Mindfulness

Introduction Mindfulness has gained considerable attention in health related literature over the last two decades with the influx and increasing acceptance of Eastern practices. Mindfulness has become popular, but, why is this so? Lewis (2006) captured the promise mindfulness holds for counseling professions, “For decades,we have been interested in discovering the common curative ingredients uniting the various forms of psychotherapy. Mindfulness appears to be one of those factors, much like the therapeutic alliance or mentallization (p. 83). What is mindfulness? The first broad use of the term mindfulness originates from the English language and relates to having implicit awareness of context and informational content (Langer, 1989), such that a counselor might be mindful of culture, client developmental needs or standards of practice. Mindfulness by this definition means to take heed of or to take care (Dryden & Still, 2006). This is not the type of mindfulness addressed within this article. Mindfulness will refer to our second usage which is an English transliteration of the Pali word Sati (Germer, Siegel, & Fulton, 2005). Mindfulness can be simply described as purposely placing one’s attention in the present in a non-judgmental way while limiting evaluative thought processes. This second usage of the word mindfulness is contingent upon the regulation of attention (Kabat-Zinn, 1990). According to Brown and Ryan (2003), attention and awareness are basic components of consciousness that have distinctive functions. There is awareness which registers stimuli by “searching the inner and outer environment” like radar would register flying objects in a certain field of airspace, and attention, the capacity to narrow the focus to specific stimuli within 14 awareness, much like a spotlight can pick out an object in space (Brown & Ryan, p. 243). For example, a counselor may sit in session and have a floating awareness of the many of internal and external stimuli such as the content of conversation, internal emotions, nonverbal communication, sound of the heater, or sun coming in through the window. From the field of awareness, the counselor’s attention might focus primarily on stimuli most important to counseling: a client non-verbal reaction, the counselors own internal response, the memory of what was just said, and the client’s facial expressions. In an interview with Sykes Wylie and Simon (2004), Jon Kabat-Zinn commented, “Mindfulness is really about bringing attention to virtually any situation or any circumstance or any mental state. It’s not about staying in any one particular state” (p. 64). It allows for a state of mind that is alert, relaxed, and “aware of our thoughts without identifying with them or allowing them to take over” (Ladner, 2005, p. 19). Germer et al. (2005) suggested, “Mindfulness is simply about being aware of where your mind is fromone moment to the next, with gentle acceptance” (p. xiii). The practice is usually as simple as resting attention on the immediate task at hand-i.e., smelling coffee, listening to the sound of a passing car, feeling wool or a pine cone, noticing the bodily sensation of gravity while swaying, or perhaps, observing the sensationsofbreathing during consecutive exhalations. The important aspect of mindfulness practice is to “remember to reorient” and to gently do so whenever elaborative patterns of thinking arise have clouded direct experience (Germer, 2005, p. 6). The professional literature has also examined mindlessness which points to what mindfulness is not. In the literature, mindlessness is defined as focused attention on a subset of contextual cues that “trigger various scripts, labels and expectations, which in 15 turn focus attention on certain information while diverting attention away from other information” (Nass & Moon, 2000, p. 83). Hayes and Shenk (2004) noted that verbal events are important and essential to psychological flexibility and creativity, however sometimes the functions of language dominate one’s sense of reality thus creating inflexibility. As an example, a counselor ruminates on a therapeutic rupture with a client and is thereby unavailable to the client in the present moment. Mindlessness may also be acting automatically or rushing around with a scattered mind. One might say mindfulness techniques help a person be more open to the many facets of experience because they are not caught up in mindlessness (Kabat-Zinn, 2005; Langer, 1992). In contrast to mindlessness, mindfulness is resting attention with an attitudinal disposition of non-striving, non-judgment, acceptance and non-conceptual curiosity. Mindfulness is not a trance, hypnotic state or dissociation. So it is neither a method to escape or avoid life, nor is it thought blocking, or even, surprisingly, a solution to the fact of decay, disease and death. It is a technique used to live in the present moment as fully as possible despite aspects of pain or pleasure. “Mindfulness is a deceptively simple concept that is difficult to characterize accurately” (Brown & Ryan, 2003, p. 242). In the literature, mindfulness has been referred to in several ways: as a psychological process, as a method or practice, and also as a skill that can be developed (Germer, 2005; Hayes & Wilson, 2003; Kabat-Zinn, 2003). Multiple meanings attributed to the word mindfulness have led to some confusion and difficulty when defining this construct (Hayes & Shenk, 