Read an Excerpt
Ruth A. Baer, University of Kentucky
Psychological interventions based on mindfulness and acceptance have attracted extraordinary interest in a very short time. The New York Times recently described mindfulness meditation as "perhaps the most popular new psychotherapy technique of the past decade" (Carey, 2008). Although mindfulness meditation originates in ancient Buddhist traditions that have evolved over many centuries, the incorporation of secular forms of mindfulness practice into contemporary Western settings is quite recent.
Mindfulness-based principles and practices are applied to psychological treatment in many ways. Some therapists maintain a personal practice of mindfulness meditation to improve their own well-being and peace of mind and develop a more attentive, balanced, and compassionate presence during therapy sessions, but don’t teach mindfulness to their clients (Germer, Siegel, & Fulton, 2005). Others incorporate wisdom and insight from Buddhist teachings on concepts such as impermanence and acceptance into their discussions with clients without explicitly teaching their clients to engage in mindfulness practices (Shapiro & Carlson, 2009). Most of the empirical literature, however, describes structured treatments in which formal or informal mindfulness practices are explicitly taught as a central therapeutic ingredient. The best known of these, which have accrued substantial support for their efficacy, are acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), dialectical behavior therapy (DBT; Linehan, 1993), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002) and mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982, 1990). Research on these approaches, including variations and adaptations for specific disorders and populations, appears regularly in the empirical literature, as do new books for professional and lay audiences. Professional training in the implementation of these interventions is increasingly available.
Much of the literature supporting these treatments emphasizes the reduction of symptoms or distress as the primary outcome of interest. Fewer studies have examined the processes and mechanisms by which beneficial outcomes are obtained. For people seeking treatment, reduction of symptoms is often the primary goal. However, the advancement of science and practice is better served when studies investigate not just whether treatments work, but how they work. If we understand how treatments work, we can increase their effectiveness by refining components that are responsible for therapeutic change and de-emphasizing or eliminating components that aren’t active ingredients.
For example, it is generally assumed, both in Buddhist meditation traditions and in contemporary interventions, that mindfulness training should enable participants to be more mindful of the experiences of daily life. In turn, being more mindful should lead to reductions in suffering and increases in well-being. But do mindfulness-based treatments actually work this way? Do participants learn to be more mindful in daily life? Is that why their psychological health improves? Is it possible that improvements are due to other factors, such as social support, attention from a caring therapist or teacher, increased ability to relax, or the general psychological education and discussion that occurs while participating in a structured treatment? Answering these questions requires understanding the processes of change, and this requires methods for assessing the relevant processes. Without such methods, we cannot say whether participants in mindfulness training learn to be more mindful in daily life, or whether this is important in accounting for the benefits of mindfulness training.
The purpose of this book is to examine important questions about how mindfulness- and acceptance-based treatments work. What is changing when people participate in these interventions? Are they becoming more mindful or more accepting? If so, are these changes important in accounting for the improvements in psychological functioning, well-being, and quality of life that typically result from these interventions? The following chapters address these questions for several important processes in a variety of populations. In this introduction, I provide historical background about the origins of mindfulness-based interventions, a brief review of the populations and disorders to which they are often applied, and an overview of the processes believed to be central to their mechanisms of action.
Origins and Applications of Mindfulness Training
Mindfulness meditation originated in ancient Buddhist traditions that are approximately 2,500 years old. As Buddhism spread across Asia, it evolved into several subtraditions and schools of thought that vary in their specific practices. The three primary branches are described by Kabat-Zinn (2003) as the Theravada tradition, the Mahayana or Zen tradition, and the Vajrayana or Tibetan tradition. The ancient texts that elucidate the nature of mindfulness are core teachings for all of these branches and their subdivisions. These texts describe mindfulness as an attentional stance that is embedded within an ethical framework centered on nonharming of self and others. The practice of mindfulness within this ethical context is believed to cultivate insight into the nature of human suffering and how to relieve it (see also Gunaratana, 2002; Nhat Hanh, 1976).
In recent decades, several forms of Buddhist meditation have been introduced into Western culture (Goldstein, 2002). Westerners who have studied extensively with Buddhist masters in Asian countries have founded meditation centers in North American and Europe, where they offer mindfulness retreats of varying lengths. Guidance and instruction in mindfulness meditation is also available at many wellness centers and mental health facilities. Numerous books for the lay audience describe mindfulness meditation practices (e.g., Goldstein & Kornfield, 1987; Gunaratana, 2002). In addition, as noted earlier, several recently developed structured interventions incorporate mindfulness training and now have considerable empirical support for their efficacy. These interventions are briefly reviewed here.
