘real’ the psycho-analyst is the more he can be at one with the reality of the patient. Conversely, the more he depends on actual events the more he relies on thinking that depends on a background of sense impression.

(Bion 1970: 28)

How compatible Bion’s clinical philosophy is with a Buddhist framework is a big and underexplored question. There is much in his understanding of thinking as secondary to ‘preconceptions’ and desires that is compatible with the theories of cognition. However, in his metapsychology, Bion also remains committed to confessedly mystical conceptions of truth, and something like a soul, that carry the imprint of Vedanta rather than Buddhism.

The strictures of Freud and Bion were intended to sharpen the analysts’ receptivity and acuity of observation, including the uncomprehending apprehension of features that would otherwise be obliterated by the usual habits of the analyst’s mind. Attention becomes important because training it helps the analyst to observe and to analyse more effectively. However, Bion also acknowledged its direct importance for the analyst’s patient:

If the psycho-analyst has not deliberately divested himself of memory and desire the patient can ‘feel’ this and is dominated by the ‘feeling’ that he is possessed by and contained in the analyst’s state of mind, namely, the state represented by the term ‘desire’.

(Bion 1970: 42)

While Bion was still formulating his views on psychoanalytic procedure, Karen Horney had made attention the cornerstone of the analyst’s technique. In stating this, she conjoins understanding and attention:

I have dwelt on the quality of the analyst’s attention and understanding because all the help he can give the patient follows from his understanding. Allowing for some exaggeration, analysts would need no books on analytical technique if their understanding was complete.

(Horney 1951: 99)

Horney insisted that effective therapeutic work reflected the quality of the analyst’s attention, which should have three (overlapping) qualities: wholeheartedness, comprehensiveness, and productiveness.

By wholeheartedness, Horney says she is referring to the power of concentration or absorption in one’s work, with any tendency to be distracted being noted and filed for future reference. She comments that being wholeheartedly in the service of the patient requires a kind of self-forgetting at the same time.

Another aspect of wholehearted attention is unlimited receptivity . . . letting everything sink in. . . . This kind of concentration of which I am speaking involves your feelings and is not just cold detached observation. Unlimited receptivity means being in it with all your feelings. [Horney is referring particularly to feelings toward patients here.] . . . The best advice I can give is that everything come up, emerge, and at the proper time, be observed.

(Horney 1987: 20-1)

On comprehensiveness, Horney says, ‘The meaning of letting all sink in can only be DON’T SELECT TOO EARLY’ (21). She describes a number of practical problems with this, including a personal blindness preventing receptivity; interrupting too early (because preconceived ideas impair listening and prevent things from sinking in in in a wholehearted way). Horney recommends that analysts need to pay attention to themselves because they are the tool that pays attention to what is going on. Thus, analysts monitor their own attention for signs of interest and disinterest. This is complemented by an appreciation of the degree of effort the patient exerts from moment to moment. Throughout, an analyst also pays constant attention to the patient’s disturbances and the changes that take place in them. Horney admits that the range is enormous but comments that, as in driving a vehicle, ‘The more one understands, the more the observations and impressions fall into line, and the easier it becomes to pay attention to them’ (26-7).

The third aspect, productivity, is perhaps the most original. It is also the most problematic, in that Horney gives two quite different accounts of it. Both reflect a (valued) tendency for trained attention to ‘set something going’ (Horney 1951: 189). In one account (Horney 1987), she describes productivity in terms of the analyst’s capacity to make sense of things. In the other (Horney 1951), the productivity of attention is evident in patients’ awareness of themselves, their trust in the analyst, their fear of their conflicts, and their acceptance of responsibility for themselves.

It may be no accident that Horney had some personal contact with Zen Buddhism at the time of formulating how, in addition to helping the analyst function as a trained observer, the extension of attention toward the patient might be therapeutic in itself. It may also be worth observing that, once he saw intuition as an end in itself, Bion became highly sceptical of equations between psycho-analysis and ‘treatment’, and about the value of ‘improvement’ (cf. Symington and Symington 1996: 171) in a manner incompatible with Horney’s faith in measured progress.

Two other analytic writers who successfully integrated Buddhist understanding in their work have provided clarifications about ‘bare attention’. Mark Epstein writes, ‘It is the fundamental tenet of Buddhist psychology that this kind of attention is, in itself, healing’ (Epstein 1996: 110). And, after affirming the centrality of attention to every aspect of an analyst’s work, Nina Coltart applies the recognition of the healing potential of bare attention directly to psychoanalysis:

The teaching of Buddhism is what is called bhavana or the cultivation of the mind with the direct aim of the relief of suffering in all its forms, however small; the method and the aim are regarded as indissolubly interconnected; so it seems to me logical that neutral attention to the immediate present, which includes first and foremost the study of our own minds, should turn out to be our sharpest and most reliable therapeutic tool in psychoanalytic technique since there, too, we aim to study the workings of the mind, our own and others, with a view to relieving suffering.

(Coltart 1992: 183)

As regards my own practice, and how Buddhism has affected my clinical work with patients, one of the earliest things I noticed was the deepening of attention. Bare attention has a sort of purity about it. It’s not a cluttered concept. It’s that you simply become better, as any good analyst knows, at concentrating more and more directly, more purely, on what’s going on in a session. You come to concentrate more and more fully on this person who is with you here and now, and on what it is they experience with you; to the point that many sessions become similar to meditations. When this happens, I usually don’t say very much, but a very, very closely attending to the patient, with my thought processes in suspension, moving toward what Bion called ‘O’; a state which I see as being ‘unthought-out’, involving a quality of intuitive apperception of another person’s evolving truth. All this undoubtedly became easier to do as a result of my Buddhist practice. Sessions became more frequently like meditations. That is about the most powerful effect Buddhism had on my clinical practice.

(Coltart 1998: 176-7)

The idea that mindfulness augments processes intrinsic to analytic procedure includes awareness of the analyst’s own reactions as well as observation of the patient:

If you’ve done a lot of vipassana and have managed to foster this split attitude of observation detached from thinking and reacting, yes, it’s got to help the countertransference as well, hasn’t it?

(Coltart 1998: 178)

These two writers illustrate quite different ways of introducing mindful awareness to psychoanalytic psychotherapy. Coltart did nothing overtly to change the rules of analytic procedure with her patients. As the above quotations show, she recognised that the quality of her own close attention affected the atmosphere and activity of her sessions, without her needing to change her basic psychoanalytic technique.

Mark Epstein has written even more extensively about the impact of interleaving Buddhist studies with psychotherapeutic training and practice, which, for him, has been significantly different. Epstein has long incorporated psychoanalytic thinking, particularly that of Winnicott, in his psychotherapeutic work, which he refers to as Buddhist psychotherapy, but he has developed a distinctive, eclectic style. In his first book, Epstein suggests that mindfulness training could help other therapists to find the personal resources that Freud had demonstrated in his capacity to work in the intensity of the transference with whatever patients projected there, but which Epstein felt other therapists usually lacked (Epstein 1996: 183-4).