2004). Bishop and colleagues (2004) formed a professional panel on mindfulness to propose by consensus an operational definition of mindfulness for empirical research. They proposed a two 16 component model of mindfulness that emphasized the cognitive processes of mindfulness practice. The first component of this model involves the “self-regulation of attention” so that it is centered on immediate experience of internal and external stimuli and involves metacognition, or in other words “the recognition of mental events occurring in the moment. The second component involves adopting a particular orientation toward one’s experiences in the present moment, an orientation that is characterized by curiosity, openness and acceptance” (p. 232). Hayes and Shenk noted that this is a good start in advancing the definition of mindfulness for research, but “seems to give less emphasis to a nonevaluative perspective, to context, to observing and describing, or to a basic perspective on language and cognition” (p. 253). Shapiro, Carlson, Astin, and Freedman (2006) also noted that Bishop’s definition overlooks the importance of intention to mindfulness practice. Mindfulness has been referred to as a technique or method. For example, practicing mindfulness is often taught as a structured step-by-step process which involves: (a) resting attention on current experience with an accepting and open attitude, (b) catching/noticingwhen attention is narrowed to consuming thoughts (e.g., noticing rumination about personal financial problems), (c) remembering to reorient, (d) reorienting or “switching” attention to current experience without judgment of the previous distraction( Bishop et al., 2004, p. 231), and then, (e) when the practice period is over, cease to practice. Sometimes another step is added, which is labeling, noting or naming the mental state (e.g., fantasy) prior to reorienting the mind. Mindfulness is also associated with the practices that were traditionally taught in Buddhism. Some of the more central practices are body scanning, mindfulness of 17 breathing, walking meditation and sitting meditation (Gunaratana, 2002; Kabat-Zinn, 2005). Body scanning is taught as a formal practice or technique where it is important to maintain “awareness in every moment, a detached witnessing of your breath and your body, region by region, as you scan from your feet to the top of your head” (Kabat-Zinn, 1990, p. 89). During the practice of body scanning one systematically observes the body, one area after another, primarily recognizing any and all sensations (painful, pleasant or neutral), and secondarily external events, emotions, and cognitions that may arise while observing the body (Hamilton, Kitzman, & Guyotte, 2006). When attention is consumed by mindlessness (e.g., excessive worry about the body), the practitioner notices this mental activity (possibly labeling it “worry”), and then gently reorients attention back to the body and breath. As another example of a traditional mindfulness exercise, walking meditation is taught as a technique in various forms (e.g., fast or slow, unstructured or deliberate path of movement), but essentially in walking meditation one observes the present-moment experience of walking (Kabat-Zinn, 1990). Mindfulness is also referred to as a skill (Germer, 2005), because mindfulness methods and their related qualities of mind and body can be developed with practice. For example, Valentine and Sweet (1999) found that as the practice of mindfulness and meditation increases so too does the ability to sustain attention. Brown and Ryan (2003) commented that although attention and awareness are basic and natural capacities of most people, they observed, “(a) that individuals differ in their capacity and willingness to be aware and to sustain attention to what is occurring in the present and (b) that this mindfulness capacity varies within persons because it can be sharpened or dulled by a variety of factors” (p. 822). Bishop and colleagues (2004) made the observation that 18 mindfulness requires ability, the ability to switch back or return one’s attention to a given stimuli. However, Hayes and Shenk (2004) added that many other methods for sustaining attention may exist without the ability or skill of switching one’s attention. In theory, mindfulness is also a skill that may transfer across learning and behavioral domains, such that those who learn to focus on the present experience of breathing are better able to transfer the ability to be present for other experiences such as eating, communicating, observing difficult emotions or pain, and riding a bike. Finally, to the degree that one automatically engages in mindfulness, mindfulness can be defined as a habit. Ideally, mindfulness is a habituated way of being, a way of being flexible and open. The philosophy informing mindfulness training places emphases on the actual practice ratherthan on goal attainment. Many western therapies and mindfulness meditation ease suffering; however, in its traditional sense, mindfulness is not practiced to get rid of disease and disorder. Furthermore, the theoretical underpinnings do not assume pathology (Hamilton et al., 2006). For example, at first glance, mindfulness practice appears to be a relaxation technique. However, unlike relaxation techniques which are expressly used to reduce undesirable conditions of body and mind, mindfulness methods create conditions for acceptance and put the