Mindfulness and Psychotherapy

In this article the author (Kati Yamanaka-Simpson) summarises the current knowledge available on the psychological processes underlying mindfulness, a brief discussion on some ways of integrating mindfulness in psychotherapy settings, and also brings to light ethical issues that may arise in the therapeutic room based on ethical discussions already taking place in the Mindfulness-Based Intervention community.

 
Mindfulness and Psychotherapy
Mindfulness has become the fastest-developing area in clinical practice (Pollack, Pedulla & Siegel, 2016). A quick search on published scientific articles in 2016 alone resulted in more than 900 research papers (Harzing, A.W., 2017). More than two decades of empirical research have demonstrated evidence supporting the efficacy of utilising Mindfulness Based Interventions or MBI’s to treat clinical and nonclinical populations (Shapiro, 2009). Recent studies have also demonstrated that MBI’s can benefit clients suffering from a variety of mental and medical health conditions such as substance abuse, gambling addiction, human immunodeficiency virus, chronic pain, anxiety, depression, heart disease, psoriasis, fibromyalgia, cancer and trauma (Gill et al., 2014; Baer, 2003; Grossman et al., 2010; Shonin, Gordon, Griffiths, 2013). The Mental Health Foundation in 2010 surveyed general practitioners and found out that 75% of them believed that mindfulness was beneficial to their patients with mental health difficulties (MHF, 2010). Its ever-expanding list of empirically supported treatments is impressive and as Pollack, Pedulla & Siegel who are all, respectively, President and board members of the Institute for Meditation and Psychotherapy (IMP) in the USA, contend in their book Sitting Together, that mindfulness in psychotherapy is “…proving to be a remarkably powerful technique to augment virtually every form of psychotherapy” (2016, pg. 1) and in agreement Gill et al argues that “Mindfulness practices and related ideas have become influential in the evolution of psychotherapy, resulting in new approaches to mental health treatment” (2014, pg.125). This new approach to mental health treatment also referred to as the Third Wave therapies (Hayes, 2004) began back in 1979 with Jon Kabat-Zinn’s mindfulness programme Mindfulness-Based-Stress Reduction or MBSR (Kabat-Zinn, 1982), followed by Mindfulness-Based Cognitive Therapy or MBCT (Segal, Williams & Teasdale, 2002). The MBIs have also expanded into the development of Psychotherapy approaches utilising cognitive-behavioral roots, namely Acceptance and Commitment Therapy (Hayes, Strosahl & Wilson, 1999) and Dialectic Behaviour Therapy (Linehan, 1993).
 
Psychological Processes Underlying Mindfulness
Mindfulness can be defined as “paying attention in a particular way: on purpose, in the present moment, and non-judgementally” (Kabat-Zinn, 1994, pg.4). This definition facilitates the explanation of the main psychological processes that underlie mindfulness therapeutic mechanisms as follows:
Paying attention in a particular way relates to monitoring the focus of attention or ‘metacognition’. Metacognitive processes allow a decentring from thoughts. Allen et al. contend that by understanding that thoughts are transient mental events, and not always an accurate picture of reality, this can lead to metacognitive insight and relief  (2006). Paying attention on purpose and in the present moment can enhance awareness about a wandering mind which easily gets lost into thinking, ruminating and worrying over past and future. “The mind wanders. Ideally, it does not wander so far that it forgets it is reading this chapter. But consciousness does have an inevitable drift, changing its contents moment by moment” (Weigner. 1997, pg. 295). Paying attention builds the capacity for concentration, and concentration aids clients to see the workings of the mind with more clarity. As the internal chatter slows down and there is less involvement with verbal narratives clients’ have more capacity to exercise choice in their behaviour. Without concentration, it is very difficult to practice open monitoring and compassionate acceptance, these are the two other skills necessary for developing mindfulness (Pollack, Pedulla & Siegel, 2016). Paying attention non-judgementally means that instead of thinking about or analysing thoughts, images, feelings, emotions, sensations, clients learn to be with them, bringing an attitude of interest, curiosity, and acceptance to the experience (Pollack, Pedulla & Siegel, 2016). “Of particular importance for psychotherapy is the attitude of acceptance: active, non-judgmental embracing of experience in the here and now” (Pollack, Pedulla & Siegel, 2016, pg.5). As individuals start to experience their self-critical chatter or the never ending ruminative patterns of the mind, these can overwhelm them, in these moments more acceptance is crucial, and this is introduced by exercises for loving-kindness, self-compassion and equanimity (Kabat-Zinn, 1994).
Mindfulness, as it is taught in Western countries, is adapted from Buddhism religion (Kabat-Zinn, 2017; Shonin, Gordon & Griffiths, 2013; Germer, Siegel, Fulton, 2005). Buddhist Psychology shares the same basic framework for understanding psychological disorders as in Western Psychology by identifying symptoms, etiology of illnesses, prognosis and treatment. In Buddhist Psychology, symptoms correlate to the suffering that all human beings endure and it is not seen as a medical disorder, but as the “result of the nature of our relationship to the existential realities of life” (Germer, Siegel, Fulton, 2005, pg.31). Another common ground with Western Psychology is in the fact that Buddhist Psychology also believes that a significant part of human suffering is caused by distortions in thoughts, feelings, and behaviour and also the major role conditioning plays in a client’s life (Germer, Siegel, Fulton, 2005). The same as in Western Psychology, prognosis in Buddhist Psychology depends on what disorder is being treated, however in a more simplistic explanation the prognosis in mindfulness treatment can be highly optimistic in that it promises less suffering once clients learn to embrace life as it is, reaching a level of  acceptance (Germer, Siegel, Fulton, 2005). Both Psychology schools argue that suffering to be alleviated needs a combination of introspection (i.e., exploring the content of mind in psychodynamic; changing irrational patterns of thinking in CBT; and observing the mind moment-by-moment in mindfulness leading to insight into the workings of the mind) and prescribed behavioural changes (Germer, Siegel, Fulton, 2005).
There are however a few differences amongst some of the Western Psychotherapy approaches and Buddhist Psychology. In CBT distress is seen to be caused by erroneous thinking and fixing mistaken ideas leads to relief, and in Psychodynamic approaches the thought is not what needs to be examined per se, but what lies beneath them regarding motivations, conflicts and desires behind the spoken word, in mindfulness the practice consists of observing the arising and passing of thoughts, sensorial, perceptive and cognitive events, thinking obstructs direct perception into the nature of reality because “…with the absence of discursive thought, a clear and penetrating awareness remains” (Germer, Siegel, Fulton, 2005, pg 37).
 
