PLEASE SCROLL DOWN FOR ARTICLE
Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-acces...
Teaching mindfulness to psychotherapists in clinical practice: The
Mindful Therapy Programme
CAMERON AGGS1
* & MATTHEW BAM...
reductions in stress, state and trait anxiety, negative
affect and rumination, as well as increased self-
reported empathy...
were followed up. The most common reason parti-
cipants stated for dropping out was difficulty mana-
ging the travel and t...
indicated ‘Demonstrates no understanding/no skills
identified’ to 3/4 (‘Demonstrates excellent under-
standing/all skills ...
Results
Treatment of data (MT-S)
The results of data testing supported the assumption
of normality, with skewness and kurt...
Mean, standard deviation, and t-test results for the
Mindful Therapy Scale (MT-S)
Analysis of t-tests for the MT-S reveale...
ratings of the relevance of mindfulness within clinical
settings and confidence in using mindfulness within
client related...
conclusions regarding generalisability of state-based
attending skills can be made to therapy settings.
Limitations
There ...
Germer, C.K. (2005). Mindfulness: what is it? What does it
matter? In C.K. Germer, R.D. Siegal & P.R. Fulton (Eds.),
Mindf...
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Teaching Mindfulness to Clinicians (Cameron Aggs)

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Teaching Mindfulness to Clinicians (Cameron Aggs)

  1. 1. PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
  2. 2. Teaching mindfulness to psychotherapists in clinical practice: The Mindful Therapy Programme CAMERON AGGS1 * & MATTHEW BAMBLING2 1 Mindfulness Training Australia, Maroochydore and Brisbane, Australia, and 2 Australian Catholic University, Psychology, Virginia, Australia Abstract Introduction: Initially proposed as a treatment modality for psychological disorders, mindfulness is now being promoted as a means of enhancing both therapist self care and therapeutic efficacy. The degree to which mindfulness can be learned by therapists to manage their own and clients’ processes in therapy is as yet unknown. This study examines training outcomes of a standardised introductory mindfulness programme for mental health professionals. Methods: Forty-seven mental health professionals completed an eight-week mindful therapy (MT) training programme and associated measures. Results: Compared with baseline scores, participants demonstrated knowledge acquisition on all measures, including increased mindfulness in clinical work, increased capacity to intentionally invoke mindful states of consciousness, and higher participant ratings of well-being over the course of training sessions. Discussion: This research provides preliminary evidence that a brief, standardised mindfulness training programme can achieve acceptable knowledge and skills outcomes for therapists that can aid their therapeutic practice. Of note, increased ‘therapeutic mindfulness’ in this study resulted from changed mindfulness ‘attitudes’ (i.e. a more accepting and equanimous orientation within therapeutic work) as opposed to a clear demonstration of increased attention-regulation skills. The implications of these and other results for programme development and wider research are discussed. Keywords: mindfulness; Mindful Therapy Scale; therapist well-being Introduction There has been increasing interest in the therap- eutic potential of mindfulness in recent years (Kabat-Zinn, 2009). Mindfulness can be described as the practice of being present with the immediate experiences of our lives. Mindfulness states of mind are cultivated through the self-regulation of attention on moment-to-moment experience, underpinned by attitudes of acceptance, curiosity, and non-judgmental warmth (Shapiro, Carlson, Astin, & Freedman, 2006). Central to this capacity is the ability to inhibit secondary appraisals (Segal, Williams, & Teasdale, 2002), and to return one’s attention to the present moment when distracted (Bishop et al., 2004). To date mindfulness has been incorporated into psychodynamic (Safran & Reading, 2008), cognitive and behavioural (e.g. Hayes, Strosahl, & Wilson, 1999; Roemer & Orsillo, 2008), humanistic (e.g. Andersen, 2005), attachment-based (Wallin, 2007), and positive psychology frameworks (e.g. Hamilton, Kitzman, & Guyotte, 2006). Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1982), Mindfulness Based-Cognitive Therapy (MBCT; Segal et al., 2002), Dialectical Behaviour Therapy (DBT; Linehan, 1993), and Acceptance and Com- mitment Therapy (ACT; Hayes et al., 1999) appear to be the most widely used modalities. In addition to its role as a clinical intervention, mindfulness may have applications to increase both the well-being and effective practice of therapists. In relation to well-being, a study conducted by May and O’Donovan (2007) found that higher levels of mindfulness was associated with increased work satisfaction, as well as decreased burnout among mental health professionals. In addition, therapists participating in MBSR courses have demonstrated *Corresponding author. Email: cam@bemindful.com.au Counselling and Psychotherapy Research, December 2010; 10(4): 278Á286 ISSN 1473-3145 print/1746-1405 online # 2010 British Association for Counselling and Psychotherapy DOI: 10.1080/14733145.2010.485690 DownloadedBy:[Aggs,Cameron]At:09:2124November2010
