what_are_the_benefits_of_mindfulness_a_practice_review_of_psychotherapy
Psychotherapy
2011. Vol. 48. No. 2,198-208 @ 2011 American Psvcholoeical Association PRACTICE REVIEW What Are the Benefits of Mindfulness? A Practice Review of Psychotherapy-Related Research Daphne M. Davis and Jeffrey A. Hayes Pennsylvania State University Research suggests that mindfulness practices offer psychotherapists a way to positively affect aspects of therapy that accountfor successfultreatment.This paper provides psychotherapists with a synthesis of the empirically supported advantages of mindfulness. DCfinitions of 血@ndfulness and evidence-based interpersonal, affective, and intrapersonal benefits of mindfulness are presented. Research on therapists who meditate and client outcomes oftherapists who meditate are reviewed.Implications for practice, research, and training are discussed. Keywords: mindfulness, psychotherapy, meditation,literature review Mindfulness has enjoyed a tremendous surge in popularity in the past decade, both in the popular press and in the psychotherapy literature (Didonna, 2009a; Shapiro & Carlson, 2009). Owing largely to the success of mindfulness-based stress reduction (MBSR) programs and the centralrole of mindfulness in dialecti- cal behaviortherapy, as well as acceptance and commitment therapy, mindfulness has moved from a largely obscure Buddhist conceptto a mainstream psychotherapy construct. Advocates of mindfulness would have us believe that virtually every client, and theirtherapists, would benefitfrom being mindful.In fact, mind- fulness has been proposed as a common factorin psychotherapy (Martin,1997). Among its theorized benefits are self-control (Bishop et al., 2004; Masicampo & Baumeister, 2007), objectivity (Adele & Feldman, 2004; Brown, Ryan, & Creswell, 2007; Leary & Tate, 2007; Shapiro, Carlson, Astin, & Freedman, 2006), affect tolerance (Fulton, 2005), enhanced flexibility (Adele & Feldman, 2004), equanimity (Morgan & Morgan, 2005),improved concen- tration and mental clarity (Young,1997), emotionalintelligence (Walsh & Shapiro, 2006), and the ability to relate to others and one's self with kindness, acceptance, and compassion (Fulton, 2005; Wallace, 2001).Is mindfulness as good as advertised, how- ever? What does the research literature have to say aboutthe benefits of mindfulness? The purpose ofthis paperis to provide psychotherapists with information aboutthe empirically supported advantages of mindfulness, contextualized by effect sizes ofthese advantages.In addition, we review research on practices that have been found to promote mindfulness, as well as the effects on therapists and trainees exposed to mindfulness meditation. The paper concludes with implications for practice,reseiirch, and train- ing. We begin by exploringthe meaning ofthe term "mindful-ness." Definitions: Ancient and Modern The term "mindfulness" has been used to referto a psycholog- ical state of awareness, a practice that promotes this awareness, a mode of processing information, and a characterologicaltrait (Brown et al., 2007; Germer, Siege], & Fulton, 2005; Kostanski & Hassed, 2008; Siegel, 2007b). The word mindfulness originally comes from the Pali word sati, which means having awareness, attention, and remembering (Bodhi, 2000). Mindfulness can sim- ply be defined as "moment-by-moment awareness" (Germer et al., 2005. p. 6) or as "a state of psychologicalfreedom that occurs when attention remains quiet and limber, without attachmentto any particular point of view" (Martin,1997. p. 291.italics included in originaltext). Forthe purposes ofthe present paper, and forthe sake of consistency with most ofthe research thatis reviewed subsequently, mindfulness is defined as a moment-to-moment awareness of one's experience withoutjudgment.In this sense, mindfulness is viewed as a state and not a trait, and while it might be promoted by certain practices or activities (e.g., meditation),it is not equivalentto or synonymous with them. When slightly different definitions of mindfulness are used in the literature thatis reviewed,these shall be noted. Mindfulness has similarities to other psychotherapy-related con- structs. For example, mindfulness is similarto mentalization (Bateman & Fonagy, 2004. 