MBSR
MBSR was developed by Jon Kabat-Zinn (1982, 1990) and first offered in 1979 at the University of Massachusetts Medical School. The goal of the program was to make mindfulness meditation available and accessible in a Western medical setting while remaining true to the essence of Buddhist teachings. Kabat-Zinn had practiced and studied mindfulness meditation for years and began offering a ten-week group program for patients with a wide variety of stress-related and chronic pain conditions who were referred by their physicians because their medical treatment had been unsatisfactory. The program is described as educational rather than a form of psychotherapy and is based on intensive practice of several forms of mindfulness meditation. It also includes didactic instruction on the nature of stress and discussion of how to apply mindfulness to the difficulties of daily life. The program was originally called stress reduction and relaxation because of concerns that meditation wouldn’t be viewed as an acceptable activity for patients in an academic medical center. Now known as MBSR, in its standard form it is an eight-week group program for up to thirty participants with a wide range of stress-related conditions. Groups meet weekly for 2.5-hour sessions, and week six often includes an all-day session.
MBSR has been used with many populations in a variety of settings. Medical populations that have shown reduced distress or increased well-being include patients with cancer (Carlson, Speca, Patel, & Goodey, 2003), heart disease (Tacon, McComb, Caldera, & Randolph, 2003), fibromyalgia (Weissbecker et al., 2002), other forms of chronic pain (Kabat-Zinn, 1982), and chronic fatigue syndrome (Surawy, Roberts, & Silver, 2005), as well as mixed medical populations (Reibel, Greeson, Brainard, & Rosenzweig, 2001). Significant benefits for nonclinical populations also have been reported, including mental health and medical professionals and students (Shapiro, Astin, Bishop, & Cordova, 2005; Shapiro, Brown, & Biegel, 2007) and healthy adults with work-related stress (Davidson et al., 2003; Williams, K., 2006).
Variants of MBSR for other populations also have been developed. For example, mindfulness-based relationship enhancement (MBRE; Carson, Carson, Gil, & Baucom, 2004), which is designed for couples, has been shown to provide significant improvements in relationship quality and personal adjustment. Mindfulness-Based Eating Awareness Treatment (MB-EAT; Kristeller, 2003; Kristeller & Hallett, 1999) is a treatment for binge eating that incorporates elements of MBSR with mindful eating of several types of food, as well as guided meditations related to body shape and weight, hunger and satiety cues, and binge-eating triggers. Other adaptations with at least preliminary support include mindfulness-based art therapy (MBAT; Monti et al., 2005), which combines elements of MBSR with art-making activities and was developed for medical populations, and mindfulness-based relapse prevention for substance abuse (MBRP; Witkiewitz, Marlatt, & Walker, 2005). In most published studies, the eight-week format is maintained. However, several authors have reported on shorter versions of MBSR for a variety of populations and outcome data suggest that these can be as effective as the standard eight-week version (Carmody & Baer, 2009). Other reviews of the MBSR literature are provided by Baer (2003); Grossman, Neimann, Schmidt, and Walach (2004); and Salmon and colleagues (2004).
MBCT
MBCT is an adaptation of MBSR designed to prevent relapse in participants with a history of depressive episodes (Segal et al., 2002). It was developed in consultation with Kabat-Zinn and his colleagues and includes many of the same mindfulness practices used in MBSR. It also incorporates cognitive therapy exercises that cultivate the understanding that thoughts are not facts and do not have to control behavior. Like MBSR, MBCT is an eight-session group program with 2 or 2.5-hour weekly sessions and an all-day session in week six. Groups are usually limited to twelve participants. Although MBCT was originally developed for people whose depression has remitted, recent research suggests it is probably effective for those with ongoing depressive episodes (Barnhofer et al., 2009; Kenny & Williams, 2007). In addition, preliminary support for adaptations with other populations is beginning to appear. Examples include MBCT for bipolar disorder (Williams, J. M. G., et al., 2008), generalized anxiety disorder (Craigee, Rees, Marsh, & Nathan, 2008; Evans et al., 2008), binge eating (Baer, Fischer, & Huss, 2005a, 2005b), anxious children (Semple, Lee, & Miller, 2006), and older adults with depression and anxiety (Smith, 2006; Smith, Graham, & Senthinathan, 2006).
DBT
DBT was developed at the University of Washington, beginning in the late 1970s, by Marsha Linehan, who was working with suicidal and self-injurious women, many of whom met criteria for borderline personality disorder (BPD). Her clients typically had severe and chronic negative affect and multiple problematic behaviors. Although their level of suffering was very high, they often found suggestions about behavior change to be invalidating and reacted with anger, which led to high rates of attrition (Linehan, 1997). However, if they didn’t work on behavior change, their lives remained chaotic and miserable. Linehan studied historical and biographical accounts of torture victims, holocaust survivors, and others who had endured great suffering and found that the concept of acceptance was often central to descriptions of their experiences. It appeared that those who were able to accept the reality of their circumstances without avoidance, suppression, or denial were more likely to experience personal growth (Linehan, 2002). To learn more about acceptance, which was not widely discussed in psychology at that time, Linehan studied Zen Buddhism (Butler, 2001). She began incorporating acceptance-based methods, including validation and mindfulness skills, with traditional cognitive behavioral strategies. Because her clients were unwilling or unable to engage in lengthy meditation practices, she developed behavioral exercises for teaching mindfulness and acceptance skills without engaging in formal meditation. These skills appear to enable clients to tolerate the emotional pain associated with changing their behaviors to build better lives and to accept undesirable aspects of their histories and current circumstances that cannot be changed.
DBT has been very favorably received by clinicians looking for effective treatment for clients with BPD (Scheel, 2000; Swenson, 2000). DBT programs are now widely available (although more are needed). Standard outpatient DBT typically includes weekly individual therapy and group skills training, telephone consultation as needed, and a therapists’ consultation group. Duration is usually one year, although shorter versions have been developed. Applications for substance abuse problems, eating disorders, intimate partner violence and other family problems, self-harm in adolescents, and depression with comorbid personality disorders in older adults have been developed and studied, along with adaptations for inpatient psychiatric and forensic settings and outpatient private practices (Dimeff & Koerner, 2007; Marra, 2005; Safer, Telch, & Chen, 2009; Rathus, Cavuoto, & Passarelli, 2006). Recent reviews of the DBT literature are provided by Lynch, Trost, Salsman, and Linehan (2007) and Robins and Chapman (2004).
ACT
ACT, developed by Steven Hayes and colleagues beginning in the late 1970s, is based on a philosophy known as functional contextualism and a theory of human language and cognition known as relational frame theory (RTF), both of which are beyond the scope this introduction (see Hayes et al., 1999, and Hayes, Barnes-Holmes, & Roche, 2001, for more detail). In its original form, the therapy was called comprehensive distancing because it emphasized the development of a particular perspective on thoughts. From this perspective, which is very similar to the concept of decentering in cognitive therapy, thoughts are seen as just thoughts—mental events that come and go and don’t necessarily reflect truth, reality, or personal worth and need not influence behavior. Comprehensive distancing encouraged participants to notice and identify their troubling thoughts as just thoughts, and to engage in adaptive behavior while having these thoughts, regardless of the content of the thoughts. The name of the treatment was changed to acceptance and commitment therapy to signify acceptance of a wide range of internal experiences (thoughts, emotions, sensations) while choosing and committing to potentially effective behavior consistent with goals and values. ACT incorporates many mindfulness exercises to facilitate awareness and acceptance of thoughts and feelings.
ACT was designed to be applicable to numerous populations and settings. The current literature describes adaptations for depression (Zettle, 2007), anxiety (Eifert & Forsyth, 2005), anger (Eifert, McKay, & Forsyth, 2006), smoking and substance abuse, chronic pain and other medical conditions, living with psychosis, self-harm in BPD, worksite stress, and stigma and burnout in mental health professionals, among others (Hayes & Strosahl, 2004). Adaptations for children and adolescents (Greco & Hayes, 2008) and for group interventions (Walser & Pistorello, 2004) have also been described. A recent review of the ACT literature is provided by Hayes, Luoma, Bond, Masuda, and Lillis (2006).
What Is Changing When People Participate in Mindfulness- and Acceptance-Based Treatments?
Researchers and clinicians are studying several interesting psychological processes that may help to explain why mindfulness- and acceptance-based treatments lead to reduced distress and improved well-being. Each of these is discussed in more detail in one of the chapters in this volume. Here we present a brief overview.