  3. 3. reductions in stress, state and trait anxiety, negative affect and rumination, as well as increased self- reported empathy, positive affect and self- compassion, when compared with controls (Shapiro, Astin, Bishop, & Cordova, 2005; Shapiro, Brown, & Biegel, 2007). There is also preliminary evidence to suggest that therapists might enhance client out- comes after they have received mindfulness training (Grepmair, Mitterlehner, Loew, Bachler, et al., 2007; Grepmair, Mitterlehner, Loew, & Nickel, 2007). However not all studies have shown a positive correlation between therapist mindfulness and client outcome (Stanley, Reitzel, Wingate, Cukrowicz, Lima, & Joiner, 2006). Mindfulness training protocols for clinicians re- ported in the literature have been provided using a curriculum based on Zen meditation practice (e.g. Grepmair et al., 2007; Grepmair et al., 2007), or within modality specific frameworks such as MBSR. These training formats often do not include a focus on therapy-related skills. This may be problematic given findings that in certain circumstances (e.g. when therapists in training are using manualised treatments), higher levels of therapist mindfulness may be counterproductive (e.g. Stanley et al., 2006). To address this issue, a new clinically focused mindful therapy (MT) programme has been devel- oped to teach mindfulness relative to therapy specific skills. In this new programme mindfulness skills are first taught in relation to therapist practice and self- care. They are then applied within the context of empirically supported therapeutic relationships skills. These include managing the therapeutic alliance, client-centred delivery of therapeutic tech- niques, therapist empathy, working through rup- tures and strains, as well as the use of the Self (for a review see Norcross, 2002). There is considerable evidence pointing to the importance of therapist specific and relationship variables with relation to client outcome (Lambert & Simon, 2008), and considerable overlap between these skills and mind- fulness processes (Germer, 2005). This provides a robust rationale to focus on these aspects in MT training. An important issue with progressing this research is that none of the existing published measures of mindfulness contain items relating to mindfulness within the therapy setting. As a result, a clinically specific mindfulness measure (the Mindful Therapy Scale: MT-S) has been developed for this study to evaluate therapists’ mindfulness relative to therapist- client variables. It is expected that the development of a therapist specific MT programme will provide the basis for further investigations into whether teaching mindfulness to therapists translates into enhanced client outcomes, and if so what skills or processes might be the mechanisms in predicting outcome. Hypotheses After completing the MT training programme parti- cipants will have significantly higher post-training declarative knowledge scores compared to baseline. Participants will also demonstrate attitude change with respect to using mindfulness within client- related work. In addition, participants’ data will reflect significantly higher post-training ratings of well-being compared to baseline. Participants will also have a significantly higher post-training capacity to invoke a mindfulness state compared to baseline. Lastly, after completing the MT training pro- gramme, participants will indicate through self- report a significantly higher capacity for in-session mindfulness compared to baseline. Method Aims The current study aims to examine whether a clinically focused mindfulness training programme for therapists can be standardised and taught to clinicians, as evaluated by (1) skill and knowledge acquisition, and (2) attitude change among thera- pists who complete the programme. Participants The lead author, as part of a research project for a higher psychology degree, provided five separate training programmes to participants at the Queens- land University of Technology over a 14-month period. Seventy-seven participants commenced the mindful therapy (MT) training programme, and 58 (74%) completed six to eight sessions of the programme. Consistent with Shapiro et al. (2005), six sessions constituted the minimum training con- sidered necessary to acquire core knowledge and skills, and provided the minimum session number cut off for data used in this study. Forty-seven participants attended an optional time delayed ninth session where follow up post-measures were admi- nistered. A cross-section of course drop-outs (n04) Teaching mindfulness to psychotherapists in clinical practice 279 DownloadedBy:[Aggs,Cameron]At:09:2124November2010