practitioner in touch with the multiple experiences and layers of self. Efforts to make progress are not central while engaging in mindfulness practice, though paradoxically, clients and even the helper must have a reason for practicing mindfulness methods in the first place. Mindfulness also entails an orientation toward certain attitudes. Kabat-Zinn (1990) suggested that a non-judging stance, patience, adopting a beginner’s mind, trusting yourself and experience, non-striving, acceptance, and an ability to let go or 19 release attachment to conditions. It is not that one maintains all of these attitudes while practicing, but that the overall practice is marked by these attitudes. Furthermore, these listed attitudes simply point at the felt experience, orientation or space that is occupied when practicing mindfulness. Gunaratana (2002) provided a series of rules or slogans to remember about the right attitudinal orientation: “don’t strain,” “don’t rush,” “don’t expect anything,” “don’t cling to anything or reject anything,” “let go,” “accept everything that arises,” “be gentle with yourself,” “investigate yourself,” “view all problems as challenges,” “don’t ponder,” and “don’t dwell upon contrasts” (pp. 39-42). Mindfulness and meditation The terms mindfulness, meditation and mindfulness meditation are often used interchangeably. As noted above, discussing mindfulness may be confusing because different “psychological processes and methods are described with the same term” (Hayes & Wilson, 2003, p. 166). Conversely problematic, multiple terms refer to the same mindfulness practice adding to confusion. So for example, placing attention on the experience of walking might be referred to as mindful walking, walking meditation, or kinhin. After all, mindfulness is a pre-scientific activity and concept that has not yet fully matured in a coherent manner conducive to scientific research (Hayes & Wilson). For this reason, mindfulness meditation often refers to the traditional exercises of Buddhism. In English, the term meditation describes many different activities (e.g., guided meditation, contemplative meditation, mindfulness meditation, devotional meditation) and seems to have been the best word to capture the essence of the practices that had come from the East. Regardless of whether the term mindfulness or meditation is applied, mindfulness methods have various attentional foci, but essentially they support non-20 evaluative observation (Hamilton et al., 2006). So for the current research, meditation refers to those types of meditation that do not intentionally focus on cognitive content or contextual factors (e.g., devotion or contemplation). The exception to this is that at times one might label or name the mental content before returning focus in mindfulness meditation. A distinction can also be made between mindfulness meditation and other types of meditation based on the rigor of attention regulation. One way to conceptualize the difference is by viewing meditation as either concentrative or receptive in how attention is regulated (Valentine & Sweet, 1999). In concentrative meditation (e.g., Transcendental Meditation), a specific focus is vigorously maintained, or even manipulated, to the exclusion of all other stimuli (Brown, 1977; Takahashi et al., 2005). In this style, one returns to the narrow focus of concentrative attention. In receptive meditation (e.g., mindfulness) one has a ‘wide-angle lens’ approach and broadly orients to a range of stimuli (Shapiro, 1982). Mindfulness meditation requires self-regulation of attention and monitoring of mental activity but has a quality of pure observation of phenomena. Research comparing these two types of meditation has demonstrated differences in how each type cultivates attention (Valentine & Sweet) and effects psychophysiology (Takahashi et al.). History of Mindfulness So is mindfulness a fad or here to stay? Mindfulness has been practiced in the East for at least 2,500 years. It is part of the repertoire of Eastern physical, mental and spiritual health. In the West, long standing meditation traditions emphasized devotion and contemplation making the introduction of mindfulness with its present moment 21 orientation a new addition. Mindfulness emerged out of the tradition of Buddhism. It’s in its early stages of Western clinical use and empirical study. Buddhism’ historical founder, Gautama Buddha(Siddharth), taught techniques such as meditation and mindfulness as part of a spiritual path that addresses Dukkha, a complex term often described as suffering, but includes a more basic human sense of unsatisfactoriness that arises in response to unavoidable painful and pleasurable life circumstances (Carlson, 1989; Schumacker & Woener, 1994; Styrk, 1968). Though mindfulness has its origins in Buddhism, it is a basic technique that has widespread cross-cultural applications. This undoubtedly is due to its emphasis on experiential reality rather than on particular cultural constructs or informational content. Baer (2003) remarked that mindfulness techniques can be taught in the context of western mental health without reliance on Buddhist spiritual teachings. The field has taken steps in order to separate the religious context from the clinical training of clients (Dimidjian & Linehan, 2003). Seemingly, this has not been a difficult process. Mindfulness use was popularized in health settings by the work of Jon Kabat-Zinn at the Massachusetts’ Medical School and by the publication of his highly useful and practical book on mindfulness, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face, Stress, Pain and Illness, now in its 15th anniversary revised edition (Kabat-Zinn, 1990, 2005). This book introduced the American lay person to mindfulness, but also to a novel wellness idea that is latent in the method: mindfulness is not primarily an allopathic or naturopathic cure, but a way to face and embrace symptoms, illness, ourselves and life. One can face and embrace difficulty with attention and acceptance, and the subsequent result is reduced symptoms, better health and improved quality of life. Kabat-Zinn’s introduction of Mindfulness Based Stress Reduction (MBSR), a 22 mindfulness-based treatment program, gained wide acceptance and continues to receive support from emerging research. As its popularity grew as a practical tool, researchers began to make efforts to define mindfulness and to understand its effects on physical and mental health (Bishop et al., 2004,Shapiro et al., 2006). Research into mindfulness has examined benefits that apply to both the counselor and client when they practice mindfulness (Christopher, Christopher, Dunnagan, & Schure, 2006; Newsome, Christopher, Dahlen, & Christopher, 2006). Furthermore, research has investigated the effects of mindfulness use in clinical settings noted by the following categories: (1) the effects of mindfulness training on clients or the training of clients to use mindfulness methods on their own, (2) the effects of counselor mindfulness as a result of personally practicing mindfulness outside of counseling sessions, and (3) the effects of counselor in-session mindfulness. The majority of research in health related fields has examined clinical outcomes when clients are trained to use mindfulness practices. Mindfulness training is in the process of being adopted into healthcare systems (Bonadonna, 2003; Shigaki, Glass, & Schopp, 2006). Within healthcare, mindfulnessbased techniques havebeen integrated as an adjunct to conventional treatment modalities. Research has suggested that mindfulness-based interventions are effective for treatment of physical symptoms. It has been applied as a primary, secondary and tertiary intervention strategy (Bonadonna) for clinical work with disease, disorders and symptoms that range from the acute (e.g., headaches) to the chronic (e.g., HIV, cancer). Mindfulness has been applied to a number of physical health problems such as high blood pressure and cholesterol levels (Ryback, 2006), cancer (Ott, 2006), Psoriasis (Kabat-23 Zinn, 2003, Kabat-Zinn et al., 1998), traumatic brain injury (Bẻdard et al., 2003; McMillan, Robertson, Brock, & Chorlton, 2002), insomnia (Lundh, 2005; Thomas, Inka, Burkhard, Matthias, & Johannes, 2006). Mindfulness methods have been used in symptom management, but also with assisting client acceptance of health concerns, resulting in decreased levels of perceived pain (Dahl & Lundgren, 2006; Plews-Ogan, Owens, Goodman, Wolfe, & Schorling, 2005). It has been used successfully in palliative care as well (Bruce & Davies, 2005; Plews-Ogan et al.). In western mental health, mindfulness has been “adopted as an approach to increasing awareness and responding skillfully to mental processes that contribute to emotional distress and maladaptive behavior” (Bishop et al., 2004). Research has shown mindfulness to be effective in the treatment of anxiety disorders (Semple, Reid, & Miller, 2005), depression (Rokke & Robinson, 2006; Telner, 2005), borderline personality disorder (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006; Shaw Welch, Rizvi, & Dimidjian, 2006), addiction (Bowen et al., 2006), and eating disorders (Baer, Fischer, & Huss, 2005; Kristeller, Baer, & Quillian-Wolever, 2006). Thus far, research has been positive, however, research on mindfulness has been mostly done without control groups and has drawn results from research on treatment packages, such as MBSR, making it tough to note the variables related solely to mindfulness (Allen et al., 2006, Grossman, Niemann, Schmidt, & Wallach, 2004; Hamilton et al., 2006; Shigaki et al., 2006). The desire to explore effects of mindfulness-based methods appears to be increasing. Another important step has been the advent of mindfulness-based treatment programs and therapies, also referred to as treatment packages. Mindfulness-based treatment packages bundle together a set of different mindfulness exercises to be learned 24 or applied over several sessions. They may entail traditional mindfulness exercises or methods that encourage mindfulness (Hayes & Shenk, 2004). For example, Kabat-Zinn’s (2003, 2005) Mindfulness Based Stress Reduction (MBSR) program teaches clients how to use and integrate traditional mindfulness skills such as bodyscanning, mindfulness of breath, walking meditation, and eating mindfully. Other treatment programs combine or integrate mindfulness methods with other treatment modalities and interventions. For example, Mindfulness Based Cognitive Therapy (MBCT) uses mindfulness methods in conjunction with Cognitive Therapy (CT) (Segal, Teasdale, Williams, & Gemar, 2002; Teasdale & Williams, 2000). Treatment packages have allowed for a more standardized and even manualized approach to imparting these methods and carrying out research. The most commonly used packages outside of MBSR and MBCT are Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy .