In what ways do these different therapeutic uses of mindfulness affect mental health? Different approaches have different kinds of aims. None are necessarily identical with the intentions that motivated the traditional practices. In many cases, goals that were quite specific, problem-orientated, and measurable have been chosen as the rationale of the mindfulness-based treatment. Conventional wisdom has it that psychological treatments, like physical ones, are used to treat mental disorders, such as major depression, obsessional compulsive neurosis, or schizophrenia. People diagnosed as suffering from depression must need an antidepressant or a specific psychological treatment for the condition.
However well this may work in the prescription of physical treatments when it comes to psychotherapies, this strategy is suspect on several counts (cf. Guthrie 2000). The simplest is that there are likely to be much more reliable factors that distinguish the people who are likely to benefit from a particular intervention from those who do not than their diagnosis.
Mindfulness Based Cognitive Therapy
The experience of mindfulness-based cognitive therapy (MBCT) could be taken as a case in point here. The very rigorous conditions under which it was evaluated mean it is possible to discriminate with considerable precision when it appears to be clinically useful and when it is not. Indeed, if the results from the original trial are simply used to answer the question, `Is MBCT helpful to people with a diagnosis of depression?’, the answer would appear to be `no’ because the numbers who did not benefit dilute the impact of those who did. More people would have had to be included in the study for the latter’s positive influence to be convincing. It is also apparent how misleading it would be to say the study shows the intervention is not effective. The question really needs to be, `When is MBCT helpful?’, in which case the consistent answer has been, in that study and in a replication study (Ma and Teasdale 2004), ‘when people have had three or more episodes of depression’.
In practice, specific data allowing this kind of question to be answered are rarely available. What is always available is some account of what the users of treatment were seeking relief from, and a professional’s view of how it was expected to help. These objectives are often more specific than the terminology of diagnosis, being likely to be influenced by a mixture of theoretical considerations about how a treatment is supposed to work, as well as clinical experience (personal or reported) of what it actually achieves.
It is possible to categorize the likely impacts of mindful therapies in a way that takes this into account. The following schema, which is illustrative rather than exhaustive, has basic units that are also closer to subjective experience and to what people are likely to say they want help for
|Mood||anxiety; depression; anger|
|Intrusions||ruminations; hallucinations; memories|
|Behaviors||binging; substance dependence;|
|physical self-harm; violence|
|Problems of relating||negative attitudes to others; lack of|
|Problems of self||self-consciousness; poor self-esteem;|
In the remainder of this article, we shall be looking selectively at the contribution of mindfulness to the alleviation of mental disorders. Individual examples are likely to involve at least one, and often more than one experienced difficulty from this list. While the history of using mindfulness with a range of somatic conditions, from fibromyalgia to psoriasis, will not be discussed here, it would be exceedingly dualistic to insist on a sharp division between the two kinds of illness. In the previous chapter, the holistic origins and aims of MBSR were mentioned. When it was used in a study of anxiety disorders published in a psychiatric journal, the subjects being reported on were medical patients attending a general hospital (Kabat-Zinn et al. 1992). It was one of many papers that have noted the high psychological morbidity among such patients, although those that go on to describe acceptable and effective treatments are relatively rare. The impact of MBSR in medical settings poses interesting questions about how far it is possible to detach effects on physical and mental well-being. In the qualitative study described in Mindful Therapy, focus group participants described personal experiences in the face of pain and illness. They agreed that its helpfulness in overcoming anxiety and fear had been critical in those situations. The attempt to concentrate exclusively on mental ill-health in this chapter may therefore seem artificial.
Pathological anxiety is recognized by the appearance of physical as well as psychological symptoms. The physical symptoms include sweating, shortness of breath, palpitations, and nausea; the psycho-logical ones are typified by worry, fear for the future, and dread. These occur in many permutations, with a particular combination of physical and psychological anxiety being typical for each individual, and likely to be repeated as anxiety recurs. When anxiety takes the form of acute panic attacks, the bodily signs can become the basis for conscious fears, such as a belief that the sufferer is about to collapse or even die. Diagnosticians look for the specific features of phobias (anxiety associated with a particular object or situation, linked to their avoidance), panic attacks (acute and disabling attacks of anxiety with a considerable physical component), and the obsessions and compulsions that are characteristic of obsessional compulsive disorder. If none of these are prominent, the anxiety may be attributed to generalized anxiety disorder (GAD). It is likely to be harder to attribute the anxiety to particular precipitants with GAD, while the prognosis from all forms of treatment is also relatively poorer. In many situations, anxiety is inevitable: it is as abnormal to fail to feel it as to feel it to an extent that is truly handicapping. Health will lie in a capacity to tolerate normal levels of anxiety rather than its banishment.
Once mindfulness-based stress reduction (MBSR) had been developed, anxiety was the first specifically mental health issue to be examined. Kabat-Zinn et al. (1992) measured the symptomatic impact of MBSR on symptoms of anxiety (including panic attacks) in people who had volunteered to undergo the usual training package at general hospitals. (There was no control group.) They all, therefore, had concomitant medical conditions, many of them being likely to be sources of anxiety in themselves. Significant improvements in measures of anxiety (and depression) were recorded by the end of the program. They were sustained at a follow-up 3 years later (Miller et al. 1995) when the majority of people involved in the follow-up had continued to practice mindfulness since its conclusion. (Numbers were too small to permit analyses of the possible effect of the regularity or amount of practice.) The authors have emphasized the differences between this approach and traditional cognitive therapy. As well as pointing to the non-cognitive nature of the somatic focusing on which it relies, they remind us that the intervention was never intended to change or ‘restructure’ particular thoughts. The process of engagement had been quite different, following which MBSR was seen as setting a broader kind of inquiry in the process. Its consequences include, but were not restricted to, anxiety reduction. Technically, the study had not included an independent marker of ‘mindfulness’, and it is, therefore, possible that any of the contextual factors that the authors have highlighted could have contributed to the observed clinical improvements.
