Mindfulness-Based Treatment Approaches: Clinician's Guide to Evidence Base and Applications

Mindfulness-Based Treatment Approaches

Clinician’s Guide to Evidence Base and Applications

Second Edition

Editor

Ruth A. Baer

Department of Psychology, University of Kentucky, Lexington, Kentucky

Table of Contents

Cover image

Title page

Copyright

Contributors

Preface to the Second Edition

Part I. Introduction

Chapter 1. Introduction to the Core Practices and Exercises

Mindfulness-Based Stress Reduction

Mindfulness-Based Cognitive Therapy

Other Important Skills and Practices

How These Practices Help

Questions for Future Research

Conclusions

Part II. Current Applications for Psychological Disorders in Adults

Chapter 2. Mindfulness-Based Cognitive Therapy for Recurrent Depression

Rationale for MBCT

Does MBCT Work? Empirical Support for Efficacy and Mechanism of Action

Practical Issues

Chapter 3. Mindfulness-Based Cognitive Therapy for Treatment-Resistant Depression

The Problem of Treatment-Resistant Depression

Case Study

Studies of MBCT in Active Depression

Practical Issues in Implementing MBCT for TRD

Chapter 4. Mindfulness-Based Cognitive Therapy for Bipolar Disorder

Limitations of Pharmacotherapy for Bipolar Disorder

Psychosocial Treatments for Bipolar Disorder

MBCT for Bipolar Disorder: Theoretical and Conceptual Rationale

How We Modified MBCT for Bipolar Disorder

Clinical Case Study

MBCT for Bipolar Disorder: Empirical Studies

Practical Considerations in Using MBCT for Bipolar Disorder

Conclusions

Chapter 5. Incorporating Mindfulness and Acceptance-Based Strategies in the Behavioral Treatment of Generalized Anxiety Disorder

Brief Description of Gad

Theoretical and Conceptual Rationale for a Mindfulness and Acceptance-Based Approach to Treating Gad

Brief Overview of the Treatment

Case Study

Empirical Support to Date

Practical Considerations

Directions for Future Research

Chapter 6. Mindfulness-Based Eating Awareness Training: Treatment of Overeating and Obesity

Eating-Related Disorders and Obesity

Therapeutic Approaches

Empirical Support for MB-EAT

Case Study

Conceptual and Practical Issues

Concluding Comments

Chapter 7. Mindfulness-Based Relapse Prevention for Addictive Behaviors

Foundations of MBRP

Empirical Support

Practical Considerations

Conclusions

Part III. Applications Across the Lifespan

Chapter 8. Mindfulness-Based Cognitive Therapy for Children

Mindfulness-Based Cognitive Therapy for Children

Theory and Concepts

Empirical Support for Mindfulness as a Clinical Intervention

Other Clinical Applications of Mindfulness

The 12-Session Program

Affective and Behavioral Outcomes

Practical Issues in Working with Children

In Closing

Chapter 9. Mindfulness-Based Stress Reduction for Teens

Introduction

Overview of MBSR-T

Introducing Mindfulness to Teens

Foundational Skills of MBSR-T

Session-By-Session Outline for MBSR-T

Other Practices and Exercises

Applying Mindfulness Skills to Teen-Specific Concerns

Empirical Support for MBSR-T

Practical Issues

Conclusions

Chapter 10. Mindfulness-Based Childbirth and Parenting: Cultivating Inner Resources for the Transition to Parenthood and Beyond

Introduction

Theoretical and Conceptual Foundations

Overview of MBCP

Case Study

Empirical Support

Practical Matters

Conclusion

Chapter 11. I Am Sure to Grow Old: Mindfulness-Based Elder Care

Introduction

Mindfulness-Based Elder Care

Case Studies

Empirical Evidence

Practical Issues

Future Directions

Part IV. Applications with Medical Populations

Chapter 12. Mindfulness-Based Stress Reduction for Chronic Pain

Introduction

Theoretical Foundation and Conceptual Rationale

Case Study

Review of Empirical Support

Practical Issues for Clinicians

Conclusion

Chapter 13. Mindfulness-Based Cancer Recovery: An Adaptation of Mindfulness-Based Stress Reduction (MBSR) for Cancer Patients

Theoretical and Conceptual Rationale

Review of Empirical Support

Case Study

Practical Issues

Part V. Applications for Work-Related Stress

Chapter 14. Mindfulness for Health Care Professionals and Therapists in Training

Introduction

Theoretical Foundations: what is Mindfulness?

Why Should Health care Professionals Practice Mindfulness?

Case Study: A Graduate Course in Mindfulness

Conclusion

Chapter 15. Mindfulness Training in High Stress Professions: Strengthening Attention and Resilience

Theoretical and Empirical Foundations

Mindfulness Training in the Legal Profession

Case Study

Conclusions

Subject Index

Author Index

Copyright

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Second edition

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Contributors

Maureen Angen,     Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board, Calgary, AB, Canada

Ruth A. Baer,     Department of Psychology, University of Kentucky, Lexington, KY, USA

Nancy Bardacke

Osher Center for Integrative Medicine, University of California, San Francisco (UCSF), CA, USA

Department of Family Healthcare Nursing, UCSF, San Francisco, CA, USA

Mindful Birthing and Parenting Foundation, Oakland, CA, USA

Gina M. Biegel,     Creator of MBSR-T and founder of the Stressed Teens Program, San Jose, CA, USA

Sarah Bowen,     Department of Psychiatry and Behavioral Sciences; Department of Psychology, University of Washington, Seattle, WA, USA

Linda E. Carlson,     Department of Oncology, University of Calgary, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board, Calgary, AB, Canada

Kiki Chang,     Department of Psychiatry and Behavioral Sciences, Pediatric Bipolar Disorders Program, Stanford University School of Medicine, and Lucille Packard Children’s Hospital, Palo Alto, CA, USA

Neha Chawla,     Department of Psychology, University of Washington, Seattle, WA, USA

Sarah de Sousa,     Department of Counseling Psychology, Santa Clara University, Santa Clara, CA, USA

Thilo Deckersbach,     Bipolar Clinic, Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA

Larissa G. Duncan

Osher Center for Integrative Medicine, University of California, San Francisco (UCSF), CA, USA

Department of Family and Community Medicine, UCSF, San Francisco, CA, USA

Michelle Edwards,     Department of Counseling and Educational Psychology, New Mexico State University, Las Cruces, NM, USA

Stuart J. Eisendrath,     UCSF Depression Center, Langley Porter Psychiatric Hospital & Clinics, University of California San Francisco, San Francisco, CA, USA

Tory Eisenlohr-Moul,     Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Duke Integrative Medicine, Durham, NC, USA

Alison Evans,     Mood Disorders Centre, University of Exeter, Exeter, UK

Cara Fuchs,     Department of Family Medicine, Alpert Medical School of Brown University, Providence, RI, USA

Amy Garrett,     Department of Psychiatry and Behavioral Sciences, and Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Palo Alto, CA, USA

Jeffrey Greeson,     Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Duke Integrative Medicine, Durham, NC, USA

Natasha Hansen,     Department of Psychology, University of Colorado, Boulder, CO, USA

Britta Holzel,     Institute of Medical Psychology, Charite University Hospital, Berlin, Germany

Amishi P. Jha,     Department of Psychology, University of Miami, Miami, FL, USA

Jean L. Kristeller,     Department of Psychology, Indiana State University, Terre Haute, IN, USA

Willem Kuyken,     Mood Disorders Centre, University of Exeter, Exeter, UK

Jennifer Lee,     Columbia University Medical Center, New York, NY, USA

Michael J. Mackenzie,     Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL, USA

Lucia McBee,     Columbia University School of Social Work and Mount Sinai Hospital, New York, NY, USA

Alexandra B. Morrison,     Department of Psychology, University of Miami, Miami, FL, USA

Susan M. Orsillo,     Department of Psychology, Suffolk University, Boston, MA, USA

Lizabeth Roemer,     Department of Psychology, University of Massachusetts at Boston, MA, USA

Scott L. Rogers,     Department of Psychology, University of Miami, Miami, FL, USA

Randye J. Semple,     Department of Psychiatry & Behavioral Sciences, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA

Shauna Shapiro,     Department of Counseling Psychology, Santa Clara University, Santa Clara, CA, USA

Walter E.B. Sipe,     Langley Porter Psychiatric Hospital & Clinics and Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA

Michael Speca,     Department of Oncology, University of Calgary, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board, Calgary, AB, Canada

Sonica Thakur,     Department of Counseling Psychology, Santa Clara University, Santa Clara, CA, USA

Katie Witkiewitz,     Department of Psychology, University of New Mexico, Albuquerque, NM, USA

Ruth Q. Wolever,     Department of Psychiatry & Behavioral Sciences, Duke Integrative Medicine, Duke University Health System, Durham, NC, USA

Preface to the Second Edition

When the first edition of this book came out in 2006, it included chapters on four interventions: mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), dialectal behavior therapy (DBT), and acceptance and commitment therapy (ACT). This made good sense at the time, because these were the leading evidence-based approaches, and their similarities and differences had never been explored before in a single volume. Today, however, the literature is so large that it’s difficult to cover all four of these interventions in a single book. The present volume focuses on MBSR, MBCT, and related approaches. The commonalities and differences remain fascinating, while the range of applications has greatly expanded. Previous applications, such as for chronic pain, depressive, relapse, generalized anxiety, and the stress associated with cancer, are better understood, and new adaptations for other disorders and populations show great promise. This volume provides a practical and comprehensive guide for clinicians interested in learning more about them.

As in the previous edition, all chapters are written by clinical researchers with good scientific credentials and extensive experience with the treatment they describe. Each chapter includes a well-developed theoretical and conceptual foundation, a clear description of the treatment procedures, a review of empirical support, and a detailed case study illustrating how the intervention unfolds. Each chapter also explores the clinical and practical issues that may arise during treatment and how they can be managed. The result is a close-up view of how these treatments are implemented, the skills required of therapists, the responses that can be expected from participants, and the issues that professionals wishing to use these treatments must consider.

The introductory chapter provides a detailed overview of the exercises and practices used to teach mindfulness and acceptance skills in many of the interventions. The rest of the book is organized by the types of populations in which these treatments are used. The first section describes applications for psychological problems in adults, including depression, bipolar disorder, generalized anxiety, overeating, and substance misuse. The next section describes applications across the lifespan: for children, adults, people about to become parents, and older adults. The following sections address applications for medical populations (chronic pain and cancer) and for work- and school-related stress in nonclinical populations.