Subsequently, Epstein has advocated a more eclectic stance, likening the role he often adopts with patients to that of a coach who teaches people how to venture into their unexperienced and feared feelings (Epstein 1999: 21). The methods he adopts differ from patient to patient, and can include instructing them in meditation or telling Buddhist stories. While agreeing with therapists from the psychodynamic tradition concerning what people seeking therapy are likely to need, Epstein has gone on to reshape the repertoire of professional responses more radically than Horney.

In general, it appears that mindfulness can be assimilated within psychodynamic therapy at many levels, short of creating a com-pletely new brand of therapy. This reflects the way in which the refinement of attention has been core to psychodynamic practice since its inception and the fact that psychodynamic approaches are identified by their methods rather than by a particular problem or patient group. Before we move to consider the impact of mindfulness across cognitive-behavioural psychotherapies, it seems fitting to summarise a training package that shares both of these characteristics, and that has resisted being labelled as a therapy, although it has become increasingly linked with the techniques of cognitive-behaviour therapy as it has been adopted within mental health settings.

Mindfulness-based stress reduction (MBSR)

The work of Jon Kabat-Zinn (1990) has effectively made personal training in mindfulness available to large numbers of people, without their having to seek it either in the form of spiritual aid or as psychotherapeutic treatment. Something of the spirit of the US Founding Fathers seems to inform the wish to make mindfulness available without any requirement to accept or reject particular religious beliefs, nor to compromise or deny each individual’s continuing responsibility for their own health. Mindfulness-based stress reduction (MBSR) grew up as an optional adjunct to standard medical treatments for people attending general hospitals who suffered from painful, disabling, chronic and/or life-threatening illnesses. MBSR training has usually commenced without their being asked to see themselves as psychologically or emotionally impaired. After sampling some introductory exercises in mindfulness, they have had to choose whether to attend a full 8-week, part-time training programme.

Those who do so are then helped to become more mindful in their attitudes to their condition, and in their lives generally, through the programme’s core components. These include general education about factors inducing and maintaining stress; use of self-monitoring exercises to become familiar with personal stressors and the impact of feelings and thoughts on stress; training in mindfulness by the use of formal mediations (including yoga), as well as practice at being mindful during everyday activities; and the regular use of group discussion to promote learning of all of these. Each week, new techniques are introduced in a graded sequence, with an expectation that at least one of these will be practised daily for at least 30 minutes. The meditative techniques that are used have been chosen to build up a capacity to direct attention from one object to another, and to give students an opportunity to observe and compare the effects of different procedures in order to make future choices about which procedures are likely to be most helpful to them. The extended exercise likely to be used most frequently through the programme sessions is the ‘body scan’, a modified version of a vipassana exercise in which attention is moved around the body. Sitting meditations develop the capacity to be mindfully aware of breathing, body sensations and posture before selective attention is paid to sounds, thoughts and emotions in turn. After this, undirected ‘choiceless awareness’ is practised, to foster a non-clinging open-ness to whatever experiences arise.

As an illustration, the following instructions for mindful breathing would be consistent with this approach:

Example 1: Sample instructions for mindful breathing (Mace 2007)

1.  Settle into a comfortable, balanced, sitting position on a chair or floor in a quiet room.

2.  Keep the spine erect. Allow the eyes to close.

3.  Bring your awareness to the sensations of contact wherever your body is being supported. Gently explore how this really feels.

4.  Become aware of your body’s movements during breathing, at the chest and at the abdomen.

5.  As the breath passes in and out of the body, bring your awareness to the changing sensations at the abdominal wall. Maintain this awareness throughout each breath and from one breath to the next.

6.  Allow the breath simply to breathe, without trying to change or control it, just noticing the sensations that go with every movement.

7.  As soon as you notice your mind wandering, bring your awareness gently back to the movement of the abdomen. Do this over and over and over again. Every time, it is fine. It helps the awareness to grow.

8.  Be patient with yourself.

9.  After 15 minutes or so, bring the awareness gently back to your whole body, sitting in the room. 

10.   Open the eyes. Be ready for whatever is next.

Mindfulness of the body is also developed through two kinds of movement meditations. In one, sequences of relatively simple and physically undemanding yoga postures are worked through, to provide novel physical sensations as a focus for mindful attention. In the other, ‘walking meditation’, ordinary walking movements are repeated, at varying speeds, to deepen awareness of the bodily sensations that accompany them. Just as the ‘yoga’ sequences are a deliberate modification of traditional hatha yoga in detail and in intention, so the other exercises have analogues to classical practices without copying these exactly. The emphasis is on the cultivation of bare attention, whatever the context, whether there is movement or not. So even the walking meditation, superficially closest to its traditional model, is different from it but akin to the other core exercises in MBSR because it omits any commentary about ‘now I am doing this . . . now I am doing that . . .’.

The programme can also use techniques whose relation to bare attention is more tangential, although they are likely to improve the quality of meditation. These include visualisation, as when a sense of groundedness and implacability is fostered through picturing and then identifying with a mountain as part of a guided meditation. They also include techniques to foster positive feeling such as loving-kindness. These are often introduced when the timetable includes an additional, day-long session three-quarters of the way through the course.

What binds the elements together is a guided education in patterns of personal reactivity, with particular attention being paid to those that are linked to subjective stress. Becoming more sharply aware of the tide of bodily sensations, thoughts and feelings is in the service of greater awareness of their interdependence. Between sessions, students will be encouraged to note down the patterns of their responses to pleasant and unpleasant events and to other people. In the sessions, they will discuss these openly, as practice of the mindfulness exercises supports insight of these kinds. Alongside a broadening awareness of what is going on at any moment, a greater ease and capacity to enjoy, but not be submerged by, individual experiences is usually reported by participants.

The programme’s widespread popularity has been underpinned by research evidence of its contribution to the relief of symptoms and suffering across conditions ranging from chronic pain to psoriasis (for reviews, see Bishop 2002; Baer 2003; Grossman et al. 2004). This has included evidence of MBSR’s impact on hormones mediating stress responses (Marcus et al. 2003) and immune reactivity (Davidson et al. 2003). Throughout, the effect of MBSR programmes on patients’ levels of anxiety and depression has been a consistent theme (Kabat-Zinn et al. 1992; Reibel et al. 2001). Its impacts on psychological health are considered in more detail in the next chapter. Even if the practice of MBSR, as a training that is offered by instructors rather than therapists, has remained substantially unchanged over the last 15 years, it has been the pro-genitor of a growing range of purpose-built adaptations for specific client groups. These tend to combine some of the core exercises, such as the body scan and sitting meditations, with alternative psycho-educational content and additional stratagems. The willingness to design new therapeutic packages targeted at a defined clinical need, often organised around a plausible theory of symptom formation, has been a characteristic of the cognitive-behavioural tradition that has probably been crucial in gaining such wide acceptance for its methods.