Observations made by this group on another group of medical patients also have considerable implications for the future use of mindfulness-based interventions in people with anxiety. After selecting 74 people from a cohort whose anxiety levels were above average, Kabat-Zinn et al. (1997) found that a subgroup of nine had predominantly cognitive symptoms of anxiety. In 20 others, anxiety had a heavily somatic expression, being mixed in the remainder. The investigators enquired systematically into the preferences of the 29 people whose expression was clearly cognitive or somatic, for different techniques within the MBSR program. Yoga was seen by the investigators as the most somatically focused exercise, and sitting meditation as the most cognitive, with the body scan as intermediate between the two. Whereas Kabat-Zinn and colleagues had hypothesized that people with cognitive symptoms seek and prefer cognitive techniques for anxiety reduction, they found the opposite. The nine participants with a cognitive pattern of anxiety tended to prefer yoga to sit meditation; the 20 with marked somatic anxiety symptoms, the reverse. The benefits of the programme were broadly comparable for all groups. This finding supports the introduction of a variety of techniques within the mindfulness training programme and the encouragement that is given to participants to make a personal selection from these. The complementarity this study indicates between presenting symptoms and mindfulness methods has not been formally tested in a comparative study of outcomes.
No formal studies of mindfulness-based interventions appear to have been conducted specifically on people with phobias, although mindfulness was one component of the work of Schwartz et al. (1996) on the obsessional compulsive disorder. Although effective, evidence-based treatments exist for both of these conditions already, it would be reasonable to expect mindfulness to potentiate the impact of exposure-based treatments if it helps people to overcome experiential avoidance.
Generalised anxiety, however, and the incessant conscious worry that goes with it, has been more refractory to other treatment approaches. Roemer, Orsillo and colleagues at Boston have given considerable thought to the functions of worry in devising a multicomponent, 16-week treatment programme that combines features of MBCT, DBT and ACT in the treatment of generalised anxiety. Preliminary results from a randomized controlled trial (Roemer et al. 2006) suggest that it is at least as effective as existing cognitive treatments, but it will only be possible to consider the role of individual components once the study is complete.
The mood changes of depression have received considerable attention. Depression is recognized as a clinical problem once a tendency to sadness, tearfulness, and apathy starts to take on a life of its own, and becomes a serious obstacle to getting on with ordinary activities. As well as reduced interest in things that ordinarily bring pleasure, including eating and sex, sleep is disrupted and is less refreshing. A daily pattern of mood change may become evident, with the greatest intensity of depression at a particular time each day (especially early in the morning). Thoughts are consistently pessimistic with ideas about oneself and the past becoming negative and coupled with a tendency to dwell on the past rather than the present or the future. Concentration is impaired, with greater difficulty in maintaining attention – an effect that seems closely related to sleep disruption. Progression of these features can lead to a state of profound slowing of movements and speech; loss of interest in others and in ordinary routines; and increasingly fixed ideas of failure, hopelessness, and possibly guilt. These may be coupled with thoughts of death, self-harm, and suicidal acts.
Links between depressed mood and attentiveness have long been recognized. The impairment of concentration that is frequently reported commonly refers to an inability to maintain concentration (and short-term memory) through ordinary tasks. Patients may take much longer than usual to read a newspaper article, and then complain they cannot recall anything they have just read. Apart from a general apathy, the withdrawal of interest from others during depression has been noted and was the basis of Freud’s psychodynamic observations concerning the narcissistic basis of melancholia (Freud 1920). Freud describes how attention is withdrawn from others in the real world in favor of an internal object that is not only felt to be absent but, like a missing tooth in the mouth, becomes an overriding preoccupation. Another important observation concerns the apparent paradox of depressed people’s visible lethargy and the restlessness of their thinking processes. The persistence of depressive thinking once symptomatic remission has been otherwise achieved has been an important aspect of the ‘residual symptoms’ of depression that have been shown to identify people at greater risk of future relapse (Fava 2000).
Although both cognitive therapies based on the work of A. T. Beck and interpersonal therapy (IPT) have been successful in trials in the treatment of individual episodes, they have not necessarily prevented the increase in the risk of becoming depressed that is seen with each successive episode. The relative risk of relapse in depression for a given number of past episodes is also known to be greater among people whose recovery is incomplete, leaving them with residual symptoms such as the social withdrawal and depressive attitudes that Fava described. This indicates that a psychological process could be directly linked to the continuing vulnerability to relapse.
Unipolar depression was taken by Teasdale, Williams, and Segal as the paradigm of a common, chronic, relapsing mood disorder that might be helped by mindfulness-based treatment. As mentioned in Mindful Therapy, their MBCT was effectively designed as an intervention package for people who, while currently well (and enjoying unimpaired concentration), were at risk of further relapse. Two well-matched cohorts of people who had been depressed on at least two occasions as adults were randomized to treatment with MBCT or treatment as usual. Although the study was designed to determine whether there was a difference between the capacity of these treatments to prevent future relapse, it did not lead to a simple `yes’ or `no’. Instead, initial stratification of the sample into a majority who had been depressed three times or more, and smaller groups in each condition who had been depressed only twice, led to separate reporting of the results for each subgroup. They have been dramatically different, with MBCT significantly reducing the risk of relapse compared to usual treatment in people having three or more depressive episodes, whereas there has been no different for people having only two past episodes in either the original study or a smaller replication study (Ma and Teasdale 2004).
It has been noted that the risk of relapse for patients receiving `treatment as usual’ is greater according to the number of previous episodes they have had. MBCT has the effect of keeping the risk of relapse stable among patients experiencing more than three episodes, however many episodes they have had. Moreover, the level at which it stabilizes is little more than where it ordinarily stands after two episodes with treatment as usual. This suggests that, whatever mechanism may be at play, MBCT effectively neutralizes a potent factor that otherwise increases the future risk of relapse.
