Skillful Means of Mindfulness Intervention Delivery: Modeling mindfulness in body, speech, and mind WSPA Conference October, 2014 Brennan Gilbert PsyD Western Washington University Rev. Tim Burnett Mindfulness Northwest Red Cedar Zen Community
Introductions To Yourself To Us To Each Other To Our Time Together Today: Our Hypothesis: Mindfulness interventions, and our interactions with participants, will be more effective with increasing clarity around: What mindfulness is; Why it is beneficial; And how we can communicate this to clients. So we will focus on: Intent and motivation; Defining mindfulness and meditation; Modeling in our communications.
Why Mindfulness Meditation? Buddhist framing described by Brown (2006) Pointing Out the Great Way: The Stages of Meditation in the Mahamudra Tradition The Decision to Pursue Meditation is A Logical Decision Based on certain understanding of one s situation, supported by an understanding of how to truly change, and powered by the knowledge and belief that one s efforts will yield results. Like all experiences, the intent and knowledge we bring to our experiences governs how we interpret it, respond, and the meanings we discover. It is impossible to pour liquid into a vessel without some belief that, first, you are capable of pouring it, and second, the vessel can contain the liquid. An action as mundane as pouring liquid requires at least some degree of faith. Likewise, a beginner cannot pour the nectar of the teachings into the vessel of the mental continuum without faith. (Brown, 2006, p. 58)
Intent What do we say about the value of learning mindfulness? What do you say? Share! What is mindfulness and how do you introduce the intent behind the practice? Why do we meditate? What are your ideas? From a Buddhist perspective: The development of Right Mindfulness is to facilitate the ability to remain in Right View and Right Intent (Thanissaro, 2005). Reciprocal relationship between intent, mindfulness, and understanding.
Mindfulness Intervention Effectiveness Multiple meta-analyses have found robust support for MBSR and MBCT (e.g. Fjorback, Arendt, Ornbol, Fink, & Walach, 2011; Greenson, 2009; Hofmann, Sawyer, Witt, & Oh, 2010; Sedlmeier, Eberth, Schwarz, Zimmermann, Haarig, Jaeger, & Kunze, 2012) and Loving-Kindness Meditation (Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). These are nuanced studies - not the focal point of this presentation! Not included in this research are individual client experience and non-research study experiences; how do you know that mindfulness works? Placebo effects? Greeson et al. (2011) found that expectation to benefit from MBSR course predicted increases in mindfulness scores. Familiarity effects? Vetesse (2009) found that populations with presumed mindfulness familiarity (e.g. college and medical students; referrals from individual therapists) showed higher gains. The effects found in the current analyses show that meditation affects people in important ways. It now remains to be discovered what exactly the effects are, when and why they occur, how they relate to what we already know in psychology, and what we might learn from them to augment and enrich current psychological theories. (Sedlmeier et al., 2012, p. 1163)
Practice and Impact Attrition & Adherence Baer (2003) found about a 15% attrition rate (in published, research) study groups) Inconsistent measurement of adherence to at-home meditation (Baer, 2003; Vettese, 2009) Those that have measured, have most often found most participants are not following the recommended practice rates (Baer, 2003; Carmody & Baer, 2007; Vettese, 2009) Does Practice Time Matter? Loving-Kindness Intervention: More meditating, more positive emotion (Fredrickson et al., 2008) Vettese (2009) meta-analysis: only 24 of 98 studies noted relationship between outcome and home practice, but: Few studies track home practice rates Inconsistent outcome findings (small sample sizes, different populations, different interventions) Populations with MM familiarity (college, medical students; referrals) showed higher gains. 2 of 3 of the studies included showed gains in mindfulness as a function of home practice. CBT homework has weak to moderate effects but studies not designed to measure homework effects (correlation vs. incremental/experimental) Interesting question: is mindfulness the cause of the benefits?
Buddhist Practices for Increasing Intent and Motivation Clarifying Intent and Outlook Four Notions That Turn the Mind (Thrangu, 2003) 1) Preciousness of human birth 2) Immediacy of death ( only the time of death is unknown ) 3) Unsatisfactoriness of regular existence (samara) 4) Cause and effect (karma) Stories of Triumph Applying These to Mindfulness Interventions: Preciousness/Opportunities Visualizations: (e.g. Imagine you or someone else handling a situation well using mindfulness) Think about cause and effect; knowing that at any moment you can be mindful by creating different causes ( as this happens, that happens ) Reflect on what supports and hinders motivation in your life. Recognize the pain lack of awareness has caused you (habitual responding or ignorance about a problem)
What is Mindfulness? Psychological Perspectives Bishop et al (2004) concerned about lack of a consensus definition undermining the science, what do we mean when we are studying mindfulness? We propose a two-component model of mindfulness. The first component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present 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 Wallace and Shapiro (2006) proposed that meditation training supports balance in four domains: (1) intent and motivation, (2) attention regulation, (3) cognition, and (4) affect regulation. Jon Kabat-Zinn (1994b) adds purposefulness to his operational definition frequently used in mindfulness classes which may frame participant understanding in important ways: Mindfulness is paying attention in a particular way: on purpose, in the present moment, and non-judgmentally. And Shapiro and Carlson (2009) emphasize that mindfulness is an emergent property (awareness) and a process (practice). It is important to remember that mindfulness is both an outcome (mindful awareness) and a process (mindful practice): (1) Mindful awareness: an abiding presence or awareness, a deep knowing that manifests as freedom of mind (e.g., freedom from reflexive conditioning and delusion), and (2) Mindful practice: the systematic practice of intentionally attending in an open, caring, and discerning way, which involves both knowing and shaping the mind (Shapiro & Carlson, 2009).