Cognitive-behavioural therapies (CBT)

Quite distinct ways of incorporating mindfulness within psychotherapy have arisen within the cognitive-behavioural tradition over the last 15 years. Cognitive psychology and Buddhist psychology are in broad agreement about the dependence of emotional disturbance on pervasive patterns of thinking and perception. In contrast to most psychodynamic therapies, recent cognitive-behavioural treatments tend to be designed as interventions for people with a specific set of clinical needs or disorder, rather than as a broad-spectrum therapy. These aims have informed the design of a positive flood of new ‘mindfulness-based’ interventions, which include:

  • mindfulness-based eating awareness training (MB-EAT) (Kristeller and Hallett 1999)
  • mindfulness-based relapse prevention (MBRP) (Witkiewitz et al. 2005)
  • mindfulness-based relationship enhancement (MBRE) (Carson et al. 2004)
  • dialectical behaviour therapy (DBT) (Linehan 1993a)
  • acceptance and commitment therapy (ACT) (Hayes et al. 1999)

 Mindfulness-based cognitive therapy (MBCT) 

The clinical approach of MBCT’s founders was already becoming distinctive within cognitive therapy. Zindel Segal’s collaboration with the psychoanalyst Jeremy Safran on interpersonal schemas was a clear demonstration of how relational factors were being brought into the centre of therapy (Safran and Segal 1990). Their recognition of the therapeutic usefulness of ‘decentering’ from cognitions – rather than trying to remove or change them – was also complemented nicely by John Teasdale’s by then long-standing interest in ‘differential activation’. This was a way of short-circuiting attention given to negative cognitions, which would otherwise compound the lowering of someone’s mood. With Mark Williams, they all shared a theoretical as well as practical interest in the factors that make people vulnerable to repeated depression and the prevention of relapse. Having agreed that a therapeutic strategy based on attentional switching was the way forward, they have been candid about the circumstances that led them to include a far more thorough programme of mindfulness practice within their therapeutic package than they had first thought necessary (cf. Segal et al. 2002: 55-7).

As its name suggests, MBCT adds training in specific cognitive skills to the framework of MBSR (Segal et al. 2002). MBCT is very similar in its organisation and content to MBSR, although it is usually taught in smaller groups than the 30 or so that have been common in some centres. It also remains similar in ethos, with an expectation that MBCT therapists will have (and maintain) personal experience of mindfulness that they regularly draw on as they assist their patients going through the programme. In comparison, MBCT training in mindfulness has placed marginally less emphasis on bodily movement and has incorporated a 3-minute ‘breathing space’. (This is a very brief, transportable routine for rapidly restoring a mindful attitude in three, minute-long, phases: a deliberate review of current events and reactions, becoming mindful of the breath as a means of restoring an internal sense of calm, and a movement back out to the surroundings in which the sense of calm is maintained and carried forward.) Instead of stress education, exercises for the monitoring and analysis of dysfunctional thinking and its specific relationship to body sensations and mood are included. Yet, in essentials, very little is changed – the decentering from negative cognitions that is overtly worked toward in MBCT being equivalent to the mindfulness of thinking that MBSR has always aimed to teach. Although MBCT was originally developed as a prophylactic intervention for use with people with an established history of relapsing depression, it is being increasingly used as a treatment intervention in its own right. Variants have developed to meet the specific needs of other client groups with mental health problems, which take into account the particular difficulties they face from a cognitive perspective, as well as particular needs they may have in engaging with the treatment approach. 

For instance, mindfulness-based eating awareness training (MB- EAT) represents an extension of MBSR and MBCT designed for people with binge eating disorder. The resulting programme is usually longer than 8 weeks, and is premised upon mindfulness practice reversing the lack of awareness of bodily and internal states that has been commonly observed among people with eating disorders. In practice, Kristeller and Hallett have found restoration of sensitivity to feelings of satiety to be therapeutically essential. A complementary goal with this population has been to provide a means of living with prominent guilt feelings. Meditations designed to foster feelings of forgiveness are a key component of the programme for this reason. (Here modern practice is replicating traditional Buddhist training, where meditations to develop concentration and mindfulness are often interspersed with others that develop positive social emotions such as loving-kindness or compassion.) At the same time, as the name suggests, MB-EAT has placed particular emphasis on the practice of mindfulness in the kitchen rather than in meditation sessions to ensure it is employed where it is needed most. As the list of interventions indicates, other variants of MBCT and MBSR have been derived to meet other clinical needs.  

In moving from MBSR to MBCT, mindfulness interventions have become more like other therapies, with the instructor likely to be seen as a therapist. Other adaptations have also been made in response to the perceived needs of people diagnosed with mental disorders, a major example being the distinctive framework devised for dialectical behaviour therapy.

Dialectical behaviour therapy (DBT)

For many mental health professionals, DBT is the only therapy drawing on mindfulness that they can name. It is a relatively complex treatment with a complex philosophy. As its name suggests, its goal was originally a behavioural one, reducing self-harming behaviour in the form of taking overdoses, self-cutting or deliberately seeking dangerous situations. Intended for people with a repeated history of such acts, it was also fostered as a treatment for borderline personality disorder (BPD), in which such behaviour is especially common (and one of the criteria for the diagnosis). Although some elements of the design of DBT can appear less necessary and harder to transmit than others (not least the concept of ‘dialectics’), it is a package of therapeutic techniques and teachings that reflects a distinct perception of the origins of the psychological difficulties common to people diagnosed with BPD, and an analysis of the limitations of alternative treatments. In fact, a direct link is made between these two – people with BPD, having repeatedly faced experiences of invalidation in their early as well as their adult lives, are especially prone to experience further rejection of themselves during conventional psychological treatments. Linehan sees this risk in CBT’s traditional emphasis on targets and change. This is at the expense of acceptance, which DBT therapists are expected to demonstrate and to help their clients find for themselves. The continuing importance of striking a creative and acceptable balance between acceptance and change is one justification for the therapy’s being ‘dialectical’. The philosophy of acceptance permeates the model of BPD that underpins treatment. The pathology results from multiple ‘dysregulations’ – of mood, interpersonal relationships, sense of self, behaviour and cognition. In each case, there has been a vicious cycle of nature and nurture that, without any imputation of failure, compromises the adult’s moves to maintain control. Instead, there are extremes and discontinuities that, in the case of emotional dysregulation, for instance, are likely to reflect lasting changes in the way the brain processes experiences and affords responses to them. As a first step toward self-acceptance, patient and therapist need to agree on an accurate picture of this dysregulation, its likely origins and continuing consequences, without these becoming a source of further recrimination.

DBT was created as a mindfulness-based, but not a meditation-based, therapy. There is a formal split in its structure between therapeutic sessions, provided through individual meetings with a personal therapist, and skills training, provided in a group format alongside other people with BPD. The skills learned are divided into acceptance skills (in the form of mindfulness and distress tolerance) and change skills (regulation of emotions and interpersonal effectiveness). However, mindfulness skills are clearly first among apparent equals. They are taught first, and constantly referred back to in the presentation of other skill types. This teaching takes place in a didactic group setting, in which members of the therapist team provide lectures and seminars, whose learning points are reinforced through group discussion of their relevance to patients’ own experiences and predicaments and the provision of printed handouts for further study. The first element to be presented is perhaps Linehan’s most significant contribution to the study of ‘mindfulness’. It is a delineation between three forms of ‘mind’, termed ‘reasonable mind’, ‘emotional mind’ and ‘wise mind’. 

To understand what is most characteristic of Linehan’s model of the divided mind, it can be helpful to compare it with two famous tripartite mental models that preceded it (and seem to inform it) – those of Plato and Freud. What all three have in common is a recognition of the scope for conflict between aspects of the mind, based upon their capacity to influence its actions. Plato distinguished appetitive, passionate and rational aspects. Although these are difficult to translate exactly into modern psychology, their potential for conflict is graphically illustrated in his metaphor of the chariot, in which the horses of desire and passion strain against the efforts of the charioteer, reason, to tame them (cf. Plato’s Phaedrus). In the Freudian model of id, ego and superego (Freud 1923), appetite and reason continue to characterise the first two, embodying the concepts of the pleasure principle and the reality principle. While their opposition is sustained through divisions drawn between what is unconscious and conscious, the superego defies this functional distinction by including unconscious affects, such as guilt, as well as conscious ideals that inform a person’s ideas about what they should strive to be like. According to this model, conflict is manifest not only in the pull of instinctual wishes, but also from opposition experienced in the ego in its relation to the shoulds of the superego.

In comparison, divisions within Linehan’s model are functional rather than structural. In a way that is very consistent with the Platonic model, the different modes of mind can each be experienced as being in control at different times, and they can rapidly displace one another. The relationship between the wise mind and the rational mind can resemble healthy assertion of the ego against the strict demands of the superego in the Freudian model. According to Linehan, when logical thinking dictates intentions, the rational mind is in play; when strong feelings dictate, the emotional mind is in control, and the content of thoughts will reflect this. The wise mind transcends both of these, being recognised only when reason and feeling are in balance. In addition, intuition will be engaged, and there will be a sense of cohesion underlying conscious experience. The mindfulness skills instructor therefore works initially to help clients discriminate between these modes of functioning, and to reject the results of emotional mind acting in isolation.

Linehan’s description of individual mindfulness skills emanates from a model aimed to serve the needs of people experiencing considerable internal chaos and for whom clear structures and guidance are likely to be welcome. Indeed, she offers what is effectively a cognitive-behavioural analysis of them. Three ‘what’ skills are complemented by three ‘how’ skills. The former comprise observing, description and spontaneous participation. These activities are seen as mutually incompatible and are to be practised separately. Observation involves stepping back to ensure that a mindful awareness is engaged. It is intended to be the antithesis of the impulsivity to which people with BPD are ordinarily prone. Description, involving the deliberate naming of events as they occur, is seen as an important step in discriminating between incorrect construction of situations and a more objective perspective. Spontaneity in action may appear to risk confusion with impulsivity, but the goal is a wholehearted commitment to mindful action that is free from conflict. The three ‘how’ skills apply to all of these ‘whats’. They concerned being non-judgemental, one-minded and effective. These counteract, respectively, the client group’s tendency to adopt highly polarised opinions (whether idealizing or harshly critical), to succumb to mindlessness or distraction, and to be so influenced by assumptions concerning other people’s reactions or rigid principles that they fail to meet the needs of the moment in order to propitiate a private form of pride. After these skills are practised through a series of exercises, they are brought to bear on the subjects of the remaining three modules, that is, emotions, distressing experience and relationships.

If the emphasis on awareness is common to other mindfulness-based approaches, Linehan’s approach shows the influence of Zen most in its emphasis on spontaneous action as a goal (among the ‘what’ skills) and in its view of the therapist’s role. Zen teaching, characteristically iconoclastic and antitheoretical, has always held complete identification between thought and action as an ideal. The means it has adopted to induce such a state of being, particularly in the Rinzai Zen tradition, has included unexpected and paradoxical interventions from a Zen teacher designed to nudge the student into the fundamentally different state of being (‘enlightenment) that is the goal of Zen study. This can range from the setting of cryptic questions (‘koans’) for the student to contemplate to provocative demonstrations. Linehan’s therapists are encouraged to see their task as assisting patients in the discovery of their own ‘wise mind’ in a way that presumes they have some greater understanding of this, and to adopt an ‘irreverent’ attitude that has the power to provoke and surprise. When working individually with clients, the therapist also has considerable license to intervene in order to guide them toward responses likely to be in tune with the ‘wise mind’.

To act in this way naturally requires a complementary set of skills from the therapist. However, these, too, are learned on the basis of a behavioural analysis of the role, rather than a personal internalisation of attitudes, awareness and non-reactivity. DBT therapists rarely undergo DBT themselves. Moreover, as teachers of mindfulness, they are free to decide how they should experience it for themselves. The implications of such differences in approach are discussed more fully below.

Lynch and colleagues (2006), recognising how a Zennish form of mindfulness will emphasise being completely immersed in action, suggest four mechanisms for the effectiveness of mindfulness within DBT. These are 1. behavioural exposure and learning new responses (such as non-doing); 2. emotion regulation (by decoupling negative response and amplifying cognitive appraisals); 3. reducing belief in internal rules (which tend to feed undermining self-images); and 4.  attentional control. By the last, they are referring to a learned capacity to focus on process at will, rather than the objects of attention. However, some therapists appear to interpret this as teaching a capacity to divert attention at will to other, more benign, objects through distraction rather than a change of attentional mode. 

While it is potentially helpful to try to analyse the mode of action in this way, the analysis offered by Lynch et al. (2006) is unlikely to be the last word. Strictly speaking, it lists effects of mindfulness in terms of changes secondary to other processes, rather than mechanisms by which mindfulness has such effects. (The point will become clearer in the discussion below of Martin’s work.) The importance of being as specific as possible about the mechanisms through which mindfulness works is evident from the discrepancy between different accounts of how mindfulness acts within DBT. For instance, reduction in impulsive behaviours during DBT has been attributed both to an improved capacity to participate with awareness in all the processes that lead up to an action (e.g. Linehan 1993b: 63), and to greater acceptance of the painful negative emotions that otherwise trigger impulsive actions (e.g. Welch et al. 2006: 122). Before making the explanations fit theoretical abstractions such as ‘affect regulation’, it may be important to ground them in successful clients’ own accounts of how their functioning has changed.

Acceptance and commitment therapy (ACT)

Like MBCT and DBT, acceptance and commitment therapy (often called ‘act’ rather than ACT for short) has been named as a ‘third-wave’ cognitive therapy. It is based on a radical behavioural analysis of patients’ difficulties. From this, a selection of appropriate therapeutic strategems is made from a full and varied menu. They fall under six main headings, four of which are acknowledged to be ‘mindfulness functions’, that is, ‘contact with the present moment’, ‘acceptance’, ‘cognitive defusion’, and ‘self as context’. The first two correspond to the receptive awareness and to the suspension of judgement that have been key to modern conceptions of mindfulness. The third, ‘cognitive defusion’, a deliberate disidentification from thoughts, is the expected outcome of a series of exercises that focus directly on clients’ relationship to their thoughts. An example of the kind of practical exercise that a therapist might introduce for this follows. In practice, it would be followed by detailed examination of the client’s experience by the therapist to underline the intended lesson.