The main trial sheds little light on this directly. (It was also so much in advance of its time that no measures of patients’ attainments in mindfulness in response to the training could be included.) However, all three principal investigators were distinguished psychopathologists who had already thought extensively about depression and the ways in which metacognitive changes could have observable clinical consequences. A sub-study conducted with the Welsh participants in the main trial also showed that MBCT reduced over-general autobiographical memory among such formerly depressed patients (Williams et al. 2000). In a parallel study on the participants from Canada and Cambridge, Teasdale et al. (2002) devised a marker of `metacognitive awareness’ that could be given to participants in both study groups after the MBCT subjects had received their intervention during the second year of the follow-up period. With it, Teasdale attempted to gauge the extent to which subjects would demonstrate what he calls ‘metacognitive insight’ when they are exposed to depressive thoughts following a negative stimulus. One explanation of why some people responds at such a juncture by relapsing into full-blown depression and others do not is that the relapses react to such depressive thoughts as if they were literally true and/or part of them. Non-relapses, using an ability to access a different metacognitive set, are much less troubled because, without having to rationalize or resist, they simply do not identify with the negative thoughts. However, instead of accessing responses to actual events, Teasdale’s test of metacognition elicited an autobiographical memory with a probe before recording the subjects’ account of their feelings. Independent raters then assessed the metacognitive awareness that was displayed.
The same instrument had been used to rate metacognitive awareness both before and after treatment of patients in another trial with residual depression by orthodox cognitive therapy (Paykel et al. 1999). They had shown a small but significant improvement in metacognitive capacity relative to patients who did not have the orthodox cognitive therapy. Despite methodological weaknesses, Teasdale concluded that the studies suggested not only that MBCT could exert its effects, as hypothesized, through changes in subjects’ relationship to cognitions rather than their content, but also that this might be an important mode of action of other forms of cognitive therapy in depression.
In clinical terms, the rationale of using mindfulness to prevent relapse of depression concerns the role of rumination or persistent and automatic elaboration of negative thoughts concerning oneself and how one should be. Rumination was identified as a factor in prolonging depressive episodes by Nolen-Hoeksema (Nolen-Hoeksema and Morrow 1991, 1993), being operationalized along with three other coping styles (distraction, problem-solving, and dangerous activities) in the Response Styles Questionnaire (RSQ) (Nolen-Hoeksema and Morrow 1991). The effect of mindfulness in reducing depressive ruminations appears to be robust, being replicated by Ramel et al. (2004). MBCT’s role in relation to depressive ruminations is hypothesized to bring about a general switch in ‘mental mode’. Accordingly, mindfulness brings about a ‘decentring’ in relation to each successive experience that is incompatible with the chain reactions characteristic of the ordinary mental mode. If depressive ruminations no longer receive the kind of reactive attention that allows them to amplify, the negative mood changes that are usually consequent on this will be prevented (cf. Segal et al. 2002: 75).
Anger and emotional regulation
Unwelcome emotion is far from exhausted by anxiety and depression, although these two are highlighted by conventional classifications of mental disorders. In psychotherapeutic practice, however, difficulty in controlling anger, internally or toward others, is a common complaint. It is interesting how prominent the topic can be in the self-help books renowned Buddhist teachers, such as Thich Nhat Hanh or the Dalai Lama, write for Western audiences (e.g., Lama 1997; Hanh 2002) while it receives little direct attention in the Western mindfulness literature. Yet empirical studies confirm that unresolved anger commonly underlies anxiety symptoms and depression (Bloch et al. 1993). Much practical therapeutic experience is summed up in Neborsky’s (2006) comment: `Studies of improvement [in intensive short-term psychotherapy] show ability to access sad feelings reduces symptoms and ability to access anger correlates with character change’ (Neborsky 2006: 526).
Excessive and uncontrolled anger is a recognized feature of borderline personality disorder (BPD). A simple rationalization of this would be to see it as one aspect of general impulsivity, in which urges to gratify sexual, oral, or attachment needs are relatively unrestrained, with violence, promiscuity, clinging, bingeing and substance misuse being more likely. However, the concept of emotional regulation has become popular as a way of accounting for emotional volatility and evident difficulty in containing aggression by attributing it to failures in neurodevelopment as well as early psychological care (Schore 1994). This has been influential in the treatment philosophy of dialectical behavior therapy (DBT) (Linehan 1993a) and the importance that education has assumed within the model as part of the process of validating clients’ experiences. Mindfulness has been used as the key to successful intervention in reducing aggression on the part of a learning-disabled adult (Singh et al. 2003). As the paper’s colorful title suggests, this was through a deliberate deflection of attention when angry feelings arose to the soles of his feet.
Behaviors: binge eating
Mindfulness has been incorporated into two treatments that have been used with demonstrable success with people who binge. DBT has been used primarily with binge eating disorder rather than bulimia nervosa (Telch et al. 2001). The adaptation of DBT has involved reorganisation of group training sessions, with down-playing of the personal therapeutic component. Core skills in mindfulness, emotion regulation, and distress tolerance are taught in sequence. Although one guiding rationale for this was that bingeing behaviour is a means of affect regulation, the female subjects evaluated after treatment showed no real change in their affective state, although they made considerable improvements in bingeing behaviour, largely maintained at 6-month follow-up. It has appeared that patients’ ability not to react to negative affect was strengthened, indicating the importance of the cultivation of mindfulness within the programme. However, no independent measures of mindfulness have been used in the course of evaluation.