2006; Fonagy & Bateman, 2008),the developmental process of understanding one's own and others' behaviorin terms ofindividuals'thoughts,feelings, and desires. Both constructs emphasize the temporary, subjective, and fluid nature of mental states and both are thoughtto enhance affect regulation and cognitive flexibility (Wallin, 2007). Mindfulness differs from mentalizing in that mindfulness is both being aware of the "reflective self engaged in mentalizing, and the practice of fully experiencing the rising and falling of mental states with acceptance and without attachment and judgment. Wallin proposes that the receptivity that mindfulness fosters enables the process of mentalization to occur. A second construct,intersubjectivity (Benjamin,1990), has been theorized to relate to Buddhist psychology (Epstein, 2007; Surrey, 2005; Thompson, 2001; Wallace, 2001) and to being in the present momentin psychotherapy (Stem, 2004). Mテndfulness and intersubjectivity are similarin thatthey both enable a sense of connection with others (Thompson, 2001), or what Thich Nhat Hanh (1987) calls interbeing.Interbeing is a Buddhist notion that by living in the present moment,the interdependent nature of all phenomena and people is experienced (Hanh,1987). To date,there is no research relating 山王ndfulness with either mentalization or intersubjectivity. Finally,insight,the conscious process of making novel connec- tions (Hill & Castonguay, 2007), can be construed as a beneficial outcome of mindfulness practice. Siegel(2007b, 2009) has pro- posed a neurological basis forthe connection between 皿テndfulness and insight, and research discussed laterin this article has begun to supportthis proposition. How Can Mindfulness Be Enhanced? Although there are several disciplines and practices that can cultivate mindfulness (e.g., yoga,tai chi, qigong; Siegel, 2007b), the majority oftheoretical writing and empiricalresearch on the subject has focused on mindfulness developed by mindfulness meditation. Meditation refers to: A family of self-regulation practices thatfocus on training attention and awareness in orderto bring mental processes under greater voluntary control and thereby foster general mental well-being and development and/or specific capacities such as calm, clarity, and concentration (Walsh & Shapiro, 2006. p. 228). While a myriad of meditation practices including Tibetan and Zen Buddhist meditation styles also cultivate mindfulness,the term mindfulness meditation is typically used synonymously with Vipassana, a form of meditation that derives from Theravada Buddhism (Gunaratana, 2002; Young,1997). Vipassana is a Pali word forinsight or clear awareness and is a practice designed to gradually develop mindfulness or awareness (Gunaratana, 2002). Mindfulness is systematically cultivated in Vipassana practice by applying one's attention to one's bodily sensations, emotions, thoughts, and surrounding environment(Bodhi, 2000; Germer, 2005; Germer et al., 2005; Gunaratana, 2002; Wallace, 2001; Young,1997). While it may be assumed that all meditation practices equally benefitthe practitioner,research ratherintriguingly suggests that different styles of meditation practice elicit different brain activity patterns (Cahn & Polich, 2006; Lutz, Dunne, & Davidson, 2007; Valentine & Sweet,1999). For example, 仰山ndfulness meditation more than concentrative forms of meditation (e.g.,focusing on a mantra) has been shown to stimulate the middle prefrontal brain associated with both self-observation and metacognition (Cahn & Polich, 2006; Siegel, 2007b) and foster specific attentional mech- anisms (Valentine & Sweet,1999). With the advancement of neurologicaltechnology, mindfulness researchers are examining distinct components of mindfulness meditation such as focused attention, open monitoring (nonjudgmental moment-to-moment observation of one's experience), and loving-kindness compassion practice and their specific physiological outcomes (Lutz, Slagter, Dunne & Davidson, 2008; Lutz et al., 2009). Empirically Supported Benefits of Mindfulness As research evidence begins to accumulate concerning the pos- itive outcomes of mindfulness,itis possible to categorize tliese benefits along several dimensions. Three dimensions that are par- ticularly relevantto psychotherapy pertain to the affective,inter- personal, and otherintrapersonal benefits of mindfulness. Another empirically supported benefit of 山山ndfulness, empathy, will be discussed laterin the paper when research is reviewed on thera- pists who practice mindfulness meditation. Practical examples of mindfulness-based interventions that could be used with clients are provided in Table 1. Table 1 Examples of Mindfulness-Based Interventions for Clients Benefits Practical mindfulness-based interventions to use with clients Emotion regulation Decreased reactivity & increased response flexibility Interpersonal benefits Intrapersona] benefits "Can you stay with whatis happening right now? ... Can you breathe with whatis happening right now?"' Slowly scan your entire body starting at your toes. Notice any sensations in your body withouttrying to change them.3 For couples: Face each other,look into each other's eyes and notice whatreactions, feelings, and thoughts arise.5 Therapist and client can practice mindfulness meditation together during the therapy session." "What can you tell me about your experience right now? Notice any changes in yourfeeling, however subtle."'2 Can you allow and acceptthis feeling and stay in touch with it withoutreacting to it? If not, whatis happening in your experience that's reacting to this feeling? 4 For couples: Face each other,look into each other's eyes, and practice sending loving-kindness to one another.5 Informal daily practice can include: walking and eating meditations, such as mentally saying "lifting .... stepping forward.. heel touching..toe touching ..lifting ..." when walking.7 1 (Morgan, 2005. p.135). 2 (Morgan, 2005. p.138). 3 (Body Scan, Kabat-Zinn,1990). 4 (Adapted from Didonna, 2009b). 5 (MBRE, Carson et al2006). 6 h (Lysack, 2005). 7 (Germer, 2005. p.14). Affective Benefits Emotion regulation. There is evidence that mindfulness helps develop effective emotion regulation in the brain (Corcoran, Farb, Anderson, & Segal, 2010; Farb et al., 2010; Siegel, 2007b). In terms of proposed mechanisms of change, Corcoran et al. theorize that mindfulness meditation promotes metacognitive awareness, decreases rumination via disengagementfrom perse- verative cognitive activities, and enhances attentional capacities through gains in working memory;these cognitive gains,in turn, contribute to effective emotion regulation strategies. In support of Corcoran et al-'s model,research indicates that mindfulness meditation is negatively associated with rumination and is directly related to effective emotion regulation (Chambers, Lo, & Alien, 2008; McKim, 2008; Ramel, Goldin, Carmona, & McQuaid, 2004).In particular, 20 nonclinical novice meditators who participated in a lo-day intensive mindfulness meditation retreat were compared to a waitlisted control group on 山エndful- ness,rumination, affect, and performance tasks for attention switching, sustained attention and working memory (Chambers et al., 2008). Following the meditation retreat,the meditation group had significantly higher self-reported mindfulness, decreased neg- ative affect,fewer depressive symptoms, and less rumination com- pared to the control group.In addition,the meditation group had significantly better working memory capacity and greater ability to sustain attention during a performance task compared to the con- trol group. Differences were not detected between the groups on self-reported anxiety or positive affect. Chambers et al.'s (2008)finding that mindfulness training de- creased rumination is consistent with research with participants having chronic mood disorders. Ramel et al.(2004)found that participants in an 8-week MBSR training had significantly less reflective rumination compared to: a) participants'initialrumina- tion scores, and b) a control group matched on age, gender, and initial depressive symptoms.In addition, decreases in rumination scores were significantly predicted by participants' amount of meditation practice.In another study, prepost scores after an 8-week MBSR intervention were compared among a community sample that experienced ongoing anxiety, depression, and/or chronic pain (McKim, 2008). Following MBSR, participants had significantly higher scores on self-reported mindfulness and sig- nificantly lower scores on self-reported rumination, psychological distress, depression, anxiety, and physicalillness. Mindfulness scores significantly predicted anxiety,rumination, medical symp- toms, and psychological distress. Furthermore,the relationship between mindfulness and depression was significantly mediated by decreased rumination. A recent meta-analysis of 39 studies supports the efficacy of mindfulness-based therapy forreducing anxiety and depression symp- toms (Hoffman, Sawyer, Witt, & Oh, 2010). MBSR and Ⅲ士ndfulness- based cognitive therapy constituted the majority of mindfulness-based therapies in tliese 39 studies. For clinical populations,the average prepost effect size was large, and a moderate effect size was found among nonclinical populations. For19 studies that assessed depres- sive and anxiety symptoms in long-teⅠ巾 follow-ups, moderate effect sizes supporting the effectiveness of mindfulness interventions were detected. Hoffman et al. concluded that mindfulness-based therapy has utility for potentially altering affective and cognitive processes that underlie multiple clinicalissues. Hoffman et al.(2010)'s findings are consistent with evidence that mindfulness meditation leads to increased positive affect and decreased anxiety and negative affect(Davidson et al., 2003; Erisman & Roemer, 2010; Farb et al., 2010; Jha, Stanley, Kiyo- naga, Wong, & Gelfand, 2010; Way, Creswell, Eisenberger, & Lieberman, 2010).In one study, participants randomly assigned to an 8-week MBSR training group were compared to waitlisted controls on self-report measures of depression, anxiety, and psy- chopathology and on neuralreactivity as measured by functional magnetic resonance imaging (fMRI) after watching sad films (Farb et al., 2010). Participants exposed to MBSR displayed significantly less anxiety, depression, and somatic distress relative to the control group (Farb et al., 2010). Stillfurther,fMRI data indicated thatthe MBSR group had less neuralreactivity while exposed to the films than the control group, and they displayed distinctively different neuralresponses while watching the films than they did priorto the MBSR training. These findings suggestthat mindfulness medita- tion shifts individuals' ability to employ emotion regulation strat- egies that enable them to experience emotion selectively, and that the emotions they experience may be processed differently in the brain (Farb et al., 2010; Williams, 2010). In a study oftrait mindfulness. Way et al.(2010)investigated the relationships among mindfulness, depressive symptoms, and neural activity in a nonclinical sample of adults. Trait mindfulness was found to be inversely related to amygdala activity when participants were in a resting state; amygdala activity was further associated with depressive symptoms. This study provides support thattrait mindfulness may alter baseline amygdala activity so that serves a preventive or buffering role in depressive mood. Erisman and Roemer(2010) conducted a study in which partici- pants in an experimental group were exposed to a brief mindlulness intervention and then watched film clips that contained either positive affect or mixed affect. Compared to a control group, participants in the experimental group reported more positive emotions after watch- ing the film clips containing positive affect and reported less negative emotions after watching affectively mixed film clips. Jha et al.(2010) examined working memory capacity and emo- tional experience among a military group who participated in an 8-week mindfulness training, a nonmeditating military group, and civilians; both military groups were in a highly stressful predeploy- ment period. The nonmeditating military group displayed decreased working memory capacity overtime whereas working memory ca- pacity among nonmeditating civilians was stable across time. Within the meditation military group, working memory capacity increased in proportion to actual amount of meditation practice.In addition, med- itation practice was directly related to self-reported positive affect and inversely related to self-reported negative affect. Working memory capacity mediated the relationship between meditation practice time and negative affect. These findings suggestthat adequate mindfulness meditation practice may enhance working memory capacity, similar to results obtained by Chambers et al.(2008),thereby promoting effective emotion regulation during periods of stress when working memory may otherwise diminish. Thus,research indicates that meditation may elicit positive emotions, minimize negative affect and rumination, and enable effective emotion regulation. Even eight weeks of mindfulness meditation practice may alterthe ways in which emotions are regulated and processed in the brain (Williams, 2010). Emotion regulation has such strong empirical support as a benefit of mind- fulness meditation thatrecently the term "mindful emotion regu- lation" was coined to referto "the capacity to remain mindfully aware at alltimes,irrespective ofthe apparent valence or magni- tude of any emotion thatis experienced" (Chambers, Gullone, & Alien, 2009. p. 569). Decreased reactivity and increased response flexibility. Research has demonstrated that Ⅲ士ndfulness meditation enables people to become less reactive (Cahn & Polich, 2009; Goldin & Gross, 2010; Ortner, K士ner, & Zeiazo, 2007; Siegel, 2007a, 2007b) and have greater cognitive flexibility (Moore & Malinowski, 2009; Siegel, 2007a, 2007b). Evidence indicates that 皿士ndfulness med- itators develop the skill of self-observation that neurologically disengages automatic pathways created from priorlearning and enables present momentinputto be integrated in a new way (Siegel, 2007a). Meditation activates regions ofthe brain associ- ated with more adaptive responding to stressful or negative situ- ations (Cahn & Polich, 2006; Davidson et al., 2003). Activation of this region ofthe brain corresponds W士th fasterrecovery to base- line after being negatively provoked (Davidson, 2000; Davidson, Jackson, & Kalin, 2000). Moore and Malinowski(2009) compared a group of experi- enced mindfulness meditators with a control group who had no meditation experience on measures assessing their ability to focus attention and suppress distracting information. The med- itation group had significantly better performance on all mea- sures of attention and had higher self-reported Ⅲテndfulness. Mindfulness meditation practice and self-reported mindfulness were correlated directly with cognitive flexibility and atten- tionalfunctioning. In another study,individuals with one month to 29 years of mindfulness meditation practice experience viewed pleasant, unpleasant, and neutral pictures and then had theirreaction times measured to categorizing tones as either short orlong (Ortner et al., 2007). Reaction time was thoughtto represent emotionalinterference with the categorization task. Meditation experience was inversely related to emotionalinterference when viewing unpleasant pictures. Ortner et al. suggestthat mindfulness meditation practice may help individuals disen- gage from emotionally upsetting stimuli, enabling attention to be focused on the cognitive task at hand.In a follow-up study, participants were assigned to either a 7-week training in mind- fulness meditation,relaxation meditation, or a waiting list con- trol group. The mindfulness meditation group exhibited less emotionalinterference in response to the unpleasant pictures than the other groups. Ortner et al.'s findings supportthe notion that mindfulness meditation decreases emotionalreactivity. In addition, Cahn and Polich (2009) assessed the reactions of very experienced mindfulness meditators to distracting stimuli. Findings revealed that while in a meditative state, practitioners displayed minimal emotional and cognitive reactivity to distracting stimuli. These findings supportthe notion that mindfulness med- itation contributes to decreased reactivity. A recent study investigated the effects of MBSR training on emotionalreactivity and regulation of negative self-beliefs among adults with social anxiety disorder(Goldin & Gross, 2010). Par- ticipants completed two attention tasks before and after participat- ing in an 8-week MBSR training.In preposttests, participants displayed lowerlevels of negative emotion, decreased amygdala activity, and increased levels of activity in areas ofthe brain associated with attentional deployment. Interpersonal Benefits The question of how mindfulness affects interpersonal behavior has been pursued recently by scholars who have addressed con- cepts such as mindfulrelating (Wachs & Cordova, 2007), mindful responding in couples (Block-Lemer, Adair, Plumb, Rhatigan, & Orsillo, 2007), and mindfulness-based relationship enhancement (MBRE)(Carson, Carson, Gil, & Baucom, 2006). Evidence indi- cates thattrait mindfulness predicts relationship satisfaction, abil- ity to respond constructively to relationship stress, skillin identi- fying and communicating emotions to one's partner, amount of relationship conflict, negativity, and empathy (Bames, Brown, Krusemark, Campbell, & Rogge, 2007; Wachs & Cordova, 2007). Bames et al.found that people with highertrait mindfulness reported less emotional stress in response to relationship conflict and entered conflict discussion with less anger and anxiety. Evi- dence shows that mindfulness is inversely correlated with distress contagion and directly correlated with the ability to act with awareness in social situations (Dekeyser, Raes, Leijssen, Leyson, & Dewulf, 2008). Thus, empirical evidence suggests that mind- fulness protects againstthe emotionally stressful effects ofrela- tionship conflict(Bames et al., 2007),is positively associated with the ability to express oneselfin various social situations (Dekeyser el al., 2008), and predicts relationship satisfaction (Bames et al., 2007; Wachs & Cordova, 2007). Given thatthe therapeutic rela- tionship is emotionally intimate, potentially conflictual, and inher- ently interpersonal,therapists'trait mindfulness may aid their ability to cultivate and sustain successfulrelationships with clients. OtherIntrapersonal Benefits In addition to the affective and interpersonal benefits identified above, mindfulness has been shown to enhance functions associ- ated with the middle prefrontallobe area ofthe brain, such as self-insight, morality,intuition, and fear modulation (Siegel, 2007b, 2009). There is also evidence that mindfulness meditation has numerous health benefits including increased immune func- tioning (Davidson et al., 2003; see Grossman, Niemann, Schmidt, & Walach, 2004 for a review of physical health benefits). Mind- fulness meditation has been shown to improve well-being (Car- mody & Baer, 2008) and reduce psychological distress (Coffey & Hartman, 2008; OStafin et al., 2006). Neuroplasticity - the rewiring that occurs in the brain as a result of experience - now explains how regular mindfulness meditation practice alters the brain's physical structure and functioning (Davidson et al., 2003; Lazar et al., 2005; Siegel, 2007a; Vestergaard-Poulsen et al., 2009). Changes in the structure ofthe brain include thicker brain regions associated with attention, sensory processing and sensitivity to internal stimuli(Lazar et al., 2005), distinct gray matter concentrations (Holzel et al., 2008), and thicker brain stems, which may accountfor positive cognitive, emotional and immunoreactive benefits (Vestergaard-Poulsen et al., 2009). Research suggests that states experienced during mind- fulness meditation eventually can become effortless traits over time (Farb et al., 2007; Siegel, 2007a). T卜us,the longertherapists practice mindfulness meditation,the more they may benefitfrom its effects. Other benefits of mindfulness meditation practice include in- creased information processing speed (Moore & Malinowski, 2009), decreased task effort(Lutz et al., 2009), and having fewer thoughts that are unrelated to the task at hand (Lutz et al., 2009). In particular, Lutz et al.'s research implies that due to increased attentional skills and increased ability to manage distractions, therapists who practice mindfulness meditation may have an in- creased ability to be presentto their clients. Effects of Meditation on Therapists and Therapist Trainees Whereas the literature on the benefits of applying mindfulness approaches to psychotherapy clients is vast(see Didonna, 2009 and Baer, 2006 forreviews),research on the effects of mindfulness on psychotherapists is gradually emerging. This body ofliterature will be reviewed and synthesized below. Practical examples of mindfulness-based interventions fortherapists and therapisttrain- ees in practice are shown in Table 2. Table 2 Examples of Mindfulness-Based Interventions for Trainees and Therapists Benefits Empathy Compassion Counseling skills Practical mindfulness-based interventions fortrainees' and therapists' mindfulness In trainee dyads in "therapist" & "client" roles: Have therapists track theirinternalresponses to client, and what makes them feel more and less empathetic towards client.7 Visualize an image, color, or memory that elicits feeling friendly towards yourself. Visualize sending this feeling towards an image of yourself, or a challenging client.9 In dyads, sitin silence with eyes open. Pay attention to yourinternal experience in the presence of another person, practicing to bring your attention back to their breath when it wanders.10 In dyads, pause after each person speaks and consciously relax While pausing, with acceptance and curiosity ask yourself: Whatis happening now? What am Ifeeling now? What mightthis person be experiencing?3 Practice sending loving-kindness towards oneself,towards a loved one,towards a 'neutral' client,towards a challenging client, and towards all beings.9 Decreased stress & anxietv Other benefits for therapists Bring your attention to your experience of breathing. Imagine seeing a client. Pay attention to any feelings of anxiety and fear. Notice how they shift from momentto moment, allowing whatis to be there.'' Therapists can practice formal sitting mindfulness meditation individually orin groups. In trainee dyads in "therapist" & "client" roles: Have therapists let go ofjudgments and the desire to say 'something' and practice fully listening to clients. Have therapists track when their attention wanders off and practice returning attention to back to present moment. Jn dyads, have each person track their own internalfeelings, thoughts, & sensations as they stand at varying distances @ from each other. Practice with an accepting attitude towards internalreactions with eyes open, with eyes closed,facing each other, & with their backs facing each other.'0 In between sessions,take one minute each to:1) Ask 'whatis my experience right now?' 2) Notice the sensation of each in and out breath 3) Expand your awareness to your whole body with an attitude of acceptance.'2 7 (Adapted from Shapiro & Izett, 2008). 8 (Adapted from Deep Listening & Authentically Speaking, Surrey, 2005). 9 (Adapted from Morgan & Morgan, 2005). 10 (From author's (Davis) mindfulness training at Naropa University). 