This book is intended for clinicians, researchers, teachers, and students at all levels of expertise. Newcomers to this area will find helpful descriptions of the nature of mindfulness, its theoretical and conceptual underpinnings, how we think it works to reduce suffering, and how the interventions are implemented. Readers with more extensive knowledge can expect to broaden their understanding of the wide range of mindfulness-based approaches and gain interesting insights about the creative ways in which they are being applied. All readers are likely to be inspired to further exploration of this growing area with great potential for the treatment of numerous difficult problems and the cultivation of wisdom, insight, compassion, and well-being.

Part I

Introduction

Outline

Chapter 1. Introduction to the Core Practices and Exercises

Chapter 1

Introduction to the Core Practices and Exercises

Ruth A. Baer     Department of Psychology, University of Kentucky, Lexington, KY, USA

Abstract

Interventions based on the practice of mindfulness meditation and related skills are increasingly popular and empirical support for their efficacy continues to grow. The present volume focuses on mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982, 1990, 2013), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002, 2013), and closely related interventions. This introductory chapter provides a general overview of MBSR and MBCT in their standard forms, with emphasis on their mindfulness and acceptance-based skills, practices, and exercises. Mechanisms through which mindfulness training leads to beneficial outcomes are briefly discussed and important questions remaining for future research are considered. Building on the foundation provided by this introductory chapter, the remaining chapters describe adaptations and new interventions for specific populations. Each chapter includes theoretical foundations, a summary of empirical support, and a case study illustrating a typical course of treatment and practical issues that arise in implementing it.

Keywords

Mechanisms of change; Meditation; Mindfulness-based cognitive therapy; Mindfulness-based stress reduction; Mindfulness-based treatment

From a Western psychological perspective, mindfulness is typically defined as a form of nonjudgmental and nonreactive attention to experiences occurring in the present moment, including bodily sensations, cognitions, emotions, and urges, as well as environmental stimuli such as sights, sounds, and scents (Kabat-Zinn, 1990; Linehan, 1993a). Most Western discussions of mindfulness acknowledge its roots in Buddhist meditation traditions, which for many centuries have maintained that the practice of mindfulness facilitates insight into the nature of human suffering and develops adaptive characteristics such as wisdom, equanimity, compassion, and well-being. Instruction in mindfulness has become widely available in Western society. Meditation centers in North America and Europe offer retreats in the Buddhist traditions with guidance and instructions in mindfulness practices. Numerous books about mindfulness and meditation are available for the general audience (e.g., Goldstein, 2003, 2013; Gunaratana, 2011; Salzberg, 2011). Of most importance to the present volume is the rapidly growing array of mental health treatment and stress-reduction programs based on secular adaptations of mindfulness training, several of which now have extensive empirical support for their efficacy in a wide range of populations.

Mindfulness has been conceptualized as a state, as a trait-like or dispositional quality, and as a set of skills. Bishop et al. (2004) provided a two-component definition of mindfulness as a state. The first component is the intentional self-regulation of attention so that it remains focused on present-moment experiences (i.e., thoughts and feelings) as they arise. The second component is an attitude of openness, acceptance, and curiosity toward whatever arises. In general, a person in a mindful state is intentionally and flexibly aware of and attentive to the ongoing stream of internal and external stimuli occurring in each moment, and is observing them with a stance of openheartedness, interest, friendliness, and compassion, regardless of whether they are pleasant, unpleasant, or neutral. Dispositional mindfulness is the general tendency to adopt a mindful state consistently over time and in many situations: noticing internal and external experiences; attending to them with acceptance and openness; and staying aware of ongoing behavior, rather than acting mechanically or automatically while preoccupied with other matters (Brown & Ryan, 2003). The skills training approach to mindfulness, which characterizes the treatments described in this volume, suggests that with the regular practice of a variety of exercises, people can learn to be more observant, accepting, and nonjudgmental of their daily experiences and to participate with awareness in their ongoing activities. That is, they learn to adopt a mindful state more often and more consistently across situations and over time. The evidence suggests that practicing mindfulness leads to increases in general tendency to be mindful in daily life and to improvements in mental health.

Empirically supported mindfulness-based interventions include many methods for teaching mindful awareness. Some of these are formal meditation practices, in which participants sit quietly for periods of up to 45 minutes while directing their attention in specific ways. Others are shorter or less formal exercises emphasizing mindfulness in daily life, in which participants bring mindful awareness to routine activities such as walking, bathing, eating, or driving. Several general instructions are common to many formal and informal mindfulness practices. Often, participants are encouraged to focus their attention directly on an activity, such as breathing, walking, or eating, and to observe it carefully. They are invited to notice that their attention may wander into thoughts, memories, or fantasies. When this happens, they are asked to note briefly that the mind has wandered, and then gently return their attention to the present moment. If bodily sensations or emotional states arise, participants are encouraged to observe them carefully, noticing how they feel, where in the body they are felt, and whether they are changing over time. Urges or desires to engage in behaviors, such as shifting the body’s position or scratching an itch, also are observed carefully, but are not necessarily acted on. Brief covert labeling of observed experience, using words or short phrases, such as aching, sadness, thinking, or wanting to move is often encouraged. Some mindfulness exercises encourage observation of environmental stimuli, such as sounds, sights, or smells. Participants are encouraged to bring an attitude of friendly curiosity, interest, and acceptance to all observed phenomena, while refraining from evaluation and self-criticism (and noticing these nonjudgmentally when they occur), or attempts to eliminate or change what they observe. For example, no attempt is made to evaluate thoughts as rational or distorted, to change thoughts judged to be irrational, to get rid of unwanted thoughts, or to reduce unpleasant emotions or sensations. Rather, cognitions, sensations, and emotions are simply noted and observed as they come and go.