Mindfulness-based eating awareness training (MB-EAT) (Kris-teller and Hallett 1999) has also been used with binge eating disorders. Each has adopted a different rationale and modified its process for use with this client group. Kristeller and Hallet adapted MBCT to highlight cognitions concerning eating behavior. Clients believed exercises focusing on these were particularly helpful. Ana-lyses of therapeutic effects has suggested that enhancing sensitivity to internal satiety cues is particularly important, a finding that has subsequently influenced the model. The introduction of meditation to foster feelings of forgiveness (to counter the feelings of guilt commonly encountered with this population) has also been favorably received. Baer and colleagues (Kristeller et al. 2006) have recently reported that, when successful, MB-EAT increases clients’ mindfulness and decreases their belief that they would lose control if they refrained from bingeing.
A different mindfulness-based approach has been used with considerable success in the management of substance misuse. Like the 12-step programmes within Alcoholics Anonymous and Narcotics Anonymous, it demands a different sort of commitment than most therapies, aiming to get to the roots of someone’s motivation and dependence. Marlatt et al. (2004) have actively arranged pro-grams whereby people with severe dependence can enter a residential programme based upon a very traditional Buddhist meditation retreat. This involves living alongside others in silence, except for interactions with the teacher, and meditating from 4 am until midevening through a 10-day period. The meditation, based upon the Burmese vipassana school of S. N. Goenka, involves exclusive attention to the breath over the first 3 days before the introduction of mindfulness to body sensations. This is interspersed with daily `dhamma talks’, in which recorded seminars covering the basics of Buddhist philosophy and the rationale of the meditations are screened. As might be inferred from Chapter 1, these provide an analysis in which craving is a virtually universal habit that cannot be overcome directly because of the nature of mental proliferation. However, it can be reversed through a gradual psychological purification that the meditations facilitate. Although the spartan and intense regime is unusually challenging, Marlatt has been pleasantly reassured by the determination that most entrants to the programme have shown. He has also organized treatment programmes of this kind within custodial institutions: the immediate results in terms of inmates’ behavior change have meant that the considerable disruption of running such a programme within a secure institution has been willingly tolerated by the authorities.
The other approach, of mindfulness-based relapse prevention, has involved direct adaptation from MBSR (Witkiewitz et al. 2005), some of the experiences in developing MB-EAT being taken into account. The use of mindfulness to enhance internal sensitivity as well as a more disengaged interest in urges to use substances follows naturally from these authors’ long-standing interest in relapse prevention, and the use of mindfulness to facilitate early recognition of individual relapse signatures. The use of mindfulness-based group treatments with attenders of a residential programme has been of additional interest, as the immediate impact of the pro-gramme on mediators of the stress response has been demonstrated through significant reductions in salivary cortisol (Marcus et al. 2003).
The impulsive and auto-aggressive actions that lead to drug overdose and deliberate self-injury can be considered separately from the mood changes of depression. These behaviors are common among people diagnosed with BPD but have also proven to be the most tractable aspect of that syndrome when DBT is offered. The finding of a consistent and lasting reduction in suicidal behavior accounted for much of the interest with which the first evaluation was received (Linehan et al. 1991) and has remained when the evaluation has been more rigorous and statistically robust (Linehan et al. 2006).
The clinical importance of suicide prevention has also served to refine ideas on the probable contribution of mindfulness here in terms of its action and timing. Williams and Swales (2004) refer to DBT as a ‘stage one’ treatment, offering practical support and techniques for regaining personal control when suicidal urges are acute. Other techniques are combined with mindfulness in order to bring this about. However, they feel that more purely mindfulness-based measures are likely to be helpful subsequently. People who are prone to suicidal acts are prone to distorted evaluations of their situation, especially where perceptions of entrapment are concerned. (It appears that cognitive habits rather than events have more and more of a role to play as suicidal behavior becomes more chronic.) These authors hypothesize that the capacity of people to resist suicidal impulses rationally is also challenged because their problem-solving capacity is impaired through a combination of over-general memory and depressive rumination. The kind of mindfulness practice that MBCT supports, in robbing depressive rumination of its potency through differential activation of a decentred mode of experiencing, would therefore have significant potential in preventing future suicidal actions. This important hypothesis is being evaluated in clinical studies.
Intrusions: hallucinations and delusions
People diagnosed with psychotic illnesses frequently suffer from mental intrusions in the form of hallucinations (fully formed sensory experiences that do not correspond with other people’s perceptions of external events) and delusions (recurrent thoughts that are bizarre or irrational but which the person is inclined to believe). These can be the source of a good deal of distress, as can the poor circumstances in which many people having illnesses like schizophrenia live. Previous treatment strategies of cognitive-behavioral therapy have tended to concentrate either on reduction of these symptoms or on the enhancement of coping skills that would reduce distress and improve functioning by dealing with concomitant problems with adjustment, self-image, social functioning, and motivation. Two different mindfulness-based strategies have now been used with some success with this patient group, the differences between them mirroring the contrast between those earlier approaches.
In the UK, Chadwick et al. (2005) have used a kind of mindfulness training, modified to their patients’ circumstances, based on breathing meditation. After an initial session in which attention is focused by a brief body scan, mindfulness of breathing is used in sessions and between them to develop patients’ ability to reduce anxiety prior to attempts to face negative, intrusive experiences directly and with acceptance. Because there can be inaccurate beliefs about the experiences (for instance, that they are caused by another, persecutory, person), acceptance here will involve recognizing their transcience, and letting them pass without getting caught in ruminations or judgments about them. The intervention has been offered during short sessions (no longer than 90 minutes including a break) with no more than 10 minutes’ meditation practice at a time. These are interspersed with regular comments and instructions so that no extended silent periods are imposed. Home practice is optional, and audiotapes are supplied so that it, too, would not be entirely silent if attempted. The sessions also include didactic material about aspects of mindfulness, such as letting go, how to use them in specific situations, and attempts to use mindfulness with difficult experiences are discussed at the start of the next session. The first 11 people to complete such classes have been evaluated for symptom changes (significantly improved) and their impact on their ability to use mindfulness (using the Mindfulness Questionnaire; cf. Chapter 2). This indicated a greater learned ability to use mindfulness with distressing thoughts and images than with voices. The approach was clearly new to all concerned but did not appear to increase their distress, while replies to a third evaluation measure indicated that they saw mindfulness as the most active ingredient in the whole group experience.