Example 2: Specimen ACT exercise to facilitate cognitive defusion (after Mace 2007)

This exercise is to help you see the difference between looking at your thoughts and looking from your thoughts. Imagine you are on the bank of a steadily flowing stream, looking down at the water. Upstream, some trees are dropping leaves which are floating past you on the surface of the water. Just watch them passing by, without interrupting the flow. Whenever you are aware of a thought, let the words be written on one of the leaves as it carries on floating by. Allow the leaf to carry the thought away. If a thought is more of a picture thought, let a leaf take on the image as it moves along. If you get thoughts about the exercise, see these, too, on a leaf. Let them be carried away like any other thought, as you carry on watching.

At some point, the flow will seem to stop. You are no longer on the bank seeing the thoughts on the leaves. As soon as you notice this, see if you can catch what was happening just before the flow stopped. There will be a thought that you have ‘bought’. See how it took over. Notice the difference between thoughts passing by and thoughts thinking for you. Do this whenever you notice the flow has stopped. Then return to the bank, letting every thought find its leaf as it floats steadily past.

The fourth function, ‘self as context’, is characteristic of ACT, referring to a perspectival shift in which the client is encouraged to check and reject assumptions about the substantiality and continuity of the experienced self. ACT aims to be flexibly adapted to a wide range of clinical problems (and therapist preferences). Because its exercises are often elaborate, yet intended to be adapted to several situations, they do not always fit easily into the formal/ informal framework of this book. If the repertoire of existing exercises does not match a particular clinical need, or a client’s preferences, the therapist is encouraged to devise one. Throughout, means are adjusted to goals. There is no requirement for therapist or patient to undergo formal meditation as a means to any of the mindfulness functions, although they are free to choose to.

As a radical behavioural intervention, ACT resembles psycho-dynamic therapies rather than cognitive therapies in much of its practice, because it tailors its approach to the individual at the level of personal formulation, rather than having methods that are specific to diagnosed disorders. (ACT also has much in common with existential and psychodynamic therapies in the components which are not discussed here – its attention to clients’ underlying values.)

Apart from contrasts in their procedures, all of the CBT-based interventions discussed in this section differ in their tone from those psychodynamic treatments that incorporate mindfulness. Branded with catchy multi-letter acronyms that could equally belong to pharmaceutical magic bullets, they tend to be described in the language of treatment. They can therefore present a paradox in the way they promote attitudes of acceptance and ‘letting go’ alongside a relatively prescriptive and active therapeutic style. Some unavoidable tension between formed intentions to be mindful and non-doing was noted, and is familiar to meditation teachers of all persuasions. Within therapeutic contexts, the contradiction is not without practical consequences, some of which are discussed elsewhere (Mace, in press). We have seen that meditation itself can take a back seat in some of these structured approaches, making it important to confirm, through formal process studies as well as qualitative reports, that their effects are being mediated by real changes in the capacity to be mindfully aware.

Mindfulness as a group intervention

While we have been considering mindfulness therapies in relation to the traditional categories of individual psychotherapy, it is important to remember that those in which the emphasis on mindfulness is most explicit are essentially group interventions. How, then, do these compare with more traditional forms of group psychotherapy? They are unique in a number of respects. Some years ago, I proposed a simple ABC method of delineating the differences between one group approach and another that was not dependent on theory (Mace 2002). It may be useful here. Three parameters are used to codify how a group works: its approach to affect in the group, the handling of boundaries, and the communicational style that a particular model fosters. It turns out that mindfulness-based group interventions can not only be collectively differentiated from formal therapeutic groups on each of these dimensions, but they also serve to highlight differences between, say, MBSR and DBT groups.

The attitude to affect in mindfulness groups is to turn the attention inward toward it, to face it, to recognise all the ways in which it presents, including somatic manifestations, and not to inhibit its expression as emotion. Particular techniques might be introduced for coping with particularly painful affect, such as sharing awareness with the breath when instructions might be given to ‘breathe through it’, but these are likely to serve to increase mindfulness of the affect, rather than avoidance of it. It is not necessary to try to narrate the affect, to integrate it within a story either of where it seems to belong in someone’s past experience, or of how it might reflect experiences in the group itself. Two secondary aspects of the handling of affect reflect stylistic differences between mindful therapies. One is the deliberate attention to affect with a view to developing a future capacity to tolerate it, as in the teaching of mindful ‘distress tolerance skills’ within DBT. The other is the deliberate cultivation of positive affects through meditative inner focusing. The commonest example is probably the use of ‘loving kindness’ meditations to develop and become more open to loving feelings toward others. Originally, a component of retreat days held toward the end of MBSR courses, these meditations appear to be becoming increasingly popular. The use of forgiveness meditations within MB-EAT is another example of the fostering of positive affect.

Turning to boundaries, mindfulness groups are closer to time-extended psychoeducational groups than any other in their structure. They cater for relatively large numbers of clients, and alternate between overt teaching, group discussion, and guided exercises. Boundary management by the leader is likely to need to be flexible and skilful; for instance, leaders should have the facility not to be totally ruled by a session-by-session plan, so that a sequence of skills training can unfold in a way and at a pace that best meets the needs of the individual participants. There is likely to be clear phasing of sessions, with an initial review of experiences since the previous meeting, and a final pulling together of material covered with explicit instructions for practices to be undertaken prior to the next session. Within a session, boundary management can involve division of the group into smaller units, for instance, for joint exercises in which non-visual sensation is explored, or for the discussion of potentially sensitive material.

Communication within mindfulness groups is very varied. Interaction through touch as well as verbal communication may be invited between members at some points. Group discussions are likely to involve members building upon others’ comments in the exploration of a theme rather than in personal analysis. Session leaders have to be able to communicate in many ways. They provide some overt scene-setting and teaching about the approach. They lead discussions in which their role is to respond to and validate contributions, without trying either to make these into something else through interpretation or to provide further guidance in a way that denies participants’ own expertise or fore-closes options for them. The leaders also provide direct instruction in mindfulness techniques. We have already seen some of the different forms these take (pp. 59-68). The various formats do involve different modes of communication. Helping people to apply effectively instructions of the kind cited in example 1 calls on different aptitudes than leading an exercise based on example 2. The former will involve more demonstration as well as instruction, with learning occurring through imitation as well as comprehension. This means that communication is through not only how things are said, as well as what is said, but also how the conductor behaves in other respects. The MBSR and MBCT tradition in particular has emphasised the importance of instructors embodying in their presentation the thing they are trying to teach.

Integrating mindfulness within psychotherapeutic practice

Treatments like MBCT, DBT and ACT are integrated treatments in the sense that they have been recently created as a complete therapeutic package, in which mindfulness has a relatively clear relationship to the other components within the package. They have been manualised to assist formal evaluation, and it is possible to undertake a formal assessment of a therapist’s ‘adherence’ to the approved model. However, there are other senses by which mindfulness can be integrated within psychotherapeutic practice. A flexible and eclectic approach that would be much harder for other therapists to emulate is seen in Mark Epstein’s ‘Buddhist psychotherapy. Other therapies may incorporate mindfulness as a result of the therapist’s attitude in the course of the treatment, or of the patient practising mindfulness for some or all of the treatment period, with nothing being visibly different from other treatments of the same type.

These can seem very obvious ways for therapists to introduce mindfulness into their work. One of the perennial hazards of such practices is that they are very difficult to evaluate, as it is so much harder to demonstrate equivalence between what several therapists or several patients are doing privately alongside the treatment. It is interesting therefore that one of the earliest studies of mindfulness in psychotherapy (Kutz et al. 1985b) was a study of 20 patients who attended a 10-week programme that included mindfulness of breathing, body and movement, while they continued working in long-term psychotherapy. The non-meditating therapists assessed the impact of this on the participants’ clinical status, and on their capacity to use the psychotherapy. There were small changes on some clinical parameters, reflecting an overall reduction of negativity and anxiety, although hostility, relationships, family and sexual adjustment, and emotional inhibition were apparently unaffected. However, several of these patients and their therapists noted mutative experiences in the course of meditation, some involving a capacity to access feelings and memories that had been untouched for years despite their intervention, together with improvements in insight and capacity to use the therapy productively thereafter.

While this is a more mundane approach than innovatory packages, and less specific in its impact because the patients were already in treatment for a range of difficulties, it is of huge potential importance. If augmentation of therapeutic effects through a relatively brief and inexpensive intervention like this mindfulness training package is as significant and consistent as it appeared to be from Kutz’s study, they could be translated into real improvements in cost efficiency (Kutz et al. 1985a). They would also be relatively simple to incorporate within public sector psychotherapy services, which are often responsible for providing treatments for more than 100 people simultaneously. 

Despite this, the only apparent attempt to replicate or extend the study has been a smaller, albeit controlled, one in which patients attending an MBSR course early in therapy were compared to controls who were receiving comparable treatment but no MBSR (Weiss et al. 2005). Although there was little immediate impact on clinical status, those receiving MBSR were reported to have higher scores on a measure of goal achievement specific to the study. Most significantly, they went on to terminate their therapies sooner than members of the control group, pressing the economic argument home for further serious consideration of joint provision of mindfulness training alongside exploratory psychotherapy.

Implications of mindfulness-based interventions for psychotherapy

By concentrating on treatments that have either highlighted the role of attention or are the most likely to be provided within a public mental health service, this survey is far from exhaustive. There are other approaches having strong affinities to the humanistic or person-centered traditions where mindfulness has been incorporated, not simply because it usefully extends the therapist’s tool kit, but also because the therapeutic work explicitly adopts goals that overlap with those of traditional spiritual pursuits. This is evidently so with the contemplative (e.g., Wellings and McCormick 2006) and transpersonal therapies (Rowan 2005) as well as the explicitly Buddhist psychotherapy for which David and Caroline Brazier have devised a formal training programme (Brazier 2003). 

The variety of ways that mindfulness can be intentionally offered as a helping intervention outside a traditional Buddhist framework that have been examined here still represent a considerable range. They differ not only in their methods but also in their aims. Psychodynamic and many of the mindfulness-based treatments are open to use across many conditions: others are highly specific. These therapies can differ, too, in what is actually known about how far their effects are consonant with their stated aims.

All of these contrasts are relevant to the different ways that the trainer or therapist is expected to work. The accounts are already given highlight differences in the level of overt activity that is expected, and in how far this should be explanatory, educational, group focused and so forth. Beyond these, there are critical differences in the expected relationship of the therapist to mindfulness. As already noted in the discussion of group leadership, there has been a strong insistence within MBSR on the teacher’s ability not only to experience mindfulness at first hand in order to develop it in others, but also to embody it as a living demonstration that students would internalise. Conversely, those approaches that place less emphasis on guided meditations, including DBT and ACT, tend to emphasise the importance of the non-meditative tools they promote and to downplay the significance of the therapist’s personal experience. These vacillations are hardly new, being mirrored in debates about the role of therapists’ personal preparation that have continued to divide the psychoanalytic and cognitive-behavioral traditions within traditional psychotherapies.

The differences between Buddhist psychology and the theoretical frameworks underpinning the principal psychotherapeutic approaches remain considerable, despite apparent similarities. The Buddhist view of mind understands all thought, not only that prone to clear emotional bias, to be projective and inherently distorting reality. However, it goes beyond this, in seeing distortions (whose character varies from mind to mind) at more subtle levels of preconception, and even in the form that consciousness takes. Psychodynamic thinking also has a primary concern with the mediation of experience through human relationships. Although this is relatively underplayed in most Western accounts of it, Buddhist psychology is keenly aware of the relational nature of all processes (psychological, human and otherwise), pointing to a radically relational reality in which the transience of everything is immediately apparent. At the same time, psychodynamic thinking is concerned to understand and develop, but, nevertheless, to maintain, the sense of self. Buddhist psychology, linking suffering and delusion so inextricably to the individualist ‘I’, admits no real compromise away from the sense that this ‘I’ is, at its heart, illusory. Psychodynamic thinkers who engage with Buddhism therefore are sometimes left to struggle to produce compromises concerning the self whose intricacy might be worthy of a medieval scholastic, but which evidence the depth of this difficulty (cf. Safran 2003).

Psychodynamic thinkers have more difficulty with the question of the self than either cognitive or systemic therapists. The version of the cognitive paradigm that would reduce the mind to an information-processing system would only have a place for a ‘self’ if its operational advantages were clear – and this appears to be far from the case. Cybernetics have also informed systemic thinking, in which the concept of any personal ‘parts’ as needing to be constantly reformed in the flux of systemic reorganisation, rather than being some fixed locatable entity, is consistent with its guiding assumptions.

The primacy of thinking for cognitivists is both the strength and the weakness of attempts to integrate it with Buddhist psychology. The apparent capacity of thoughts to prompt feelings, judgements and moods, both consciously and preconsciously, is well recognized. However, the implication that there is a way of thinking that, free from distortion, is a sufficient condition of psychological health is only partly accepted. It is true that ‘right thought’ (or sankappa, often also translated as ‘right intention’) is one of the steps of the Noble Eightfold Path. Right thought is cultivated by deliberate attention to and questioning of thoughts as they arise. Those that are found to be unwholesome in their content and likely consequences are to be set aside in favour of those that will promote wholesome attitudes and actions (for an exposition of this, see sutta no. 19 in the Majhima Nikaya). Such a habit of thinking can assist the establishment of its dominant twin among the factors promoting wisdom, known as ‘right understanding’ (ditthi, or ‘right view’). However, right thought, however refined, cannot in itself lead to right understanding, by which is meant a complete realisation of the nature of suffering, such that there is liberation from it. It is common ground to all the major Buddhist traditions that a realisation of this kind is not a conceptual understanding.

In the face of division between the different Western psycho-therapies, we might consider how an interest in attention cuts across traditions within psychotherapy that are generally jealous of their differences and that appear to have quite distinct identities. The intersections can be theoretical and practical. Two writers have made interesting suggestions of this kind that deserve reassessment. In an extensive paper, Jeffrey Martin (1997) notes that ‘the pro-cesses of mindfulness have been tacitly contained in Western psychotherapies all along’ (Martin 1997: 292). As a psychotherapy integrationist, he is keen to demonstrate that mindfulness could be a factor common to many therapies whose contribution is to optimise the opportunity for change within a therapy. He believes this took a consistently different form in psychoanalytic and cognitive-behavioural psychotherapies. In elaborating this, he does tend to work from idealised models of either. In writing about mindfulness, he is also heavily influenced by Ellen Langer’s cogni-tive conception, in which mindfulness is identified with the capacity to shift one’s mindset easily between multiple perspectives (Langer 1989) rather than Buddhistic ones.

Martin identifies the psychoanalytic position with the ‘open-form attention’ that is achieved by following Freud’s injunction. Most interestingly, he likens the shift in personal perspective that this requires from the analyst with the ‘decentering’ that Safran and Segal (1990) saw as an important therapeutic objective in cognitive therapy, one whose role was enhanced in MBCT. Martin was sensitive to the ambivalence of how the movement of stepping out of usual perspectives could apply to either therapist or patient, with both needing to set aside a wish for mastery and replace it with what he calls ‘fresh awareness’. He sees verbal interpretations of unconscious conflicts or transference as an aspect of this, by shifting a patient’s centre of awareness, so that the overall contribution of mindfulness here is ‘to help create an interval of time wherein Bill can view his landscape more intentionally rather than simply react’. This is contrasted with what Martin calls ‘focused-form attention’, seen as necessary for insight to be translated into action.

The implementation of focused-form attention in the present moment utilizes the insight that was previously acquired within the psychodynamic orientation, and like a catalyst, helps convert it into action through the employment of cognitive-behavioral methodology.

(Martin 1997: 305)

Focused-form attention brings about deautomisation by the interruption of, or disidentification with, automatic sequences. Martin comments, ‘Through repeated focusing of mindfulness attention, more adaptive and previously less dominant forms of experience are reinforced’ (305).

How valid is this attempt to polarise the two approaches in terms of different attentional strategies? The relationship between insight and action in psychodynamic therapies is a hugely important one, but Martin’s cognitivist preoccupations do not let him follow Safran’s own views here (Safran 1989). Safran clearly differentiates intellectual insight, which may or may not inform action, from the immediate insight that is often available at a non-verbal somatic level, particularly in transferential situations, that does prompt new forms of action. Martin seems to see focused-form attention as a kind of searchlight that allows an operation to be performed following additional voluntary actions, giving examples that include cognitive restructuring. The thrust of the work of Teasdale, Segal and Williams has been to cast doubt on the effectiveness or the usefulness of operations to replace one set of thoughts by another. By talking instead of ‘differential activation’ of entire modes of processing (e.g. Teasdale 1999), they have placed ‘decentering’ centre stage in the operation of cognitive therapeutic approaches. These objections need not detract from the simple identification of broad, evenly receptive awareness with psychodynamic work, and narrow-focused attention with cognitive-behavioral approaches, although Speeth describes how attentional shifts across the full range of breadth of focus occur within ordinary psychotherapeutic work, commenting that the extremes of what she calls ‘focused’ and ‘panoramic’ attention ‘must be seen as more heuristic than natural categories’ (Speeth 1982: 145).

Finally, following Deikman, Segal and others, Martin’s invocation of a process of ‘deautomisation’ as typical of CBT needs careful consideration. His instrumentalist approach suggests that focused attention is a precursor to another operation that will make the difference. The implication is that, in order to change a bad habit, it is necessary first to see things in such a concentrated way that the steps are clear, before deliberately changing the steps. In this sense, the cognitive restructuring that he sees as a key technique is like a musician playing a musical passage very deliberately and slowly in order to change the fingering pattern they use, or a motorist driving very slowly in order to master the actions necessary to drive a car whose steering wheel and instruments are on the opposite side to the one with which they are familiar. In either case, it seems attention has to be accompanied by deliberate, corrective actions. This does not really deal with the possibility that awareness is sufficient in itself for deautomisation – that links within series of actions are not only recognised but are attenuated at the same time by the attentive process. This would represent another way in which mindfulness introduced something that was common across therapeutic processes under different models, but which was really not adequately explained by current paradigms.

Future developments

It is possible that mindful therapy is a reformative development, tapping a therapeutic dimension that is not adequately realised within current maps of the therapeutic landscape. It is also possible that it may prompt some revision of the maps. While it is too early to assess this, some future directions of travel can be sketched. Mindfulness interfaces with three other broad currents in psycho-therapeutic thinking and practice, each of which is already challenging the traditional divisions in their own right. These are interest in the brain, interest in the body, and interest in what I prefer to call the transpersonal.

Brain therapy

There is now enormous interest in biological substrates that are potentially associated with the developmental difficulties with which psychotherapists are called upon to work. There has been great interest in the topic of affect regulation, Schore (1994) using it to organise his entire review of evidence for functional hierarchical relationships within the brain. Their great sensitivity to attachment experiences during early development accounts for variations in the capacity to regulate affects in adulthood. Accordingly, the success of therapeutic approaches in later life will depend on how well such failures in early attunement are addressed, a theme elaborated also by Fonagy et al. (2002).

While there is no shortage of colourful hypotheses about the biological basis of therapeutic action, in vivo investigations of the effects of therapy being provided for people with mental disorders remain rare (Mace 2003). Linehan (1993a) has underlined the potential importance of mindfulness in modulating affect, and this could provide the kind of specific therapeutic effect that is necessary to demonstrate clear correlations with brain processes. As recordings grow in sophistication, it is likely that these efforts will be limited by continuing conceptual confusions concerning the scope of mindfulness, to the point where neurobiology might help to demarcate truly mindful awareness. For instance, this could be a state in which, apart from increased coherence, there is a bilateral increase in the power of alpha and theta as well as fast beta waves relative to the ordinary waking state. This would contrast with other meditative states, in which there is more exclusive enhancement of one of these bands and/or delta activity.

The body

It is clear from both the traditional literature on mindfulness and the experiences of practitioners that mindfulness depends on awareness of our embodiment. Beyond the range of ‘mindful’ experience, it is rare for accounts of other meditative or ‘peak’ experiences not to involve distinctive bodily sensations.

Despite Freud’s injunction to remember that ‘the ego is a body ego’ (Freud 1914b), psychotherapy has been quite ambivalent about bodies – whether the patient’s or the therapist’s own body. Psychoanalysis has been plagued by the perceived need to recoil from and reject any somatic elements in technique – from Freud’s decision to stop touching patients and the condemnation, persecution and excommunication as heretics of somatically focused analysts such as Ferenczi and Reich. Even today, psycho-analytic organisations can professionally penalise individuals who show an interest in the bodily contribution to memory and unconscious life. This has led to a situation in which therapies with an overt somatic focus have been seen as less than respectable and as requiring a separate professional structure.

Rather than encouraging direct manipulation, some therapies, such as Gendlin’s (1996) focusing, have developed techniques for deliberately directing attention toward internal sensations in emotionally charged areas such as the chest and the solar plexus in order to activate feelings and images so that these come more fully into awareness. While he was aware of parallels with meditation, Gendlin did not refer directly to mindfulness within this attention-focusing technique. Yet, it has much in common with the kind of mindful therapy techniques that have been reviewed here. There seems to be considerable potential for their combination, not least in the capacity of mindfulness to contain as well as unlock somatically linked experience.