  4. 4. were followed up. The most common reason parti- cipants stated for dropping out was difficulty mana- ging the travel and time commitments of attending training. Participants beginning training included 45 psychologists, eight social workers, seven clinical nurses, four counsellors, two occupational therapists and two psychiatrists. Participants were 96% female with a mean age of 40.24 years (SD013.84). Seventy-eight percent (78%) were Caucasian, and 22% were of Asian descent. Over 80% of participants indicated that they had either little or no history using mindfulness, either as a personal practice or as a client-related technique. Nine percent (9%) of participants were recruited from the same degree cohort as the lead author (group 1), 10% were recruited from a local psychology practice (group 2), and 81% of partici- pants were recruited via email sent through university contacts to community-based mental health workers (groups 3Á5). Diverse professional and employment settings of participants protected against recruitment bias. Anonymity of responses was achieved through de-identification of coded data. Design and procedures A repeated measures training design, utilising a within-subjects comparison of pre- and post-course data was used for this study. The three-module programme was delivered at weekly intervals of 1.5 hour sessions over an eight-week period. Each training session typically consisted of two new topics (40 minutes in total), up to three experiential exercises (30 minutes in total), and a group discus- sion (5 minutes). Weekly training sessions included discussing homework assignments towards the be- ginning and end of each training session (10 minutes total). Manual and programme development The workshop content consisted of mindfulness as a personal practice (module I); mindfulness as a psychotherapy process skill (module II); and an introduction to mindfulness as an intervention (module III). The module one content (weeks 1Á3) was concerned with enhancing participants’ declara- tive and experiential knowledge of mindfulness. The theoretical content of this module was drawn from the IAA model of mindfulness proposed by Shapiro et al. (2006), and was informed by research con- ducted by Baer, Smith, Hopkins, Krietemeyer, and Toney (2006), relating to facets of mindfulness derived from available mindfulness measures. The experiential content of this module was informed by guided meditations used in the MBSR protocol (Kabat-Zinn, 2005). In module two (weeks 3Á5), participants were presented with an overview of the ‘relational mind- fulness’ framework proposed by Surrey (2005). In this module, therapists applied their growing under- standing of mindfulness skills to psychotherapy processes, such as maintaining the therapeutic alli- ance, working with ruptures and strains, and for enhancing ‘process empathy’ (Bohart, Elliott, Greenberg, & Watson, 2002, p. 90). The module three sessions (weeks 6Á8) included opportunities for participants to practise delivering the Three-Minute Breathing Space technique (Segal et al., 2002). In addition, this module focused on therapist and client factors relevant to the integration of mindfulness into therapeutic work. In the final week, participants were provided with a list of resources for facilitating ongoing engagement with mindfulness education and practice. Measures Mindful Therapy Questionnaire. The Mindful Ther- apy Questionnaire (MT-Q) was designed for this study due to available mindfulness measures being general and not specific to counselling and psy- chotherapy practice. To measure participants’ atti- tudes towards using mindfulness, participants on MT-Q were asked to rate their confidence using mindfulness with clients, their intentions to inte- grate mindfulness into their work, and how rele- vant they saw mindfulness within therapeutic settings. Each question was measured on a 1 (not at all) to 10 (extremely) scale. In addition, three questions requiring written responses were developed to evaluate participants’ learning outcomes from the programme. These questions assessed participants’ knowledge of mindfulness relating to: (a) ‘attending skills’ of mindfulness; (b) mindfulness attitudes (see Shapiro & Carlson, 2009); and (c) the relationship between mindfulness and psychotherapy process skills. Each question was analysed using a coding system based on the learning objectives of the first two modules of the training programme. Responses were rated by the lead author and co-rated by an independent rater for accuracy. The rating system was based on a four- and five-point scale where (0) 280 C. Aggs & M. Bambling DownloadedBy:[Aggs,Cameron]At:09:2124November2010