All components of ACT were brought into play in work that used it with inpatients having chronic psychosis (Bach and Hayes 2002; Bach et al. 2006). Commitment to work toward agreed goals based on patients’ values was introduced from the outset, while no view was expressed on the desirability of symptomatic change. Without any formal meditative practices, patients would be encouraged to experience intrusive thoughts and sensations as they actually were, rather than in terms of ideas that patients had about them. To do this, classic ACT exercises, such as using the image of ‘soldiers (moving) in a line’ to practice disidentification from thoughts (which can then be carried away on the soldiers’ rifles), are introduced. Especially if there is evidence of concomitant cognitive impairment, these may be explained and rehearsed in a more literal fashion than with other patients, such as a demonstration with toy soldiers. There is also an interest in looking at delusions in terms of their possible function in relation to other aspects of the patients; that is, how they may serve as a means of experiential avoidance in themselves. One of the characteristic features of ACT is the interest in ‘self as context’. In the case of people with psychosis, this may involve the encouragement of verbal self-description in order to enhance self-awareness, which is also more likely to be impaired than among other groups. Evaluations of this intervention included a randomized trial that demonstrated longer intervals before readmission compared to treatment as usual, although there was no symptomatic improvement (Bach and Hayes 2002). The study was repeated to ensure professional attention was equivalent between groups, with a positive trend toward reduction of risk of rehospitalization and clear evidence of symptomatic change (Bach et al. 2006). It is obviously harder to assess the contribution of `mindfulness’ in a complex intervention of this kind, and no independent assessments of patients’ mindfulness have been made.
Trauma is commonly associated with intrusive experiences in the form of extremely vivid memories, which appear suddenly while waking or asleep, and which fail to change from appearance to appearance. Other common, subsequent effects of trauma include phobic anxiety, amnesia, emotional and bodily numbing, and high states of arousal associated with vigilant attention in which the horizon is being continually scanned for signs of further danger. One definition of a traumatic experience is one that ‘defines the way people organize their subsequent perceptions’ (Van der Kolk 2002: 60). Van der Kolk is referring to the domination of experience by traumatic memory to the extent that it is clear both to sufferers and to an observer that their perception is dominated by their past because of its content, focus, and the habitually fearful reactions that meet it. (This is a most interesting definition in the light of the traditional Buddhist psychology discussed in Chapter 1. According to that, all perceptions are likely to structure future ones through conditioning!) ‘Trauma’ is, therefore, a question of degree, with some perceptual reorganizations being more evident than others.
Practically speaking, trauma is a hugely important subject. It has been said that the final measure of any doctor is how well they help others cope with pain. Trauma is a similar test for any psycho-therapist. It is one that, while instrumental in bringing many psychotherapeutic innovations to broader attention, from psycho-analysis through behavior therapy to eye movement desensitization and reprocessing (EMDR), no one has necessarily mastered. And there is not yet a widely accepted mindfulness-based treatment for trauma. A recent book on mindfulness and psychotherapy (Germer et al. 2005) has only three pages on the subject, not all of those strictly about trauma. Yet, not only is trauma common, but it is also a major issue in the use of mindfulness-based training. Past traumatic experiences that have been coped with by suppression are likely to be reactivated through exercises in which subjects are invited deliberately to turn their attention inward. This is especially likely because of a tendency for memories of traumatic events to have been associated with physical sensations. When deliberate, focused attention is moved around the body, relative anaesthesia can give way to re-experiencing these sensations, with a return of the strong affects and images accompanying the original traumatizing experience. This has implications even for non-clinical settings. Many teachers offering classes in mindfulness techniques take care to check whether prospective participants have a history of trauma. When offering a sample taste of mindfulness to a group of conference attendees or colleagues, some teachers prefer to use a form of sitting meditation rather than an exercise such as Kabat-Zinn’s `body scan’, in which focused awareness of all areas of the body is invited. Within the clinical practice, the emergence of traumatic memories, whether expected or not, remains an area of considerable practical concern.
Where practitioners have helped others to reprocess traumatic experiences in the course of MBSR, they have made significant technical adaptations, such as helping their students at the outset to establish a safe place to which they can withdraw at any time at will. This may then be augmented by other devices that help people modulate their attention, rather than focusing it inward and exclusively on the traumatic material. These can include keeping the eyes open and keeping up a verbal commentary on the unfolding experience, as in ‘Now I’m doing x . . .’.
Mindfulness is of course also a core component of approaches such as DBT and ACT. Many people receiving DBT will be known to be traumatized. As in the discussion of acute suicidal behavior, both approaches, in mixing mindfulness with other, more overtly ego-supportive techniques, have the capacity to enhance current coping and prepare people for subsequent internal exploration before it is introduced. The same probably applies to the use of positive affect in Gilbert’s compassionate mind training (Gilbert 2005), another example that mindfulness practitioners are likely to follow in practice. It is not surprising that when new packages incorporating mindfulness have been designed to assist people presenting with trauma, they have included a full range of supportive as well as exploratory techniques. This is also true of Wolfsdorf and Zlotnick’s work with adult survivors of childhood sexual abuse, in which mindfulness is encouraged within identification and management of effects, particularly anger, while exposure to traumatic memories is resisted within this `stage one treatment (Wolfsdorf and Zlotnick 2001).
There are reports in the literature of the successful use of mindfulness training with traumatized patients (Urbanowski and Miller 1996). In them, so-called concentrative meditative techniques are regularly used to stabilize awareness, and to provide a way of returning to awareness of present experience through, for instance, awareness of the breath, before more free-ranging mindful awareness is encouraged. Indeed, several of the patients reported had considerable prior experiences of such meditative techniques that, it was acknowledged, helped to prepare them for experiencing traumatic memories during mindful therapy. The object of this was essentially to bring an accepting attitude in place of the aversion that had served to maintain the intensity and isolation of the memories. (The risk of introducing an open, mindful mindset was that, instead of feared memories taking their place alongside all the other components of experience, they would flood clients’ awareness to the exclusion of anything else, reinforcing their isolation and affective charge.) Practical precautions also included building up tolerance of distress, in the context of the helping relationship, before an attempt was made to focus inwards on painful areas by mindfulness techniques. However, what is striking in this account is the additional reliance on `light trance’ to introduce a sense of distance from the experiences that are then revived and worked through in the course of an intense dialogue between therapist and client. Whether the reported use of trance has made an active contribution here or not, it will not remove the sense of risk that attaches to mindfulness within the psychotherapy of trauma.
Finally, a distinctive, if relatively untested, therapeutic approach to trauma is offered by Ogden and Minton (2000). In what they term ‘sensorimotor psychotherapy’, they apply mindfulness with distinctive methods and objectives in order to reverse the dissociation they attribute the effects of trauma to:
Mindfulness is the key to clients becoming more and more acutely aware of internal sensorimotor reactions and in increasing their capacity for self-regulation. Mindfulness is a state of consciousness in which one’s awareness is directed toward here-and-now internal experience, with the intention of simply observing rather than changing this experience. Therefore, we can say that mindfulness engages the cognitive faculties of the client in support of sensorimotor processing, rather than allowing bottom-up trauma-related processes to escalate and take control of information processing. To teach mindfulness, the therapist asks questions that require mindfulness to answer, such as, ‘What do you feel in your body? Where exactly do you experience tension? What sensation do you feel in your legs right now? What happens in the rest of your body when your hand makes a fist?’ Questions such as these force the client to come out of a dissociated state and future- or past-centered ideation and experience the present moment through the body. Such questions also encourage the client to step back from being embedded in the traumatic experience and to report [instead] from the standpoint of an observing ego, an ego that `has’ an experience in the body rather than `is’ that bodily experience.(Ogden and Minton 2000)
In working with a traumatized patient, they constantly monitor the patient’s arousal. Whenever this seems likely to go beyond what is tolerable, further questions are asked to help the patient redirect attention to sensations, to the exclusion of feelings or thoughts. They acknowledge that a capacity to do this is crucial; otherwise, the patient’s personal tolerance is likely to be exceeded. This tolerance can be quite limited, and the impact of exceeding it is particularly destabilizing among people who are seen as internally disorganized. It could mean jeopardizing their existing ability to maintain awareness away from the traumatic content. The aims that Ogden and Minton describe, in developing an exclusive awareness of sensorimotor experience, seem very compatible with traditional accounts of ‘mindfulness of the body’. Their own procedure involves patients not only becoming fully aware of sensation at that level but also developing a vocabulary in their discussions with the therapist for this somatic experience, independent of feelings and interpretations. (These can be added later if necessary.)
Given the wealth of experience that is available from the meditative traditions in cultivating the power to observe selectively but minutely, and in naming experiences (as part of letting them pass), it is curious that these authors do not seem to have recommended any exercises to build up these capacities in advance of the therapeutic sessions. Their emphasis on maintaining a somatic focus, and on ensuring it is exclusive as a way of modulating affect where necessary, appears to be unique in the therapeutic literature. (As they point out, the somatic focusing advocated by Gendlin (cf. Chapter 3) invites simultaneous opening to somatic, emotional, and cognitive components. Their method is deliberately designed to avoid this.)
The approach represented by sensorimotor psychotherapy seems promising. Its emphasis on naming and describing aside, it has much in common with the kind of traditional vipassana techniques, emphasising mindfulness of the body, that Marlatt’s substance misusers were able to tolerate. Moreover, paying close and exclusive attention to bodily sensations as a way of inoculating against anticipated trauma was a personal strategy used by several of the participants in the exploratory focus group reported in Chapter 2. They were in no doubt that its success was greatly assisted by regular prior meditative practice. If sensorimotor psychotherapy proves to have consistent positive effects, these seem likely to be potentiated by regular practice of the key mindfulness skills it requires. It also deserves a more formal evaluation of its clinical effects.
Destructive relationships have been a traditional focus of psycho-therapeutic work, often in the context of other difficulties such as mood disorders. Mindfulness has been applied in both individual and couple treatments to address underlying difficulties. James Carson and colleagues have developed mindfulness-based relationship enhancement (MBRE) as a couple’s intervention that is based upon and retains the essential structure of MBSR (Carson et al. 2004). It differs from MBSR in the way, from intake onward, couples work together in going through the programme. The content is adjusted to facilitate this, with yoga sessions making use of conjoint exercises, and additional exercises being introduced to augment bodily sensitivity through mindful touch. A departure from the usual balance of exercises is an emphasis on the practice of loving-kindness in meditation throughout the course. At other times, attention to directing and receiving positive feelings with the partner is incorporated, as in a silent two-phase, eye-gazing exercise. Recognition and acceptance of feelings that are sensed in phase one are followed by a focus on `deep-down goodness’ within both parties in phase two. In Carson’s evaluation of this package, measures of acceptance, distress, and happiness within the relationship have shown changes in the expected directions. Their rating of `closeness’ did not appear to respond (Carson et al. 2006).
This domain of traditional psychotherapy is not one that has, as yet, been opened up through clinical demonstrations of a specific effect for mindfulness in areas of self-pathology. Indeed, although people with BPD or psychotic mental states have major difficulties with internal integration and their subjective sense of agency, there appears to be little evidence as yet that these aspects benefit directly from mindfulness-based approaches. Indeed, the weakness of self-structure can be seen as a contraindication for their use, as it is too many meditative practices. Versions of the classic advice to the would-be meditator, that the ego needs to attain a certain strength before it can be softened, can also be heard in clinical settings.
On the other hand, there are few psychotherapies that, unless they are extremely superficial, do not engage a complicated network of self-judgments and sensitivities that are inseparable from someone’s feeling of individuality. When these go on being elaborated as someone becomes very moody, withdrawn, fearful, or hyperactive in a way that makes others feel they must be ill, it makes the impact of what is happening worse. And it can make the person affected more likely to resist offers of help rather than welcoming them. In an apparently unassuming paper on ‘depression, low self-esteem and mindfulness, that recognizes low self-esteem as the manifestation of an enduring difficulty in people’s relationship to themselves that exacerbates depression, Fennell (2004) map out a continuum of treatment difficulty. It is a map that would apply across different treatment approaches. According to it, people who are relatively easy to treat have relatively specific, acute problems in the context of a previously well-functioning self where any negative internal perspectives are counterbalanced by positive ones. People who are relatively difficult to treat have multiple, diffuse, long-standing difficulties that they identify with, in the context of a dysfunctional self (with chronic feelings of low self-esteem) from which positive self-perspectives are effectively absent. When it comes to the use of mindfulness to assist recovery, Fennell uses the concept of decentring to identify the crucial step in each case. In easier-to-treat patients, decentering from depression (as taught in MBCT) should be sufficient. In the chronic, harder-to-treat patients, she sees the core task in terms of trying to create an entirely new view of the self, rather than strengthening a pre-existing one. Mindfulness has to be brought to bear on people’s entire view of themselves, as part of a radical exercise in decentering from low self-esteem. The difficulties of this are not underestimated. The sense of personal threat it engenders is likely to be expressed in many ways, including resistance to working with the therapist, scepticism concerning the possibility or value of change, and failure to work as expected within the therapy.
These observations seem extremely important. They refer to the post-phase one treatment of many people who present to psycho-logical therapy services after the failure of relatively simple treatments. As there are already many effective treatments for uncomplicated anxiety disorders and depression, it is in this arena that the usefulness of mindfulness within psychotherapy is likely to receive its most critical tests – and an important opportunity to demonstrate either effect other approaches do not offer or those that would otherwise require much more elaborate or costly arrangements.
Adverse effects of mindfulness practice
It must not be assumed that all of the clinical consequences of mindfulness practice are necessarily positive or therapeutic. Attrition during trials of mindfulness-based interventions is rarely explored, and the whole question of side effects is under-researched. Known possible unintended effects that are exacerbated during intensive training retreats include restlessness, anxiety, depression, guilt, and hallucinosis (Albeniz and Holmes 2000). The experienced practitioners described in Chapter 2 had also been asked about any adverse effects they had experienced. They reported restlessness, self-criticism, and self-doubt during the early phases. One had also gone through a phase of being very judgemental toward others, while two had experienced forms of hallucinosis (auditory and visual) in retreat settings. It seems to be widely accepted that retreat settings are much more likely to precipitate perceptual disturbance, and experienced teachers may restrict access to them among meditators they believe to be vulnerable (VanderKooi 1997).
A number of significant reports of the negative effects of mindfulness exist in the older literature, including accounts of the precipitation of frank psychiatric illness. These include a well-documented case of mania (Yorston 2001) in apparent response to a brief experience of yoga and a zazen retreat, as well as reports of ‘schizophrenia’ that provide insufficient information about the phenomenology or the precipitants (Sethi and Bhargaa 2003). The one prospective study of side effects in long-term meditators is of most relevance, as, although it documents neither sensory disturbances nor frank illness, it was conducted with 27 `insight’ meditators, that is, people practicing mindfulness assessed after a meditation retreat (Shapiro 1992a). These subjects’ previous experience at the time of the study ranged from nil to more than 7 years of experience of regular mindfulness meditation, although all had the experience of formal meditation in some form. The effects reported were classified into three principal sorts:
- Intrapsychic. These were by far the most common, being reported by half of Shapiro’s sample. They comprised four kinds: `negativity’ (being judgemental, negative emotions, mental pain, and anxiety); ‘disorientation’ (confusion about self, low self-esteem, apathetic, and feeling incomplete); ‘addicted to meditation’; and ‘boredom and pain’.
- Interpersonal. These ranged across family objections to meditators withdrawing for meditation, through being too aware of others’ negative qualities (and judging these or feeling superior) to distress at recognizing how bad their current family situation was.
- Societal adverse effects. These included feelings of alienation as well as discomfort in everyday situations and difficulty in making practical adjustments.
Around 10 percent of the sample reported effects under each of items 1 and 2. In collecting these data, Deane Shapiro had asked participants to identify for themselves whether an effect was `adverse’. One of the most interesting findings was that adverse effects were more rather than less common among the more experienced meditators. Shapiro concluded that these must be being offset by accumulating positive effects. This seemed to be borne out by the reports of positive experiences that were requested at the same time.
Shapiro reported elsewhere (1992b) that there was a strong correlation between the likelihood of reporting adverse effects and participants’ thoughts before the retreat began. There was also a clear association between the length of participants’ meditational experience and their predominant motivation for meditating. Assuming these cross-sectional findings can be used to infer a progression over time, Shapiro concluded that motivation follows a sequence in which an early wish for self-regulation is displaced by one for self-exploration, and finally by one for self-liberation. This suggests that motivation of the third kind may be associated with greater tolerance of discomfort and other apparently adverse effects.
The therapeutic actions of mindfulness
A number of suggestions about how mindfulness helps in psychological treatments have been reported in these last two chapters. Some ideas were criticized as being relatively indirect and of less explanatory value than first appeared. They could also be developed in relation to a particular clinical problem (e.g. prophylaxis of depression; improving self-regulation of affect) and remain implicitly tied to that context, ignoring the potentially different ways that mindfulness works in other situations. The present chapter has reviewed some recent thinking about how mindfulness could have a positive impact on a number of quite different kinds of psychopathology, as well as the circumstances in which mindfulness itself seems most liable to be a source of the difficulty. This should make it easier to think about clinical effects more inclusively, without these being overshadowed by a narrow range of psychopathology. Indeed, it seems possible to identify three ways in which mindfulness may have direct and potentially valuable effects across most clinical situations when it is practiced by people with mental health problems.
The first way, building on some of Martin’s (1997) observations, might be called ‘de-chaining’. It reflects the close, objective observation of psychological events that bare attention brings. Not only is each event experienced in full detail, in a slowed-down way (as the concept of de-automatization tried to indicate) but each event is also seen to be less firmly linked to those that precede and follow it than ordinary perception suggests. This loosening is more than spacing out of perceptions, being a freeing up in which more alternatives become available. Examples of where this aspect is particularly important to include the treatment of habit disorders.
The second way, building on the emphasis on exposure to be found in accounts of `experiential avoidance’ in ACT, represents a sort of exposure and might be called ‘re-sensing’. The vitality of experience here reflects the absence of old reactions and reflects the capacity to welcome experiences with acceptance and equanimity as they are attended to, and a lack of fear and aversion. Examples of where this aspect is prominent in clinical situations include mindful therapy for anxiety and phobic disorders.
The third way, in recognition of the importance of mindfulness in bringing about perspectival shifts as people’s relationship to their experience changes, is still probably best called ‘decentring’. It is evident in a capacity to experience everything within awareness on the same basis, with a lessening of partial identifications (including those reinforced by linguistic habits). This aspect appears to be prominent when mindfulness-based approaches are used for problematic thoughts such as obsessional or depressive ruminations.
It seems unlikely that, if this analysis is adequate, the three ways will act in isolation of one another, or develop independently of the others in the course of mindfulness training. For instance, example 2 in the previous chapter (pp. 69-70) seems to bring about what ACT refers to as `cognitive defusion’ through a combination of dechaining and decentering. If dechaining, re-sensing, and decentring are basic actions of mindfulness in therapeutic contexts, it would seem sensible to use process measures that are sensitive to all three facets when evaluating treatments. It is also possible that therapeutic exercises used in mindfulness training may differentially develop one of these aspects more than the others.
It should be emphasized that these terms are trying to capture three intrinsic and therapeutically important actions of mindfulness, rather than secondary `mindfulness skills’. The concept of mindfulness skills refers to the way mindful attention is deliberately gathered, applied or directed. It is also likely that the repertoire of clinically relevant mindfulness skills is different from what current accounts of them suggest. This is because greater precision about what is happening suggests that not everything that has been termed `mindfulness’ in clinical contexts deserves to have been. For instance, there are at least two other kinds of use of attention that are distinct from mindfulness, although closely related to it.
One is the kind of ‘awareness of being aware’ that comes into play when attention is directed across complex objects like body posture or when providing a verbal commentary to accompany actions. We saw in Chapter 1 how this would be designated as a knowing `clear comprehension’ that grows alongside mindful `bare attention’, but is not identical with it. It appears that the functional difference between these is actively exploited in packages like DBT, where `mindfulness skills’, such as described, which have a clear and important role in fostering the capacity to attend, are more likely to enhance clear comprehension than bare attention.
The other instance is concentration, where attention is refocused in order to withdraw it from objects that are giving rise to dysphoric reactions and to direct it instead on a restful object where an intensification of attention is likely to lead to inner feelings of peace and calm. Strictly speaking, this selective narrowing of attention to prevent exploration is not mindfulness, although the stratagem can be quite powerful, for instance, when working with traumatized patients. However, it is also possible to confuse it with mindfulness in practical situations where the outward instructions seem quite similar, even if the inner action is very different. Examples of this could be an inexperienced therapist’s interpretation of the 3-minute breathing space in MBCT as the purposeful injection of a sense of calm (without paying attention to what was going on), or a DBT therapist using ‘mindfulness’ simply to distract the patient’s attention from anxiety-laden experiences onto an innocuous object.
Although the claim that some attentional skills, such as those described, are mindfulness skills may be questionable, other abilities of considerable therapeutic value may merit recognition as mindfulness skills instead. These might include directing awareness outward in order to sense and register other people’s feelings (cf. the above discussion of mindfulness-based relationship enhancement) or narrowing the band of internally focused awareness in order to explore, say, bodily sensations to the relative exclusion of others (as in the earlier discussion of sensorimotor psychotherapy).
Mindfulness-based interventions have been used across a wide range of psychological problems, including mood and anxiety disorders, post-traumatic and psychotic symptoms, bingeing and substance misuse, suicidal and impulsive actions, and difficulties in relating. These differ considerably in the extent to which their usefulness has been confirmed by formal outcome studies. The severity of any of these clinical problems is likely to be influenced by how far it is felt to be part of someone’s self, different therapeutic strategies being needed when this is the case. It is likely that the capacity of mindful therapies to make a difference in more severe and chronic cases will be important in determining their long-term future. Mindfulness is also able to precipitate mental disorders in rare cases, but it has a range of other potential side effects that should also be considered in clinical contexts. The clinical uses of mindfulness have often been rationalised through explanatory models based on the pathogenic psychological processes that it affects. Consideration of these can be helpful in refining ideas of the action of mindfulness. It is proposed that its most direct therapeutic effects reflect three interdependent actions: dechaining, re-sensing and decentering. A clear theory of action seems essential for mindfulness to be recognized as a substantial psychotherapeutic innovation.
References and Further Reading
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