Teaching Mindfulness to Clinicians (Cameron Aggs)

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Teaching mindfulness to psychotherapists in clinical practice: TheMindful Therapy Programme

CAMERON AGGS1* & MATTHEW BAMBLING2

1Mindfulness Training Australia, Maroochydore and Brisbane, Australia, and 2Australian Catholic University, Psychology,

Virginia, Australia

AbstractIntroduction: Initially proposed as a treatment modality for psychological disorders, mindfulness is now being promoted as ameans of enhancing both therapist self care and therapeutic efficacy. The degree to which mindfulness can be learned bytherapists to manage their own and clients’ processes in therapy is as yet unknown. This study examines training outcomesof a standardised introductory mindfulness programme for mental health professionals. Methods: Forty-seven mental healthprofessionals 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 increasedmindfulness in clinical work, increased capacity to intentionally invoke mindful states of consciousness, and higherparticipant ratings of well-being over the course of training sessions. Discussion: This research provides preliminary evidencethat a brief, standardised mindfulness training programme can achieve acceptable knowledge and skills outcomes fortherapists that can aid their therapeutic practice. Of note, increased ‘therapeutic mindfulness’ in this study resulted fromchanged mindfulness ‘attitudes’ (i.e. a more accepting and equanimous orientation within therapeutic work) as opposed toa clear demonstration of increased attention-regulation skills. The implications of these and other results for programmedevelopment 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: [email protected]

Counselling and Psychotherapy Research, December 2010; 10(4): 278!286

ISSN 1473-3145 print/1746-1405 online # 2010 British Association for Counselling and Psychotherapy

DOI: 10.1080/14733145.2010.485690

Downloaded By: [Aggs, Cameron] At: 09:21 24 November 2010

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 (n"4)

Teaching mindfulness to psychotherapists in clinical practice 279


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 (SD"13.84). 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 3!5). 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 1!3)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 3!5), 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 6!8) 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


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 .75!.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.



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,datawere reversecodedbefore scoring.

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 pre!postdifferences 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

(p".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 (p".01),

as did scores on constructs relating to attention

switching (p".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: M"mean; SD"standard deviation; df"degrees of free-

dom; t"t value, p"significance level; ascores range from 0!11;b,cmeasured on 0!4 point scale; dmeasured on a 0!3 point scale.

Table II. Mean, standard deviation, and t-test results for attitudechange 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. M"mean;

SD"standard deviation; df"degrees of freedom; t"t value,

p"significance level.

Table III. Mean, standard deviation, and t-test results for theStress 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. M"mean;

SD"standard deviation; df"degrees of freedom; t"t value,p"significance level.



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 (p".01). Relative to baseline, significant differences

were found on scores of the non-judging/acceptance

(p".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. M"mean;SD"standard deviation; df"degrees of freedom; t"t value,


Table V. Mean, standard deviation, and t-test results for theMindful 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. M"mean;SD"standard deviation; df"degrees of freedom; t"t value,


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

5!10 8.67 1.31

I am disappointed that I took this course 1!3 1.31 .61

I will draw upon the skills I have used in this

course in my therapeutic work

5!10 8.94 1.24

I will continue to maintain a regular mind-

fulness practice

5!10 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

1!7 2.31 1.69

I felt more relaxed after most mindfulness

sessions

6!10 9.03 1.06

I got less/more out of the course than I

expected

3!10 7.71 1.39

Note: Measured from 1 (strongly disagree) to 10 (strongly agree);M"mean; SD"standard deviation.



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 pre!post differences were observedon 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



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 MTwith 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.

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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 [email protected].

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 [email protected]



Health & Medicine

Teaching Mindfulness to Clinicians (Cameron Aggs)