  5. 5. indicated ‘Demonstrates no understanding/no skills identified’ to 3/4 (‘Demonstrates excellent under- standing/all skills and attitudes identified’). The lead author determined rankings of acceptable responses and a table of these responses were provided to the co-rater. The co-rater was a practising psychologist with experience in mindfulness practices. Rater training was provided to ensure understanding of the concepts and rating method. Inter-rater relia- bility was .95, which is considered to indicate a high level of reliability (Landis & Koch, 1977). Mindful Therapy Scale (Modified from the Five Facet Mindfulness Questionnaire; Baer et al., 2006). The 24-item Mindful Therapy Scale (MT-S) was de- signed for the present study as there was no suitable pre-existing published measures to assess in-session therapist mindfulness (or ‘therapeutic mindful- ness’). Constructs measured on this inventory mirror those on the original questionnaire (Baer et al., 2006), and related to non-reactivity to inner experience (example: ‘When I am with clients I can have strong feelings and emotions without reacting to them’); Observing/noticing/attending to sensa- tions/perceptions/ thoughts/feelings (example: ‘I no- tice how my emotions express themselves through my body when I work with clients’); Acting with awareness/automatic pilot/concentration/ non-dis- traction (example: ‘At times I struggle to tune into my clients’); Describing/labelling with words (ex- ample: ‘When I am with clients I have trouble thinking of the right words to express how I feel about things’); Accepting/non-judging of experience (example: ‘I can be highly self-critical in relation to my clinical work’). The overall Mindful Therapy measure evidenced good reliability for the full-scale score (Cronbach’s Alpha of .79). Reliability estimates for sub-scales varied with .71 (non-react), .83 (observe), .75 (describing), .57 (non-distract), and .62 (non- judge/accept). These estimates are lower than relia- bility estimates (range .75Á.91) reported by Baer et al. (2006). Copies of the MT-S can be obtained by request to the corresponding author. The Five-Minute Mindfulness Scale (FMMS). The FMMS was developed by the lead author to measure participants’ capacity to enter into and maintain a mindful state upon request. Items on this measure relate to ‘Non-distraction’, ‘Attention switching’, ‘Letting-go/non-elaboration of thoughts’, and ‘Com- fort and ease of the practice’ (which was interpreted as a measure of mastery). Each individual construct is measured by a single question measured on a 1 (very difficult) to 10 (very easy) scale. The reliability estimate for the FMMS was an alpha of .84. The scale included items such as ‘Thoughts, feelings, and sensations were allowed to rise and pass freely’ (Letting-go), and ‘Sustaining attention on immediate experience’ (Non-distraction). An alter- native measure for ‘invoked mindfulness’ is the Toronto Mindfulness Scale (Lau et al., 2006) which was not known to the research team at the time of this study. However, the FMMS mapped onto the training concepts taught in the study directly there- fore has a high degree of suitability. Stress and tension ratings. A simple participant stress measure was developed by the lead author as a pre- and post-rating of each session’s impact on stress levels. The measure is comprised of two items relating to stress and tension, rated on a 10-point scale. 1 (Not at all stressed) to 10 (very stressed), and 1 (no tension) to 10 (significant tension). The stress and tension measure was administered prior to and at the end of training each week. Responses were tallied and divided by the number of training sessions in order to deliver estimates of the average pre and post rating following every session. Participant Satisfaction Survey. The Participant Sa- tisfaction Survey contains seven items, each scored on a 1 (Strongly disagree) to 10 (Strongly agree) scale, with the exception of the question regarding parti- cipant expectations, which is measured on a 1 (Fell below expectations) to 10 (Exceeded expectations) scale. It was administered subsequent to training with other post-measures in the ninth week at follow-up. It contained statements such as ‘I will draw upon the skills I have used in this course in my therapeutic work’ and ‘I got less/more out of the course than I expected.’ Ethical considerations This study received ethical clearance by the Queens- land University of Technology ethics committee. All participants were informed of their right to withdraw from the study without penalty. Informed consent was obtained from all participants prior to their involvement in the first session of the course. Teaching mindfulness to psychotherapists in clinical practice 281 DownloadedBy:[Aggs,Cameron]At:09:2124November2010