The mindfulness-based interventions with the best empirical support are mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982, 1990), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002, 2013), dialectical behavior therapy (DBT; Linehan, 1993a, 1993b), and acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999, 2012). The previous edition of the current book included chapters on all four of these treatments. Currently, the literature is so large that it is no longer practical to cover all four of these interventions in one volume. Recent books describe numerous applications of DBT and ACT (Dimeff & Koerner, 2007; Hayes & Strosahl, 2004; Hayes et al., 2012; Koerner, 2011). The present volume focuses on MBSR, MBCT, and closely related interventions developed for specific populations. These include acceptance-based behavior therapy (ABBT) for anxiety (Roemer & Orsillo, 2009), mindfulness-based childbirth and parenting (MBCP; Bardacke, 2012), mindfulness-based eating awareness training (MB-EAT; Kristeller, Wolever, & Sheets, 2013), mindfulness-based elder care (MBEC; McBee, 2008), and mindfulness-based relapse prevention (MBRP) for addictive behavior (Bowen, Chawla, & Marlatt, 2011). Applications for nonclinical populations seeking stress reduction and enhanced well-being are also covered.

The remainder of this introductory chapter provides a general overview of MBSR and MBCT in their standard forms, with emphasis on their core skills, practices, and exercises. This will prevent redundancy across chapters in basic descriptions of the primary practices, freeing the subsequent authors to focus on adaptations or new exercises developed for their specific population, detailed accounts of how their participants respond to the treatment, empirical support for the efficacy of their treatment, and practical issues in implementing it.

Mindfulness-Based Stress Reduction

MBSR (Kabat-Zinn, 1982, 1990, 2013) is based on intensive training in mindfulness meditation and was developed in a behavioral medicine setting for patients with chronic pain and stress-related conditions. In its standard form, it is conducted as an 8-week class with weekly sessions lasting 2.5–3 hours. An all-day intensive mindfulness session is often held during the sixth week. Extensive homework practice of mindfulness exercises is encouraged. Classes may include up to 30 participants with a wide range of disorders and conditions. Rather than grouping participants by diagnosis or disorder, MBSR has traditionally included people with a wide range of problems in each group, emphasizing that all participants, regardless of disorder, experience an ongoing stream of constantly changing internal states, and have the ability to cultivate moment-to-moment awareness by practicing mindfulness skills. However, in some settings, MBSR is applied with more specific populations, such as cancer patients (Campbell, Labelle, Bacon, Faris, & Carlson, 2012), health care professionals (Irving, Dobkin, & Park, 2009), or caregivers for family members with dementia (Whitebird et al., 2013).

Many MBSR programs begin with an individual or small-group orientation and assessment session, in which the group leader explains the rationale and methods of the course and encourages potential participants to ask questions and to discuss their reasons for participating. The challenge presented by the program’s extensive requirements for home practice of meditation exercises is discussed, and participants are encouraged to make a verbal commitment to attending all group sessions and completing daily home practice assignments (at least 45 minutes per day, 6 days per week). The eight group sessions are highly experiential, with considerable time devoted to practice of mindfulness exercises and discussion of group members’ experiences with them. A wide variety of mindfulness exercises is taught. Didactic information about stress is incorporated, including topics such as stress physiology, responding to stress, and effects of appraisals on perceptions of stress.

Mindfulness Practices in MBSR

Raisin Exercise

The raisin exercise is the group’s first mindfulness meditation activity and is conducted during the first session, after group members have introduced themselves. The group leader gives everyone a few raisins and asks participants to simply look at them, with interest and curiosity, as if they have never seen such things before. Participants are then guided through a slow process of observing all aspects of the raisins and the process of eating them. First, they visually examine a raisin, paying careful attention to all aspects of its appearance. Then they notice its texture, smell, and how it feels between the fingers. Next they put it slowly into their mouth, noticing the movements of the body while doing so. This is followed by feeling the raisin in the mouth, biting it, noticing the taste and texture, and observing the sensations and movements of the mouth and throat in chewing and swallowing the raisin. When thoughts or emotions arise during the exercise, participants are asked to notice them nonjudgmentally and return attention to the raisin.

The raisin exercise provides an opportunity to engage mindfully in an activity often done on automatic pilot, or without awareness. Many participants report that the experience of eating mindfully is very different from their typical experience of eating, in which attention is focused elsewhere and the food is not really tasted. These comments illustrate the general point that paying attention to activities that normally are done on automatic pilot can significantly change the nature of the experience. Increased awareness of experience can lead to increased freedom to make choices about what to do in a variety of situations. Participants are encouraged to eat a meal mindfully during the week following session 1.

Body Scan

Participants are invited to lie on their backs, or to sit comfortably in their chairs, with their eyes closed. Over the next 40 minutes or so, they are guided in focusing their attention on numerous parts of the body in sequence, often beginning with the toes of one foot and moving slowly up the leg, then slowly through the other leg, torso, arms, neck, and head. With each body part, participants are instructed to notice the sensations that are present with openness and curiosity, but without trying to change them. If no sensations are noticeable, they simply observe the absence of sensations. This exercise differs from traditional relaxation exercises in that participants are not instructed to try to relax their muscles. If any part of the body is tense, they simply notice, as nonjudgmentally as possible, that it is tense. If they feel an ache or pain, they are asked to observe its qualities as carefully as they can. When their minds wander, which is described as inevitable, they are asked to notice this as best they can and gently to return attention to the body scan, without self-criticism or blame. The body scan is practiced during sessions 1, 2, and 8, and is assigned for homework practice during the first 4 weeks. Participants are provided with recordings to guide their home practice.

The body scan provides an opportunity to practice several important mindfulness skills: deliberately directing attention in a particular way; noticing when attention has wandered off and returning it gently to the present moment; and being open, curious, accepting, and nonjudgmental about observed experience, regardless of how pleasant or unpleasant it is. Several common experiences can be used to make these points during the discussion that follows the body scan. For example, some participants will worry about whether they have done it right. It is important to point out that there is no such thing as success or failure in the body scan, as there is no goal to achieve any particular outcome, such as becoming relaxed. Relaxation may occur, but if it doesn’t, then the participant simply notices that he or she is tense.

Participants may also perceive obstacles to completing the body scan, such as sleepiness or restlessness, the mind wandering, aches or pains, or emotional states. These experiences do not mean that the exercise was unsuccessful. The task is simply to notice whatever is present without judgment. Rather than telling themselves that this is bad, or it shouldn’t be like this, or I need to make this different, participants are encouraged to note the presence of these phenomena (including judgmental thoughts), observe them with interest and curiosity, and return attention to the body scan.

Sitting Meditation

Participants sit on a chair or meditation cushion in a comfortable posture that is both alert and relaxed. Generally, the back is relatively straight and aligned with the head and neck. Eyes can be closed or gazing downward. Participants first direct their attention to the sensations and movements of breathing. When the mind wanders off, which may occur frequently, they gently return their attention to breathing. After several minutes, the focus of attention may be shifted to bodily sensations. As best they can, participants are instructed to notice these nonjudgmentally and with acceptance, bringing an attitude of interest and curiosity even to unpleasant sensations. When possible, urges to move the body to relieve discomfort are not initially acted on. Instead, participants are invited to observe the discomfort with acceptance. If they decide to move, they are encouraged to do so with mindful awareness, noticing the intention to move, the act of moving, and the changed sensations resulting from having moved.

Sitting meditation also may include a period of listening mindfully to sounds in the environment. Participants are encouraged to notice the tone quality, volume, and duration of the sounds, without judging or analyzing them, and to observe periods of silence between sounds. Next, the focus of attention may shift to thoughts. Participants are instructed to observe their thoughts as events that come and go in their field of awareness and to note thought content briefly without becoming absorbed in it. A similar approach is taken to emotions that may arise. Participants practice observing these, briefly noting the type of emotion they are experiencing (anger, sadness, desire), and noticing any thoughts or sensations associated with the emotion. In later sessions, sitting meditation may end with a period of choiceless awareness, in which participants notice anything that may enter their field of awareness (bodily sensations, thoughts, emotions, sounds, urges) as they naturally arise. Sitting meditation is practiced during sessions 2 through 7, for periods ranging from 10 to 45 minutes, and is assigned for homework most weeks. Recordings for guided practice are provided.

Mindful Yoga

Slow, gentle Hatha yoga cultivates mindful awareness of the body while it is moving, stretching, or holding a position. The movements are readily adjustable for participants with varying levels of strength and mobility and are practiced with moment-to-moment awareness of the sensations in the body and of breathing. Participants are encouraged to observe their bodies carefully, to be aware of their limits, to avoid forcing themselves beyond their limits, and to avoid striving to make progress or reach goals, other than moment-to-moment awareness of the body and breathing. Thus, yoga is conceptualized as a form of meditation rather than physical exercise, although strength and flexibility may gradually increase. Mindful movement provides the opportunity to practice nonjudgmental observation and awareness of the body and acceptance of the body as it is. Careful observation of the body during this practice tends to reveal that the body’s limits are subject to change over time. Participants sometimes report that during yoga practice, they are better able to maintain a state of relaxed alertness than during the body scan and sitting meditation, which may induce boredom or sleepiness. Yoga is practiced in session 3 and assigned for homework in weeks 3–6. Participants are provided with recordings to guide their practice.

Walking Meditation

Slow, deliberate walking provides another way to practice focusing on the sensations in the body while moving. The gaze is generally straight ahead, rather than looking down at the feet. Attention is directed to the movements, shifts of weight and balance, and sensations in the feet and legs associated with walking. As in other meditation exercises, participants are encouraged to notice when their minds wander off and gently to bring their attention back to the sensations of walking. Walking meditation often is practiced very slowly, but can be done at a moderate or fast pace. Participants typically practice by walking back and forth across a room, to emphasize the absence of a goal to reach a destination. The goal is simply to be aware of walking as it happens. In the early stages, participants are encouraged to focus their attention on the sensations in their feet and legs. Over time, they may expand their attention to include sensations in the whole body while walking.