Mindfulness. Participants in the treatments just described devote substantial time and effort to the practice of mindfulness skills. In MBSR and MBCT, participants are asked to engage in formal mindfulness meditation for forty-five minutes per day, six day per week, and to practice mindfulness informally while doing routine daily activities. It seems reasonable to assume that engaging in these practices will cultivate greater mindfulness of the experiences of daily life, and that this will lead to reductions in suffering and increases in psychological health. Until recently, this assumption could not be tested because no methods were available for assessing the tendency to be mindful in general daily life. However, assessment tools designed to measure mindfulness have become available within the last few years. Developing these measures has required discussion of what it means, in concrete behavioral terms, to be mindful and why it should be helpful to adopt a mindful stance toward ongoing experience. Although many questions remain, the recent literature on this topic has grappled productively with these issues and is contributing to a clearer understanding of the nature of mindfulness, the changes that occur in people who practice mindfulness, and how these changes contribute to symptom reduction and increased well-being (Baer, Smith, Krietemeyer, Hopkins, & Toney, 2006; Baer et al., 2008).
Decentering. In the early days of cognitive therapy, decentering was described as a particular way of relating to thoughts in which they are observed as transitory mental phenomena that are not necessarily true or important and do not reflect on personal worth or require particular behaviors in response (Hollon & Beck, 1979). A decentered relationship to a specific thought (e.g., "I’m an idiot") includes noticing the thought when it arises and recognizing that it is a thought, rather than a fact, and that it is separate from the person having the thought. Decentering is closely related to mindfulness and is believed to play a central role in accounting for the benefits of mindfulness training. Recent advances in the assessment of decentering have made it possible to study this process and its relationship to psychological distress in people who participate in mindfulness-based interventions (Fresco et al., 2007).
Psychological flexibility. In ACT, the central therapeutic goal is helping the client develop psychological flexibility, a term that encompasses the acceptance and the commitment processes reflected in this therapy’s name. Psychological flexibility includes mindful awareness of the present moment and willingness to experience unpleasant or unwanted internal stimuli (thoughts, sensations, emotions) while either changing or maintaining overt behavior in the service of important goals and values. Recent work on the assessment of psychological flexibility has greatly advanced our understanding of the changes that occur in ACT and how these lead to improvements in the problems for which people seek treatment. The literature suggests that increases in psychological flexibility are important mediators of therapeutic change (Hayes et al., 2006).
Values. An important element of psychological flexibility is the clarification of personal values. In ACT, participants are encouraged to think deeply about what is most important to them in life (such as being a loving spouse or parent or doing work that feels meaningful and worthwhile) and to identify specific behaviors that are necessary to move their lives in these directions. Although identifying values is an element of psychological flexibility, it has received less attention in the literature than it deserves, and for this reason it has its own chapter in this book. Recent work on the assessment of values provides interesting insights about how changes in the extent to which people are acting in accordance with their values are related to changes in other aspects of their psychological functioning (Wilson & DuFrene, 2008).
Emotion regulation. The current literature includes several definitions of emotion regulation. Some of these emphasize control and reduction of negative emotions. These definitions are not consistent with mindfulness- and acceptance-based treatments, which emphasize awareness and acceptance of all emotions as they arise and controlling behavior while experiencing negative emotions by inhibiting maladaptive impulsive behavior and engaging in goal-directed behavior. Recent work on the assessment of emotion regulation as defined in this way suggests that acceptance-based treatment encourages improvement in these adaptive ways of responding to emotions, and that these changes are related to other improvements in psychological functioning (Gratz & Roemer, 2004; Gratz & Gunderson, 2006).
Self-compassion. Ancient Buddhist writings have much to say about compassion for oneself and others. Development of compassion is described as one of the central effects of the regular practice of mindfulness meditation. Self-compassion, a relatively unfamiliar concept in the Western psychological literature, includes treating oneself kindly rather than judgmentally, recognizing that painful emotions and hardships are part of the human experience, and maintaining mindful awareness of difficult experiences rather than trying to avoid them or becoming excessively immersed in them. A recently developed measure of self-compassion has allowed for interesting studies and growing evidence that treating oneself kindly is associated with numerous aspects of healthy psychological functioning (Neff, 2009). It also appears that participants in mindfulness-based interventions are likely to show increases in self-compassion.
Spirituality. Although mindfulness meditation originates in a spiritual tradition, mindfulness- and acceptance-based treatments are intentionally secular. However, several authors have argued that spirituality is an important dimension of human functioning and that understanding the psychology of spiritual experience may contribute to knowledge of how mindfulness-based therapies achieve their beneficial outcomes. Spirituality is difficult to define and measure. Nevertheless, recent work suggests that the practice of mindfulness can lead to increases in spirituality and that these are associated with improvements in many domains of psychological functioning (Carmody, Reed, Kristeller, & Merriam, 2008).
Changes in the brain. Recent advances in imaging technologies have provided ways of studying the effects of mindfulness meditation on the brain. Evidence is growing that the practice of mindfulness leads to changes in the structure and function of the brain and that these changes are associated with cognitive and emotional benefits. The initial studies compared long-term meditation practitioners to nonmeditators, making it impossible to determine whether observed differences were due to meditation in particular or to other factors associated with meditation, such as openness to experience or dietary differences. However, recent studies have shown meaningful changes in the brain in people with no previous meditation experience who completed an MBSR program. These changes appear to be related to healthy psychological functioning (Davidson et al., 2003).
Changes in attention and working memory. Recent findings also suggest that the practice of mindfulness is associated with changes in attention skills and working memory. In some ways, this isn’t surprising. Directing one’s attention in particular ways is central to the practice of mindfulness. It therefore seems plausible that repeated practice might lead to generalized changes in attention skills, which are closely related to working memory capacity. Advances in the ability to measure such changes, using objective computer-based tests of attention and working memory, have begun to shed light on the nature of these changes and how they may be related to the beneficial outcomes of engaging in mindfulness practices (Jha, Krompinger, & Baime, 2007).
How Distinct Are These Processes of Change?
Close examination of the processes of change discussed in this volume suggests that many of them are highly overlapping. As noted in chapter 1, mindfulness and decentering have very similar definitions. In the context of mindfulness-based treatments, both include nonjudgmental observation and acceptance of thoughts and feelings. Psychological flexibility, the focus of chapter 2, includes six processes, four of which are identified as mindfulness and acceptance processes. These include contact with the present moment, acceptance, defusion (which is similar to decentering), and recognition of the self as the context in which thoughts and feelings occur (rather than equating the self with the thoughts and feelings that come and go). Psychological flexibility also includes clarity about personal values (the topic of chapter 3) and engaging in values-consistent behavior even when unpleasant internal experiences are present. Similarly, emotion regulation, as defined in this volume and discussed in chapter 4, includes awareness and acceptance of emotions, along with willingness to engage in goal-directed behavior while experiencing negative emotions. A prominent definition of self-compassion, the focus of chapter 5, includes mindfulness as a central component. Spirituality, the topic of chapter 6, is defined in a variety of ways but can include compassion and a sense of higher meaning. The latter might be consistent with values as conceptualized in ACT. Spirituality defined as the transcendence of self might also be consistent with the self-as-context element of psychological flexibility (see Hayes, 1984). Additional research is required to clarify the commonalities and distinctions among these processes.
What About Other Processes?
The recent literature addresses many other psychological processes that may be important in various forms of psychopathology. An excellent discussion can be found in Harvey, Watkins, Mansell, and Shafran (2004), a book that identifies several processes that appear to be transdiagnostic; that is, they are common to several disorders and may be causal or maintaining factors. Examples include selective attention, overgeneral memory, thought suppression, and rumination. These processes are not the focus of chapters in this volume because they are conceptualized as intermediate outcomes between the processes described here and improved psychological functioning. That is, the development of mindfulness, decentering, psychological flexibility, acceptance-based emotion regulation, and so on, should cultivate flexibility of attention, observational noting of thoughts as thoughts rather than rumination, and willingness to experience unpleasant thoughts, memories, and emotions as they arise rather than attempting to avoid or suppress them.
Conclusions
The processes of change addressed in this volume are exciting because they are relatively new to the literature and have previously received little or no attention in empirically supported treatment approaches (Hayes, Follette, & Linehan, 2004). The study of mediation is also relatively new. Until recently, the treatment outcome literature rarely included analyses of mediation. Now mediational studies of mindfulness- and acceptance-based treatments are making substantial contributions to our understanding of how these treatments work. The evidence suggests that they work according to the theorized processes and that they work differently from traditional cognitive behavioral treatments (Zettle, Rains, & Hayes, in press). Chapters in part 1 of this book will discuss each of the processes introduced here. Although they are addressed separately, it is important to remember that several of them are highly overlapping and that future work will elucidate their similarities and differences. Chapters in part 2 of this book discuss processes of change in specific populations, including children and adolescents, medical populations, and adults in the workplace.