  6. 6. Results Treatment of data (MT-S) The results of data testing supported the assumption of normality, with skewness and kurtosis ranges being within acceptable limits (B 2). These assumptions were upheld by visual inspection of histograms. Probability levels were maintained at .05 for multiple analyses due to the a priori nature of the hypotheses. Whereapplicable,datawerereversecodedbeforescoring. Mean, standard deviation and t-test results for the Mindfulness and Learning Outcomes Measure Participants’ knowledge of mindfulness was assessed by obtaining qualitative responses on the MT-Q which were coded by themes, and then rated for accuracy in line with the course content by the programme facilitator and co-rater. Results of the three questions were pooled to create a total knowl- edge construct (see Table I). Compared to baseline, participants’ total knowledge had increased signifi- cantly post training (pB.01). Significant preÁpost differences were observed for each individual con- struct (all p valuesB.01). Mean, standard deviation, and t-test results for attitude change on the Mindful Therapy Questionnaire Compared to baseline, participants’ confidence with integrating mindfulness into therapeutic work was significantly higher at post review (pB.01), as was participants’ perceptions of the relevance of mindfulness in relation to their therapeutic work (p0.01). No change was demonstrated in partici- pants’ intentions to integrate mindfulness within their therapeutic work (see Table II). Mean, standard deviation, and t-test results for the Stress and Tension Measure The results of t-tests revealed that participants reported feeling significantly lower levels of stress after training sessions when compared to their ratings immediately prior (pB.01). The same pat- tern of results was true for participants’ scores on perceived tension (pB.01). The average reduction in mean stress scores across participants was 36.5%. The average reduction in tension during training sessions was 33.9% (Table III). Mean, standard deviation, and t-test results for the Five- Minute Mindfulness Scale The FMMS measured participants’ capacity to invoke mindfulness on request. Compared to base- line, participants’ scores on the non-distraction con- struct increased significantly post-training (p0.01), as did scores on constructs relating to attention switching (p0.01), letting-go/non-elaborative aware- ness (pB.01) and for mastery (pB.01) (Table IV). Table I. Mean, standard deviation and t-test results for the Mindfulness and Learning Outcomes Measure. Pre test Post test M SD M SD df t p Total knowledgea 2.28 1.38 7.15 2.01 46 13.37 .01 Mindfulness and psychotherapy process skillsb .60 .83 1.83 2.20 46 5.67 .01 Attending skillsc 1.02 .71 3.11 1.07 46 10.86 .01 Mindfulness attitudesd .66 .64 2.19 .71 46 11.60 .01 Note: M0mean; SD0standard deviation; df0degrees of free- dom; t0t value, p0significance level; a scores range from 0Á11; b,c measured on 0Á4 point scale; d measured on a 0Á3 point scale. Table II. Mean, standard deviation, and t-test results for attitude change on the Mindful Therapy Questionnaire. Pre test Post test M SD M SD df t p Confidence 3.85 2.63 6.13 1.83 46 6.10 .01 Relevance 7.38 2.03 8.23 1.53 46 2.56 .01 Intentions 7.64 1.92 8.00 1.70 46 1.08 .29 Note: Scales measured on a 10-point scale. M0mean; SD0standard deviation; df0degrees of freedom; t0t value, p0significance level. Table III. Mean, standard deviation, and t-test results for the Stress and Tension Measure. Pre test Post test M SD M SD df t p Stress 4.41 2.15 2.80 1.60 264 9.76 .01 Tension 4.78 2.16 3.16 1.66 262 10.30 .01 Note: Scales measured on a 10-point scale. M0mean; SD0standard deviation; df0degrees of freedom; t0t value, p0significance level. 282 C. Aggs & M. Bambling DownloadedBy:[Aggs,Cameron]At:09:2124November2010
  7. 7. Mean, standard deviation, and t-test results for the Mindful Therapy Scale (MT-S) Analysis of t-tests for the MT-S revealed that participants reported significantly greater in-session mindfulness on the global ‘Mindful Therapy’ mea- sure post training when compared to baseline (p0 .01). Relative to baseline, significant differences were found on scores of the non-judging/acceptance (p0.02) and the non-reactivity/equanimity con- structs (pB.01). No significant differences were found on measures of non-distraction, describing with words, and observing/internal attunement (see Table V). Range, mean, and standard deviations for the Participant Satisfaction Survey The Participant Satisfaction Survey was adminis- tered as part of the week 9 post-review. Whether the course met participants’ expectations was measured on a 10-point scale, where a score of five or six indicated ‘met expectations’. The programme met or exceeded expectations in 97.4% of cases. Results from other items also indicated high levels of satisfaction with the programme (see Table VI). Discussion The current study evaluated mindfulness training in relation to measures of therapist well-being, skill and knowledge acquisition, programme acceptability, and attitude change. Results provide preliminary evidence that a brief, standardised mindfulness training programme can achieve acceptable knowl- edge and skills outcomes for therapists that can aid their therapeutic practice. Regarding knowledge acquisition, participants demonstrated significantly higher post-training de- clarative knowledge scores when compared to base- line. Compared to responses given prior to training, participants’ scores were on average more than three times greater when measured post-training. Despite large improvements, scores on the mindfulness and psychotherapy process skills measure were not par- ticularly high when measured post-training. Contin- ued research and program development will be required to make this material more accessible to future participants. The hypothesis that mindfulness training in this study would be associated with positive participant attitudes regarding integrating mindfulness into ther- apeutic work was partially supported. Participants’ Table IV. Mean, standard deviation, and t-test results for the Five- minute Mindfulness Scale. Pre test Post test M SD M SD df t p Non distraction 5.27 1.97 6.28 1.95 46 2.79 .01 Attention switching 6.94 1.71 7.78 1.18 46 2.72 .01 Letting go/ non-elaboration 6.13 2.23 7.26 1.40 46 2.85 .01 Mastery (comfort and ease) 7.41 1.81 8.49 1.23 46 4.29 .01 Note: Scales measured on a 10-point scale. M0mean; SD0standard deviation; df0degrees of freedom; t0t value, p0significance level. Table V. Mean, standard deviation, and t-test results for the Mindful Therapy Scale (MT-S). Pre test Post test M SD M SD df t p Full scale score 6.36 .95 6.70 .90 46 2.70 .01 Non-judging/ acceptance 6.17 1.15 6.53 .99 46 2.46 .02 Non reactivity/ equanimity 6.68 1.03 7.28 1.15 46 3.41 .01 Observing/Internal attunement 6.27 1.60 6.62 1.63 46 1.22 .23 Non-distraction 6.74 1.57 6.70 1.53 46 .24 .81 Describing 5.98 1.57 6.39 1.43 46 1.50 .13 Note: Scales measured on a 10-point scale. M0mean; SD0standard deviation; df0degrees of freedom; t0t value, p0significance level. Table VI. Range, mean, and standard deviations for the Partici- pant Satisfaction Survey. Item Range M SD I would recommend the program to other mental health professionals 5Á10 8.67 1.31 I am disappointed that I took this course 1Á3 1.31 .61 I will draw upon the skills I have used in this course in my therapeutic work 5Á10 8.94 1.24 I will continue to maintain a regular mind- fulness practice 5Á10 8.51 1.32 I feel like there has been no meaningful growth in my understanding of mindfulness as a theoretical construct during this course 1Á7 2.31 1.69 I felt more relaxed after most mindfulness sessions 6Á10 9.03 1.06 I got less/more out of the course than I expected 3Á10 7.71 1.39 Note: Measured from 1 (strongly disagree) to 10 (strongly agree); M0mean; SD0standard deviation. Teaching mindfulness to psychotherapists in clinical practice 283 DownloadedBy:[Aggs,Cameron]At:09:2124November2010
  8. 8. ratings of the relevance of mindfulness within clinical settings and confidence in using mindfulness within client related work were significantly higher when measured post-training compared to baseline. In comparison, no change was found in relation to participants’ intentions to integrate mindfulness when measured at post-review. Null results for intentions may have been due to ceiling effects associated with high pre-training scores, which were 7.64 out of 10 at the beginning of training, and were 8 out of 10 at endpoint, indicating no statistical difference. The most likely explanation for this result is that participants already had a positive intention to integrate mind- fulness into their practice, and as a result the training had no effect. Overall, findings support a positive participant attitude regarding the use and suitability of mindfulness in clinical and counselling practice. Stress management and compassion fatigue are particularly pertinent issues for health professionals (Shapiro & Carlson, 2009). Consistent with pre- dictions, reductions in the perception of stress and tension were large in this study, with the observed decrement on these measures being over 33% in both cases. These findings were consistent with results from the Participant Satisfaction Survey (PSS) administered during the week nine follow- up, which indicated that participants felt more relaxed after mindfulness training sessions. As well