What is Mindfulness? Buddhist Perspectives From an Abidhamma perspective - The cultivation of mindfulness as a meditation practice entails coming to know it when we see it and learning how to develop it (Olendzki, 2008, para. 30) Mindfulness inherently ethical as one of 19 beautiful mental factors whose arising indicated absence of confusion (Thera, 1965). Mindfulness: Sati ( remembering ) ability to notice loss of awareness Earlier glosses of sati as bare awareness now criticized as incomplete (Bodhi, 2011) Samma-sati ( Right Mindfulness ) is mindfulness (sati) with clear comprehension (discernment; sampajaña) and Appamada ( heedfulness ) (Naranjo & Ornstein, 1971; Nyanaponika, 1962; Payutto, 1998; Wallace, 2008; Wallace & Bodhi, 2006). Right Mindfulness requires judgment: skillful, wise judgment informed by clear comprehension and heedfulness. ( Right Judgment ) Guardianship guarding experience against that which prevents mindfulness from arising
Preparations and Expectations Given these definitions, what instructions do we give people when we ask them to cultivate mindfulness? How do these instructions prepare people for the fluctuations of mindfulness and other mental states? How do we support their intent in a way that supports the capacity to remain committed, open, and curious?
Remembering The Relationship Therapy outcomes (Norcross, & Lambert, 2011): What accounts for change: Client factors (e.g. motivation) 40% Common factors (therapist and client relationship) 30% Specific techniques 15% Placebo/unknown 15% - also said as expectancy effects Broad review of psychotherapy outcomes found (Horvath, Del Re, Fluckiger, & Symonds, 2011) : THE ALLIANCE MATTERS!!! What is in is adapting relationship to client (Norcross & Lambert, 2011) rather than a prescribed model for a positive relationship.
What Makes For a Good Alliance? What is known about the therapeutic alliance factors that predict positive response (Bordin, 1983): Shared understanding of goals of therapy Agreement on what the tasks of the therapy are The affective bond The development and fostering of the alliance is not separate from the interventions therapist implement to help their clients; it is influenced by and is an essential and inseparable part of every- thing that happens in therapy. (Horvath et al., 2011, p. 15) Practitioners are encouraged to make the creation and cultivation of a therapy relationship, characterized by the elements found to be demonstrably and probably effective, a primary aim in the treatment of patients. (Norcross & Wampold, 2011, p. 100)
Transtheoretical Therapeutic Responses: Joining: Empathy falls here- I see you as you see you, the problem is problem. I am with you. Conveying encouragement, slight leading, reminding, deepening what is already there It is hard to sit still when your back hurts Curiosity: Expressing wonder, mild surprise, curiosity, modeling openness, reflecting, reframing lightly, Modeling curiosity, modeling openness, modeling of sequences (cause and effect) but not directly Modeling an appreciation of sequential changeability: So you started to think about the groceries, then you wondered if you had wasted time for awhile? Broadening attention: What else did you notice in that moment? Oh! That happened to you? Questioning/Teaching: Asking direct questions to teach or facilitate reflection. Assumption checking, bridging, teaching, linking concepts/teachings, mind of teacher as seeing things differently. Directions: doing/thinking about something differently; applying skills/techniques Try resuming your focus on your breath by taking three intentional breaths Shift in Perspective- Not staying within system Pithy, consciousness changing, disturbing the thoughts, questioning very deep assumptions, challenges definition of self/worldview. Does pain have to mean something is wrong? MU- Flipping ; the unsaid thing ; the unknown (not knowing) Zen level not this, not that
Practice In groups of 4 or 5: One person introduce and lead a short (5 min.) mindfulness exercise Others share their experiences As a group think of various ways to respond mindfully, that helps or supports mindfulness development! Feel free to bring in challenging scenarios! Then switch leaders
Common Difficulties Difficulties in sustaining motivation Difficulty in sustaining attention Difficulty in perceiving positive outcomes subjectively (e.g. not noticing reduced reactivity and distress) Privileging Subjective Experience: when I feel good, I m doing it right Difficulty reconciling expectations and experience More?