For some participants, sitting or lying still, as required by sitting meditation and the body scan, can be anxiety provoking, and may feel intolerably aversive. Walking meditation can be a valuable introduction to mindfulness practice. For all participants, walking meditation (at a normal pace) can also be incorporated into daily life, such as while running errands or walking between the car and the workplace. Mindful walking in daily life can help to cultivate more continuous awareness of the mind and body in the present moment.

Mindfulness in Daily Life

Participants are encouraged to apply mindful awareness to routine activities, such as washing the dishes, cleaning the house, eating, driving, and shopping. Practicing mindfulness of each moment is believed to lead to increased self-awareness and ability to make adaptive decisions about handling difficult and problematic situations as they arise, as well as increased enjoyment of pleasant moments. Awareness of pleasant moments also is cultivated during week 2 with a pleasant events calendar, in which participants note one pleasant event per day along with associated thoughts, emotions, and sensations. A similar exercise in which unpleasant events are monitored is assigned during week 3. Both of these exercises (described in more detail later) promote increased understanding of habitual reactions to pleasantness and unpleasantness, including thoughts, emotions, and sensations, and the relationships between these phenomena and behavior. Mindfulness of breathing in daily life also is encouraged and complements the formal meditative awareness cultivated in sitting meditation by promoting generalization of self-awareness to the constantly fluctuating states experienced in ordinary activities. Turning one’s attention to one’s breathing at any moment of the day is intended to increase self-awareness and insight and reduces habitual, automatic, and maladaptive behaviors.

Other Elements of MBSR

Inquiry

Each weekly session includes a particular form of discussion, known as inquiry, in which group leaders invite participants to describe and reflect on their experiences with an in-session or homework practice. Group leaders focus on detailed exploration of whatever the participants noticed during the practice, while modeling a curious, interested, open, nonjudgmental, and accepting stance toward participants’ and their own experiences, no matter what they are. This attitude creates a safe environment for group members to disclose their observations and to adopt an attitude of curiosity and openness. Through skillful use of questions and reflection, the instructor helps participants learn to identify bodily sensations, thoughts, and emotions and to observe them mindfully, with nonjudgmental acceptance; over time, they increasingly see how relating to experiences in this way can be generalized to daily life. Skillful inquiry also helps participants learn to treat themselves more kindly and compassionately. As discussed later, increased self-compassion appears to be an important mediator of the effects of mindfulness training.

Discussion of experiences that are perceived as obstacles or problems is an important element of inquiry. Participants may state that they had trouble practicing because they felt sleepy or restless, or were distracted by noises in the environment (barking dogs, traffic, etc.), that their minds wandered a lot, or that they had negative thoughts about mindfulness practice being a waste of time or of no help to them. All of these experiences are accepted with openness and curiosity and are explored nonjudgmentally. Group leaders encourage participants to notice and take an interest in these experiences, without trying to change them, and to return attention to the mindfulness exercise, as best they can. It is important to clarify that mindful acceptance does not imply passivity or helplessness. If pain or discomfort is experienced during a meditation practice, participants may choose, for example, to change their position to relieve pain, put on a sweater or open a window, let the dog in or out to reduce barking, or take other reasonable steps. However, the decision to engage in any of these actions is made mindfully and awareness of the movements is incorporated into the practice.

Homework

Homework generally includes 45 minutes of formal mindfulness practice, often guided by recordings provided by the group leaders, and 5–15 minutes of informal practice, 6 days per week. Home practice is described as critically important in developing mindfulness skills and learning new ways to relate to experience. Instructors emphasize that discipline is required to practice daily, regardless of current mood. Regular mindfulness practice is described as a challenge and an adventure, rather than a chore. It may be helpful to encourage participants to suspend judgment about the value of meditation for the duration of the program, and to do the homework with an attitude of exploration and experimentation, regardless of whether they like it or perceive immediate benefits. When participants report that they have failed to do homework during a preceding week, group leaders express interest in and curiosity about their experiences surrounding the homework. Acceptance of all experiences is encouraged, including boredom, irritation, emotional reactions, and fears and uncertainties about how meditation may help. Group leaders express nonjudgmental interest in any other factors that may have interfered with their homework practice, acknowledge the difficulty of regular practice, and encourage participants to bring their own curiosity to bear on the situation, so that they might find ways to engage in the homework more regularly. A punitive or critical attitude is avoided.

Monitoring of Pleasant and Unpleasant Events

A pleasant events calendar is introduced as a homework exercise in session 2 and discussed in session 3. Participants are asked to notice at least one pleasant event each day and to write down the associated thoughts, emotions, and sensations on the worksheet provided. Rather than looking for major events, participants are encouraged to notice smaller, momentary experiences, such as the feel of a breeze, the sound of birds chirping, or the smile of a friend. This exercise cultivates increased awareness and appreciation of pleasant events when they occur and recognition of the sensations and emotions associated with pleasantness. It also encourages catching the thoughts that can turn a pleasant experience into an unpleasant one, such as why doesn’t this happen more often? or I don’t deserve this, or this is going to end soon.

In reviewing this exercise in session 3, participants may report that small moments of pleasantness are more frequent than they had realized. Some may find that distinguishing between thoughts, sensations, and emotions is a new experience. Identifying these elements of a pleasant experience builds important skills for recognizing the elements of more challenging or upsetting experiences that lead to stress and psychological symptoms.

An unpleasant events calendar is introduced as a homework exercise at the end of session 3. As with the previous worksheet, participants are asked to notice an unpleasant experience each day and note the associated sensations, emotions, and thoughts. Working with the two versions of this exercise helps participants explore the natural human tendency to categorize experience as pleasant or unpleasant and to cling to pleasant experiences while trying to get rid of unpleasant ones. The meditation practices described earlier cultivate the ability to observe reactions of attachment and aversion and respond to them skillfully.

Incorporation of Poetry and Metaphors

The nature of mindfulness can be difficult to convey in ordinary language. For this reason, many MBSR instructors include the reading of poetry in their weekly sessions to illustrate important elements of mindfulness. For example, The Guest House, by Rumi, a 13th-century Sufi poet, uses simple but expressive language to describe a welcoming stance toward all internal experience. Poems or readings by Rilke, Mary Oliver, David Whyte, and others may be used to illustrate other important themes, such as awareness of moment-to-moment experience, recognition of internal wisdom, or experiencing life’s difficulties within a wider perspective.

Many poems include vivid metaphors. The Guest House, for example, suggests that thoughts and feelings can be seen as visitors who are welcomed regardless of whether we find them pleasant or likeable. Outside the context of poems, other metaphors may help to convey the nature of a mindful stance. For example, participants may be encouraged to think of themselves as explorers investigating new territory and taking a strong interest in everything they discover; regardless of how pleasant or unpleasant it may feel.

The All-Day Meditation Session

During this session, usually held on a weekend day between sessions 6 and 7, participants engage in sitting and walking meditations, body scans, yoga, and mindful eating (lunch) over the course of 6–8 hours. Most of the day is spent in silence, except for instructions provided by the group leaders and a period of sharing at the end of the day. Participants are encouraged not to speak to each other or to make eye contact. By refraining from interaction with each other, they allow themselves the opportunity to focus on mindful observation of their own present-moment experiences. Although some participants may find the day enjoyable and relaxing, these are not the goals for the session. The goal is to be present with and accepting of whatever comes up during the day. Some participants may experience physical discomfort or pain from extended sitting meditation, whereas others may feel strong emotions that they usually attempt to avoid. Some may feel bored, anxious, or guilty about not doing their usual tasks. The extended period of silence encourages more intensive self-awareness and provides the opportunity to practice nonjudgmental observation of experience, without engaging in habitual avoidance strategies such as busying oneself with tasks, talking to others, reading, or watching TV. This experience can be stressful for some participants and enjoyable for others. Many will report a mix of pleasant and unpleasant feelings during the day. Participants are encouraged to let go of expectations about how the day should feel, or what should happen, but to remain mindfully aware of everything that unfolds.

Teacher Qualifications

The Center for Mindfulness at the University of Massachusetts Medical School, where MBSR originated, provides a list of qualifications for MBSR instructors. These include a daily meditation practice, participation in meditation retreats of 7–10 days duration, and completion of a variety of teacher training, supervision, consultation, and professional development experiences, as well as extensive experience in leading MBSR groups. Required skills include translating mindfulness practice into accessible language, establishing effective and compassionate relationships with a wide range of clients, and facilitating interaction in diverse patient/client groups. In general, MBSR emphasizes continuity of experience between instructors and participants. All are expected to practice mindfulness regularly, and the experiences that may arise, such as self-critical thoughts, negative emotion, judgments, impatience, and lack of acceptance, are seen as common to all persons, rather than specific to those seeking help. That is, instructors and group members are all participating in the same enterprise. Additional information about MBSR can be found on the website of the Center for Mindfulness at the University of Massachusetts Medical School (www.umassmed.edu/cfm).

Mindfulness-Based Cognitive Therapy

MBCT was developed for the prevention of depressive relapse and was originally designed to be implemented in people with a history of major depressive episodes, who are currently in remission. Recent work suggests that MBCT is also effective for ongoing symptoms of depression and for bipolar disorder (see chapters 3 and 4 in this volume). MBCT is based largely on MBSR and uses many of its components. The raisin exercise, body scan, sitting meditation, yoga, and walking meditation are incorporated into MBCT, along with informal practices of mindfulness in daily life, such as mindfulness while washing the dishes, brushing one’s teeth, and taking out the garbage. Poetry and metaphors are incorporated into several sessions, as is monitoring of pleasant and unpleasant events. Didactic information focuses primarily on the nature of depression rather than on stress. MBCT is generally conducted as an 8-week group with 2-hour weekly sessions for up to 12 participants. Although the all-day session originally was not part of MBCT, many instructors now incorporate it. Many of the points discussed earlier for MBSR, such as the importance of homework, the nature of inquiry, and the continuity of experiences between instructors and group members, apply to MBCT. This section will focus primarily on exercises and practices that were developed specifically for MBCT.