as hypothesising positive results in the area of knowledge acquisition, attitude change, and well- being, this study predicted gains in the area of mindfulness-based skill acquisition. A key marker of skill acquisition was whether mindfulness training would be associated with an increased capacity to enter a mindful state on request, and higher per- ceived mindfulness with clients. Consistent with predictions, participants in this study demonstrated a significantly higher post-training capacity to invoke a mindful state of consciousness when compared to baseline scores. These results are consistent with previous research indicating positive effects of mind- fulness training on measures of ‘invoked mindful- ness’ (Anderson, Lau, Segal, & Bishop, 2007), and provides additional support for the assertion that mindfulness is a skill that therapists can learn (Shapiro et al., 2007). In relation to in-session clinical mindfulness behaviour, this study found significant positive change in the global ‘Mindful Therapy’ score, in addition to positive changes on the two indices relating to mindfulness attitudes (non-judging/ acceptance and non-reactivity/equanimity). In rela- tion to the acceptance construct, participants in this study reported being less judgmental of their pro- cesses in therapy, as well as those of their clients when compared to baseline. Relative to the non- reactivity/equanimity construct, participants re- ported an increased capacity to let go of unsettling thoughts, feelings, or images as they arose, and reported feeling more relaxed within therapeutic work compared with baseline scores. In contrast, no preÁpost differences were observed on the three indices relating to attention-regulation and noting skills of mindfulness. This suggests that training did not significantly impact upon partici- pants’ ability to remain focused on their clients during therapy, to retain an awareness of internal events, or to put their perceptions into language, when these skills were measured as independent constructs. The findings that in-session attending skills did not improve over the course of training are inconsistent with results from the FMMS, which showed an increased ability to evoke these skills on demand. The finding that participants’ mindful attitudes improved over the course of training whereas atten- tion-regulation skills did not is, however, consistent with research proposing the independence of these constructs (Cardaciotto, Herbert, Forman, Moitra & Farrow, 2008), and null results for the effects of a short course in mindfulness training (MBSR) on attention control (Anderson et al., 2007). If these construct are indeed independent, then it is possible that different periods of training may be required to address these facets. Within the context of high scores of intentions to integrate mindfulness into therapy work, the find- ings that therapists can evoke the attending skills of mindfulness, but often do not, is also reconcilable with the observations of Feldman (2004), that perhaps the most challenging aspect of being mindful is remembering to be mindful. Potentially developing visual cues to be placed in therapists’ offices (such as a picture of a figure meditating, or a leaf on a river, or small meditation bell for example) may be one way of priming this remem- bering function and making mindful therapy more likely. Greater attention to training development and further research is required before definitive 284 C. Aggs & M. Bambling DownloadedBy:[Aggs,Cameron]At:09:2124November2010
  9. 9. conclusions regarding generalisability of state-based attending skills can be made to therapy settings. Limitations There are a number of factors that limit the generalisability of these results. The primary limita- tion of this study is that it has relied on new measures that require further empirical validation. While not a significant problem in training research, no control group was used in this study. Further studies that include a control condition, perhaps comparing MT with a modality specific mindfulness programme (e.g. MBSR) with randomised partici- pant allocation, may provide a more effective eva- luative design. The present study was conducted with a self- selected sample, a small percentage of whom were known to the primary researcher. This calls into question the possible role of demand characteristics, and the likelihood that participants had pre-existing positive attitudes towards mindfulness. However, sample validity can be argued based on the con- siderable heterogeneity of participants’ professions and employment settings, and uniformed average findings across measures. There was no long-term follow-up of participants and therefore the perma- nence of training effects remain unknown. Future studies should include follow up at six and 12 months to examine skill retention and application in practice. Implications for practice Mindfulness-based approaches are gaining signifi- cant popularity with clinicians. Existing training opportunities have traditionally not focused on therapy skills and client work issues. This study demonstrates that mindfulness training for therapists enhances skills thought important for clinical work such as state-based attention regulation skills, and the capacity to bring a more accepting and less reactive orientation towards client-related processes. Results from this study suggest that training cogni- tive capacities, such as attention control, does not occur rapidly and therapists should allow additional time and practice to master this skill. We conclude that therapists can benefit from relatively brief training programs in mindfulness that focuses on clinical work. The implication for practice is that clinicians seeking mindfulness training may gain additional benefit by the therapy specific approach used in this study. Future research Current findings provide further support for the assertion that mindfulness is a multidimensional construct (Baer et al., 2006; Cardaciotto et al., 2008), and that measuring mindfulness with a multidimensional assessment tool is appropriate. Until now, non-therapy related measures have been used in the few studies that have attempted to evaluate therapist mindfulness. The current study used the new multidimensional Mindful Therapy scale (MT-S) which measures mindfulness in rela- tion to their therapeutic work specifically. While overall scale reliability was acceptable, subscale score alphas were variable. While it is likely results of the scale are valid, further empirical refinement and validation of this measure is required before it could be accepted as a standardised measure in future clinical mindfulness research. Acknowledgements Thanks to Mr David McLennan for his contribution as co-rater for this study and to Ms Deanne Armstrong for her editorial assistance. Thanks also to Dr John McLean for helpful feedback on an earlier version of the manuscript. References Andersen, D.T. (2005). Empathy, psychotherapy integration, and meditation: A Buddhist contribution to the common factors movement. Journal of Humanistic Psychology, 45 (4), 483Á502. Anderson, N.D., Lau, M.A., Segal, Z.V., & Bishop, S.R. (2007). Mindfulness-based stress reduction and attentional control. Clinical Psychology and Psychotherapy, 14, 449Á463. Baer, R. A., Smith, G.T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self- report assessment measures to explore facets of mindfulness. Assessment, 13 (1), 27Á45. Bishop, S.R., Lau, M., Shapiro, S., Carlson, L., Anderson, N.D., Carmody, J., et al. (2004). Mindfulness: A proposed opera- tional definition. Clinical Psychology: Science and Practice, 11, 230Á241. Bohart, A.C., Elliott, R., Greenberg, L.S., & Watson, J.C. (2002). Empathy. In J.C. Norcross (Ed.), Psychotherapy relationships that work (pp. 89Á109). New York: Oxford University Press. Cardaciotto, L., Herbert, J.D., Forman, E.M., Moitra, E., & Farrow, V. (2008). The assessment of present-moment awareness and acceptance: The Philadelphia Mindfulness Scale. Assessment, 15 (2), 204Á223. Feldman, C. (2004). The Buddhist path to simplicity: Spiritual practice for everyday life. Dorset: Element Books Ltd. Teaching mindfulness to psychotherapists in clinical practice 285 DownloadedBy:[Aggs,Cameron]At:09:2124November2010
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Stanley, S., Reitzel, L.R., Wingate, L.R., Cukrowicz, K., Lima, E.N., & Joiner, T.E. (2006). Mindfulness: A primrose path for therapists using manualized treatments. Journal of Cognitive Psychotherapy, 20 (3), 327Á335. Surrey, J. (2005). Relational mindfulness. In C.K. Germer, R.D. Siegal & P.R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 148Á163). New York: The Guilford Press. Wallin, D.J. (2007). Attachment in psychotherapy. New York: The Guilford Press. Biographies Cameron Aggs is the director of Mindfulness Training Australia. He is a psychologist in private practice in Maroochydore, Queensland, and an early intervention and parenting specialist with Child and Family Health, Maroochydore. He has been in- volved with mindfulness practices for over a decade. He can be contacted at cam@bemindful.com.au. Matthew Bambling is a senior lecturer in clinical psychology and course coordinator for Master and Doctorate of Clinical Psychology ACU National, Brisbane Campus, Queensland, Australia. Matthew has published in the fields of supervision, psychotherapy outcome, training of therapists and mental health and health psychology. Matthew can be contacted at matthew.bambling@acu.edu.au 286 C. Aggs & M. Bambling DownloadedBy:[Aggs,Cameron]At:09:2124November2010

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