 
Ways of Integrating Mindfulness in Psychotherapy
It has been argued (Germer, Siegel, Fulton, 2005; Barker, 2013) that the most traditional ways in which mindfulness has been integrated into therapeutic work are:

1. Through the therapist’s personal practice, where the therapist cultivates a more mindful presence. “The mindful therapist can relate mindfully to his or her patients within any theoretical frame of reference, including psychodynamic, cognitive-behavioral, family systems, or narrative psychotherapy” (Germer, Siegel, Fulton, 2005, pg.18). Mindfulness strengthens the therapeutic relationship due to factors such as the cultivation of attention, compassion and empathy, therapeutic presence and a deeper understanding of suffering and the causes of suffering (Siegel, 2010). The therapist's qualities (empathy, warmth, understanding, and acceptance) and the therapeutic relationship are considered the “most potent predictor of a positive treatment outcome” (Germer, Siegel, Fulton, 2005, pg.57).

 
 2) Mindfulness-Informed Psychotherapy: the use of theoretical-frame of reference informed by insights from mindfulness practices, psychological literature on mindfulness, or Buddhist psychology. The direct experience of the therapist is a must due to the non-conceptual nature of mindfulness. Psychotherapists that use Mindfulness-Informed Psychotherapy do not explicitly teach clients how to practice mindfulness.

1. Mindfulness-Based Psychotherapy relates to therapists’ explicitly teaching clients how to practice mindfulness. This is the case of ACT and DBT.  “The proliferation of treatment protocols is encouraging clinicians to experiment with mindfulness techniques, even if therapists do not implement the entire protocol” (Germer, Siegel, Fulton, 2005, pg.19).

 
Ethical Dilemmas
A very heated debate in this field relates to whether there is a need for those teaching mindfulness to have an experiential understanding of it which is the product of maintaining a  regular mindfulness practice (Grossman, 2010; Kabat-Zinn, 2017).
Pollack, Pedulla & Siegel, strongly affirm the need for psychotherapist to “pursue their own mindfulness practice, so that they can see first-hand the effects of various practices…”(pg.24). It is argued that “most Mindfulness Based Interventions highlight the importance of therapists’ own engagement in mindfulness practice or similar pursuits” (Gill et. al., 2014, pg.125) and Siegel (2013) openly contends that a personal experience of mindfulness in order to teach it to clients is a minimum requirement. In contrast, proponents of ACT and DBT believe that due to their approach having a coherent theoretical model clinicians utilising such approaches do not need to have their own mindfulness practice as an understanding of its psychological processes during training is considered enough (Allen et al., 2006). In the case of DBT,  the need for psychotherapists to practice mindfulness is considered “beyond what a therapeutic model can require” (Dimidjian & Linehan, 2003). ACT founders believed that mindfulness “has a coherent theoretical model and the ideas are easily conveyed to the ‘student’ by a practitioner who practices little or not at all” (Allen et al., 2006, pg. 291).  So far the scientific community has not reached a consensus on this matter as research has not yet provided an ultimate answer to validate the need for therapists integrating mindfulness to their client work to be mindfulness practitioners per se, as in Hanley et al. (2016) recent article entitled ‘Mind the Gaps: Are conclusions about mindfulness entirely conclusive?’ The author contends “It may be that instructors regular mindfulness practices are better able to relate the challenges and benefits of mindfulness to novice practitioners. However, again, very little empirical evidence exists to support or contradict this assumption” (pg. 107).
The second area of much debate revolves around the need for a clear definition of mindfulness (McCown, 2013; Grossman, 2010). Mindfulness has been taught cross-culturally and for Dr Olendizki, a scholar of the early Buddhism tradition cited in Germer, Siegel, Fulton (2005) argues that systems of psychological healing are mostly a result of the beliefs kept within one's host culture, “Our psychological lives are more influenced-if not determined- by culture” (pg.260). He argues that the reason why Buddhist psychology has been embraced cross-culturally is because of its focus on the deconstruction of conscious experience, the detailed examination of cause and effect, the understanding about the nature of suffering which occurs at the level of the mind, the understanding that mental events are continuously arising and passing and that we relate to them with desire or aversion all of which appears to be universal concerns (Germer, Siegel, Fulton, 2005). Even though embraced cross-culturally introducing mindfulness to clients with different backgrounds without the explanations about its foundational roots is seen by some professionals as unethical. Shonin, Gordon, Griffiths openly speak about this in a journal article entitled Mindfulness-based interventions: towards mindful clinical integration (2013) stating that “If unbeknownst to service-users, MBI’s are in fact attempting to teach Buddhism in reconstituted form within healthcare settings, then it is imperative to make this absolutely clear”. Baer (2013) in response to this argues that even though mindfulness as taught in the west historically finds its roots in Buddhism, there is a way of fitting it to contemporary secular settings by way of constructing a theoretical sound, evidence based approach that is supported empirically by way of relying on psychological science. “Psychological science provides well-developed alternatives for researchers and clinicians interested in secular approaches to ethics-related issues in MBI’s” (pg.955). Perhaps a way therapists’ can ethically navigate this terrain is to abide by their own professional ethical codes, and here the author quotes Bond (2015)  “Without a counsellors commitment to respecting a client’s values and capacity for self-determination their relationship will lack integrity. Integrity requires that both counsellor and client are acting autonomously” (pg. 102).
Another ethical issue the author would like to raise relates to contradictory views around the safeness of introducing mindfulness to some client populations. In 2006 a systematic review of the efficacy of meditation techniques as treatments for medical illness concluded that after investigating 958 subjects “no serious adverse events were reported in any of the included or excluded clinical trials” (Arias et al., 2006, pg. 817). It was understood that the vast majority of the serious adverse effects of practising mindfulness meditation found in literature arouse from studies on individuals that took part in rigorous meditation retreats where “physical and psychological demands are greater than those of clinical meditation” leading to psychotic episodes (pg. 823).  It is important that therapists are aware that adverse effects of mindfulness meditation to those suffering from psychosis have been found in the medical literature (Kuijipers et al., 2007). Manocha (2000) argued that “meditation is contraindicated in those suffering from psychosis and should only be applied with great caution in those with severe psychological problems” (pg.1137-1138). Ron Siegel, renowned Mindfulness-Based Psychotherapist as cited in Pollack, Pedulla & Siegel (2014), argues that to understand the adverse effects practices can have on clients, the therapist needs to evaluate clients based on the therapist’s own personal experience practising mindfulness. Through a good understanding of the client’s strengths and vulnerabilities and this an understanding arises from the observation of how the client is “open to and accept the varied contents of his or her mind, his or her affect tolerance and how readily he or she can let go of cognitive frameworks through which to understand experiences” (pg.10). Therapists are also advised to consider the strength of the therapeutic relationship, availability of supports outside the therapeutic room, early attachment history, and predisposition for psychiatric disorders (Pollack, Pedulla & Siegel, 2014).
 
Criticism
The number of scientific research carried out on mindfulness is staggering. Nevertheless, it is important to note that mindfulness literature suffers from the standard criticisms of modern scientific inquiry such as concerns about methods, low sample diversity and insufficient multicultural sensitivity. Notwithstanding it is important to consider various researches that have pointed to the questionable validity of studies carried out in mindfulness due to the lack of conceptual and operational agreement (Chiesa & Malinowski, 2011; Goyal et al., 2014). Shonin, Gordon, Griffiths (2013) argue that there are various limiting factors to the studies of MBI’s in methodological quality such as heterogeneity in how MBI’s conceptualise mindfulness and the design of its programs that can vary in length, duration, the amount of psycho-education and physical exercises.
 
Conclusion
Mindfulness is everywhere, from colouring books to PhD degrees. It is undeniably the most researched subject in the psychological arena in recent years. However, this article has highlighted a small portion of the huge amount of contradictory research findings psychotherapists will encounter when navigating the field of mindfulness in search for ways to alleviate clients suffering.  Perhaps the best way psychotherapists can abide by the Hippocratic Oath of ‘First do no harm’, is by complying with their own governing professional bodies code of ethics and regularly reviewing their work with their supervisors and not forgetting that mindfulness is not a one-size fits all approach.
 

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"Integrate Mindfulness in Psychotherapy"