References Baer, R. A. (2003). Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125-143. Bishop, S.R. et al (2004). Mindfulness: A Proposed Operational Definition. Clinical Psychology: Science and Practice, 11, 230-241. Bodhi, Bhikkhu (2011) What does mindfulness really mean? A canonical perspectives. Contemporary Buddhism, 12:01, 19-39 Bordin, E.S. (1983). A working alliance based model of supervision, The Counseling Psychologist, 11, 35-42. Brown, D. (2006). Pointing Out the Great Way: The Stages of Meditation in the Mahamudra Tradition. Summerville, MA: Wisdom. Carmody, J. & Baer, R. A. (2007). Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. Journal of Behavioral Medicine 31,23-33. Fischer, Norman (1999) Personal communication. Fjorback, L. O., Arendt, M., Ornbol, E., Fink, P., Walach, H. (2011). Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy- a systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica, 124, 102-119. DOI: 10.1111/j.1600-0447.2011.01704.x Fredrickson, B. L., Cohn, M. A., Coffey, K. A., Pek, J., & Finkel, S. M. (2008). Open hearts build lives: Positive emotions, induced through loving-kindness meditation, build consequential personal resources. Journal of Personality and Social Psychology, 95, 1045-1062. Greenson, J. M. (2009). Mindfulness research update: 2008. Complement Health Practice Review, 14, 10-18. doi: 10.1177/1533210108329862 Greeson, J. M., Webber, D. M., Smoski, M. J., Brantley, J. G., Ekbald, A. G., Duarez, E. C., & Wolever, R. Q. (2011). Changes in spirituality partly explain health-related quality of life outcomes after Mindfulness-Baser Stress Reduction. Journal of Behavioral Medicine, 34, 508-518. DOI 10.1007/s10865-011-9332-x Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169-183. DOI: 10.1037/a0018555 Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16. DOI: 10.1037/a0022186 Kabat-Zinn, J. (1994A). Mindfulness for Everyday Life. New York: Hyperion. Kabat-Zinn, J. (1994B). Wherever you go, there you are. New York:Hyperion. Lomas, T., Ridge, D., Cartwright, T., & Edginton, T. (2014). Engagement with meditation as a positive health trajectory: Divergent narratives of progress in male meditators. Psychology & Health, 29, 218-236. http://dx.doi.org/10.1080/08870446.2013.843684 Naranjo. C., & Ornstein, R. E. (1971). On the Psychology of Meditation. New York: Viking Press.
References (cont.) Norcross, J. C. & Lambert, M. J. (2011). Evidence-Based Therapy Relationships. In Psychotherapy Relationships That Work: Evidence-Based Responsiveness. John C. Norcross (ed.). Oxford University Press Norcross, J. C. & Wampold, B. E. (2011). Evidence-based therapy relationships: research conclusions and clinical practices. Psychotherapy, 48, 98-102. DOI: 10.1037/a0022161 Nyanaponika, T. (1962). The Heart of Buddhist Meditation: Satipatthna: A Handbook of Mental Training Based on the Buddha's Way of Mindfulness. Kandy, Sri Lanka: Buddhist Publication Society. Olendzki, A. (2008a). The real practice of mindfulness. Retrieved from Buddhadharma: The Practitioner s Quarterly at http://archive.thebuddhadharma.com/issues/2008/fall/mindfulness.php Payutto, P. A. (1988). Sammasati: An Exposition of Right Mindfulness. Retrieved from http://www.what-buddha-taught.net/books3/payutto_bhikkhu_sammasati.htm Sedlmeier, P., Eberth, J., Schwarz, M., Zimmermann, D., Haarig, F., Jaeger, S., & Kunze, S. (2012). The psychological Effects of Meditation: A Meta-Analysis. Psychological Bulletin, 138, 1139-1171. DOI: 10.1037/a0028168 Shapiro, S. (2009) The Integration of Mindfulness and Psychology. Journal of Clinical Psychology, Vol 65(6), 555-560 Thanissaro, B. (2005). Sammaditthi Sutta: Right View. Retrieved from Access to Insight at http://www.accesstoinsight.org/tipitaka/mn/mn.009.than.html Thera, N. (1965). The heart of Buddhist meditation. York Beach, ME:: Weiser. Thrangu, R. (2003). Pointing Out the Dharmakaya. Ithaca, NY: Snow Lion. Vettese, L. C., Toneatto, T., Stea, J. N., Nguyen, L., Wang, J. J. (2009). Do mindfulness meditation participants do their homework? And does it make a difference? A review of the empirical evidence. Journal of Cognitive Psychotherapy: An International Quarterly, 23, 198-225. DOI: 10.1891/0889-8391.23.3.198 Wallace, B. A. (2008). A mindful balance: Interview with B. Alan Wallace. Tricycle: The Buddhist Review, Spring, 60-63, 109-111. Wallace, B. A. & Bodhi, B. (2006). The nature of mindfulness and its role in Buddhist meditation: A correspondence between B. Alan Wallace and the Venerable Bhikkhu Bodhi. Unpublished Draft. Wallace, B. A. & Shapiro, S. L. (2006). Mental balance and well-being: Building bridges between Buddhism and Western psychology. American Psychologist, 61, 690-701.
More Buddhism for next time Mindful of What? 4 Foundations of Mindfulness Body (Rupa) Body-mind integration, wisdom of the body Feeling-Tone (pleasant/unpleasant) (Vedana) Colors all perceptions and thus downstream analysis Thoughts & Emotions (Citta) Ability to see problems with equanimity I am not my thoughts Habit Patterns & Assumptions about Reality (Dhamma) Everyone s a philosopher (Fischer 1999)