Three-Minute Breathing Space

This exercise, also described as a mini-meditation, encourages generalization to daily life of mindfulness skills learned in formal meditation practices. The breathing space allows participants to step out of automatic pilot at any time, even during a hectic day, and re-establish awareness of the present moment. It consists of three steps, each practiced for approximately 1 minute. The first step is to focus awareness on the range of internal experiences currently happening. The participant asks, What is my experience right now? and notices any bodily sensations, thoughts, or emotional states that are present. A stance of nonjudgmental acceptance is encouraged. Thus, the participant does not try to push away or suppress experiences, but rather acknowledges all of them, even if they are unpleasant or unwanted. The second step is to focus full attention on the movements and sensations of breathing, noticing each in-breath and out-breath as it occurs. The third step is to expand awareness to the body as a whole, including posture and facial expression, and to notice the sensations that are present, again with acceptance and without judgment.

The breathing space is introduced in session 3 of the 8-week program. Participants are asked to practice it several times per day, for the remainder of the program. Initially, participants schedule regular times for practicing it each day. In later weeks, homework includes additional breathing spaces whenever the participant feels stressed or overwhelmed. At very busy times, a full 3 minutes might not be possible, but participants are encouraged to bring awareness to inner experience, the breathing, and the body at least momentarily.

Although the breathing space may sometimes feel like a moment to relax or escape from a stressful situation, its purpose is to help participants recognize the difference between automatic reacting and skillful responding. Stepping out of automatic pilot facilitates bringing a wider perspective to any situation and making more skillful choices about how to proceed. In some problematic situations, the skillful response is to accept the inevitable unpleasantness, whereas at other times, a skillful response might include taking action to change a situation. The breathing space encourages choosing with awareness rather than reacting with automatic behavior patterns that may be maladaptive. A metaphor used in MBCT is that taking a breathing space is like opening a door, which reveals a number of corridors down which we might choose to walk. The breathing space allows us to see the options more clearly.

Deliberately Bringing Difficulties to Mind in Sitting Meditation

In session 5, the instructions for sitting meditation are extended to include a period of deliberately calling to mind a difficult or troubling issue or problem and noticing where in the body associated sensations arise. Any attempts to push away or resist these feelings are noted. As best they can, participants deliberately let go of these tendencies by allowing themselves to feel whatever is present with willingness, openness, and a gentle, kindly, friendly awareness. It is often helpful to include in awareness both the difficult sensations and the breath, so that participants imagine breathing with the difficulties. The purpose of this exercise is to counteract the usual tendency to try and avoid difficult or painful feelings. It helps participants see that difficulties can be named, faced, and worked with, and that avoidance is not necessary and may be maladaptive. Participants also may realize that their typical attitude toward negative experience is hostility rather than kindliness. Deliberately approaching problems that we usually try to avoid can be difficult; therefore, support from experienced group leaders is essential.

Cognitive Therapy Exercises

MBCT does not include traditional cognitive therapy exercises designed to change thoughts, such as identifying cognitive distortions, gathering evidence for and against thoughts, or developing more rational alternative thoughts. However, it integrates several exercises based on elements of cognitive therapy that emphasize a decentered approach to internal experience.

Thoughts and Feelings Exercise

This exercise is part of session 2. Participants are asked to close their eyes and imagine walking down the street and seeing someone they know on the other side. The participant smiles and waves, but the other person walks by without seeming to notice. Participants are invited to describe the thoughts, feelings, and sensations they experience when imagining this scenario. Their contributions to this discussion are then used to explain and illustrate the ABC model, in which a situation (A) leads to a thought or interpretation (B) which leads to a feeling or emotion (C). An important idea emerging from this discussion is that different thoughts at point B can lead to different emotions at point C. This leads to the important understanding that thoughts are not facts. Furthermore, we are not always aware of the thoughts occurring at point B, even though they may have powerful effects on our emotions. Because thoughts can have strong influence on our moods, it is important that we learn to be more aware of them. Practicing mindfulness skills will help to develop this awareness.

Discussion of Automatic Thoughts

Session 4 includes a discussion of automatic thoughts related to depression, taken from the Automatic Thoughts Questionnaire (Hollon & Kendall, 1980). Examples include I’m no good and my life is a mess. The purpose of this exercise is to help participants learn to recognize the types of thoughts that are typical of depression and to see them as symptoms of depression rather than as true statements about themselves. Group leaders emphasize that the believability of these thoughts changes with one’s mood. That is, during an episode of depression, we tend to believe that these thoughts are true. When in remission, we believe them much less. This point illustrates the importance of seeing our thoughts as mental events rather than as representations of truth or reality.

Moods, Thoughts, and Alternative Viewpoints Exercise

This exercise occurs in session 6 and requires imagining two slightly different scenarios. First, participants imagine that they are feeling down because they’ve just had an argument with a colleague at work. Shortly afterward they see another colleague who rushes off quickly, saying he or she can’t stop to talk. Participants are asked to write down what they would think in this situation. Next, they imagine the scenario slightly differently: They are feeling happy because they’ve just been praised for good work, when they see a colleague who hurries away, saying he or she can’t stop to talk. They write down what they would think in this situation. Participants’ responses usually illustrate that our thoughts are influenced by our moods. In the first scenario, we may think that the colleague is avoiding or rejecting us, whereas in the second, we may wonder about the colleague’s well-being. This exercise also illustrates that our thoughts can have powerful influence on our feelings, but that our thoughts vary so much with changing circumstances that they cannot be regarded as facts. However, our tendency to believe our thoughts is very strong. Practicing mindfulness of thoughts will help us to remember that they are not facts and to allow them to come and go.

Pleasure and Mastery Activities

This exercise occurs in session 7 and is based on the recognition that taking action