There is also a split between the content of psychotherapeutic training, and therapists’ declared attitudes to the body, and the considerable use they make of it in practice in the course of their work (Shaw 2004). This is starting to change as some therapists are becoming more willing to cross professional boundaries, seeing bodily experiences as central to psychotherapeutic work rather than as a dispensable epiphenomenon. Growing interest in mindfulness may help to reorganise the very disparate field of ‘body therapies’ by discriminating between those that depend upon physical intervention and those that do not, but pay very close attention to the body. 

The transpersonal

I use the term ‘transpersonal’ to refer to those aspects of our minds that are not exclusively dedicated to defining and pursuing individual needs and interests. It seems preferable to ‘spiritual’ and its variants, none of which seem to come without all kinds of connotations that are rarely shared. (In any case, talk of soul or spirit seems ill-suited to the agnostic and antiessentialist context in which mindfulness arose.) Whatever term is used, it does seem that an interest in personal transcendence is currently fuelling the greatest resurgence of transpersonal thinking in psychotherapy since Jung.

Buddhist thought and practices have been influential in other ways than the development of mindful therapies, leading to innovations which complement mindful practices. One example is the direct harnessing of the transpersonal affects of the ‘perfections’ or brahmaviharas, as in the meditative cultivation of compassion within compassionate mind training (Gilbert 2005). This is a method of neutralising the toxic self-attacking that can be very prominent in people having a strong sense of shame who are liable to depression. Another practice, aiming to put understanding of no-self or anatta into effect, is the development of therapeutic strategies to reduce destructive egotism through recognition of its illusoriness (Leary 2004). 

In the field of psychotherapy, while interest in the transcendent functions predates Freud, they, too, have been split off from the time of Jung, attracting a notoriety among the most institutionalised therapies that is reminiscent of the history of somatic therapies. Again, there are contradictions between official attitudes and individual practitioners’ actual interest in the transpersonal (cf. Simmonds 2004), meaning that here, too, therapists often seamlessly integrate a transpersonal dimension within their practice without necessarily drawing attention to the fact.

The need for in-depth case studies

Observations such as these may be interesting, but are unlikely to bring about change by themselves. Wherever psychotherapy is headed, it is an arena where progress is ultimately made by the demonstration of a technique’s value with real patients, through documented case histories. These reports need to be sufficiently detailed so that the steps are clear, and readers can form their own view on the relationships between process and effects. This has been as true for the major innovations that followed psychoanalysis as for Freud’s own example. Mindfulness-based psychotherapy is unlikely to be an exception. It is also true that this basic requirement to provide persuasive case histories is under many threats at present. These range from clinical journals that simply deem all case reports unworthy of their consideration, to editors who take such a zealous attitude to anonymisation that most published reports are automatically fictionalised beyond the point that accurate clinical inferences can be drawn from them, irrespective of the wishes of those they concern.

When it comes to clinical reporting, mindful therapies are faced with a similar paradox to the one facing scientific investigation of mindfulness, outlined in the previous chapter. A thorough examination of mindful psychotherapy requires methods that are appropriate and sensitive to its process. Some crucial clinical questions – for example, how far therapists need to embody mindfulness in order to foster mindfulness in their clients and for this to be therapeutic – have already been identified. Whatever third-party investigations might be set up to resolve them, psychotherapists are likely to seek additional evidence of a different kind. For a case history to illuminate the process of a mindful intervention, it would need to provide in-depth descriptions of a therapist’s awareness and of the ways in which it fluctuated, alongside a detailed account of the internal changes experienced by the patient (or patients). This would depend upon unusually detailed, contemporaneous records concerning all parties. The paradox at present is how the few published descriptions of completed therapies using mind-fulness have continued to minimise detail and permit only very general inferences. The need for truly comprehensive case reports may be the most immediate challenge for the field to overcome if it is to advance its understanding and engage the interest of greater numbers of psychotherapists.


Mindfulness is integral to well-established forms of psychotherapy, including psychoanalytic psychotherapy, as well as an ingredient in newer interventions that were designed to help patients become more mindful. Mindfulness can therefore be an attitude that is brought to bear on work within an established framework, as well as something that is taught in order to bring about specific desired effects. As overtly mindfulness-based interventions have been used with people with mental health difficulties, they have taken on more of the character of a therapy than an educational or coaching intervention. Perceived limitations in some clients’ ability to engage with traditional meditative techniques for developing mindfulness have led to the development of alternative exercises that might be less demanding but which are therapeutically beneficial. Intervention packages have continued to be adapted to address specific mental health problems through the other elements they include alongside some training in mindfulness. The field may be being held back by the relative absence of case reports that allow the dynamics of awareness to be followed in actual therapies. The next chapter discusses in more detail adaptations made in the treatment of specific mental disorders with mindfulness-based interventions.

Reference and Further Reading

  1. James, W. (1927) The Principles of Psychology (3rd edn). New York: Holt. Johnstone, L. and Dallos, R. (eds) (2006) Formulation in Psychology and Psychotherapy. Hove: Routledge.
  2. Freud, S. (1912) Recommendations for physicians on the psycho-analytic method of treatment. In Standard Edition, vol. 12, London: Hogarth, pp. 109-20.
  3. Epstein, M. (1984) On the neglect of evenly suspended attention. Journal of Transpersonal Psychology, 16, 193-205.
  4. Bion, W. (1970) Attention and Interpretation. London: Tavistock.
  5. Horney, K. (1951) The quality of the analyst’s attention. In Karen Horney: The Therapeutic Process (ed. B. Paris), New Haven, CT: Yale University Press, pp. 186-90.
  6. Symington, J. and Symington, N. (1996) The Clinical Thinking of Wilfred Bion. London: Routledge.
  7. Epstein, M. (1996) Thoughts Without a Thinker. London: Duckworth.
  8. Coltart, N. (1992) Attention. In Slouching Towards Bethlehem (ed. N. Coltart), London: Free Association Books, pp. 176-93.
  9. Coltart, N. (1998) Slouching towards Buddhism: in conversation with Anthony Molino. In The Couch and the Tree (ed. A. Molino), New York: North Point Press, pp. 170-82.
  10. Epstein, M. (1999) Going to Pieces without Falling Apart. London: Thorsons.
  11. Kabat-Zinn, J. (1990) Full Catastrophe Living. New York: Delta.
  12. Mace, C. (ed.) (2007) Mindfulness in psychotherapy: an introduction. Advances in Psychiatric Treatment, 13, 147-54.
  13. Bishop, S. (2002) What do we really know about mindfulness-based stress reduction? Psychosomatic Medicine, 64, 71-84.
  14. Baer, R. A. (2003) Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice, 19, 125-43.
  15. Grossman, P., Niemann, L., Schmidt, S. et al. (2004) Mindfulness-based stress reduction and health benefits: a meta-analysis. Journal of Psychosomatic Research, 57, 35-43.
  16. Marcus, M., Fine, P., Moeller, F. et al. (2003) Change in stress levels following mindfulness-based stress reduction in a therapeutic community. Addictive Disorders, 2, 63-8.
  17. Davidson, R., Kabat-Zinn, J., Schumacher, J. et al. (2003) Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-70.
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