11 (Adapted from Brach. 2003). 12 (Adapted from 3-minute Breathing Space from MBCT, Segal, Williams, & Teasdale, 2002). Empathy Mindfulness meditation consistently has been theorized to pro- mote empathy (Anderson, 2005; Fulton, 2005; Martin,1997; Mor- gan & Morgan, 2005; Shapiro & Izett, 2008; Walsh & Shapiro, 2006), and research utilizing a variety of methods is now accumu- lating in support ofthis premise.In a within-subjects study on meditation and empathy, counselors in training demonstrated in- creased empathy after participating in a 4-week Zen meditation training (Lesh,1970).In a between-groups experiment, premedical and medical students who participated in an 8-week MBSR train- ing had significantly higher self-reported empathy than a control group (Shapiro, Schwartz, & Bonner,1998). A qualitative study (Aiken, 2006) oftherapists who were experienced meditators found thatthey believed that mindfulness meditation helped de- velop empathy toward clients.In particular,interviews were con- ducted with six psychotherapists who each had more than lo years of experience practicing both therapy and mindfulness meditation. Consistentthemes from the data indicated that 山山ndfulness helps therapists: develop their ability to experience and communicate a felt sense of clients'inner experiences; be more presentto clients' suffering; and help clients express their body sensations and feel- ings. Finally, along similarlines, Wang (2007) used a passive design and found thattherapists who were experienced mindful- ness meditators scored higher on measures of self-reported empa- thy than therapists who did not meditate. Compassion In addition to empathy, a second therapist characteristic that seems to derive from meditation is compassion. For example, MBSR training has been found to enhance self-compassion in health care professionals (Shapiro, Astin, Bishop, & Cordova, 2005) and therapisttrainees (Shapiro, Brown, & Biegel, 2007). Kingsbury (2009)investigated the role of self-compassion in re- lation to Ⅲ士ndfulness. Two components of mindfulness, nonjudg- ing and nonreacting, were strongly correlated with self- compassion, and two dimensions of empathy,taking on others perspectives (i.e., perspective taking) and reacting to others' af- fective experiences with discomfort. Self-compassion fully medi- ated the relationship between perspective taking and 皿士ndfulness. Counseling Skills Empiricalliterature now demonstrates thatincluding mindful- ness interventions in psychotherapy training may contribute to the development of skills thatimpacttrainees' effectiveness as thera- pists.In a 4-year qualitative study, counseling students reported considerable positive effects on their counseling skills and thera- peutic relationships,including being more attentive to the therapy process, more comfortable with silence, and more attuned with oneself and clients, aftertaking a 15-week course thatincluded mindfulness meditation (Newsome, Christopher, Dahlen, & Chris- topher, 2006; Schure, Christopher, & Christopher, 2008). Coun- selors in training who have participated in similar mindfulness- based interventions have reported significantincreases in self- awareness,insights abouttheir professionalidentity (Bimbaum, 2008), and overall wellness (Rybak & Russell-Chapin,1998). Decreased Stress and Anxiety Research has found that premedical and medical students report less anxiety and depression symptoms after an 8-week MBSR training compared to a waiting list control group (Shapiro et al., 1998). The control group evidenced similar gains after exposure to MBSR training. Similarly,following MBSR training,therapist trainees have reported decreased stress,rumination, and negative affect(Shapiro et al., 2007).In addition, when compared with a control group, MBSR has been shown to decrease total mood disturbance,including stress, anxiety and fatigue in medical stu- dents (Rosenzweig, Reibel, Greeson, Brainard, & Hojat, 2003). Using qualitative and quantitative measures, nursing students re- ported better quality oflife and a significant decrease in negative psychological symptoms following exposure to MBSR (Bruce, Young. Turner, Vander Wal, & Linden, 2002). Recent evidence from a study of counselortrainees exposed to interpersonal mind- fulness training suggests that such interventions can foster emo- tionalintelligence and social connectedness, and reduce stress and anxiety (Cohen & Miller, 2009). Similarly,in a study of Chinese college students,those students who were randomly assigned to participate in a mindfulness meditation intervention had lower depres- sion and anxiety, as well as less fatigue, anger, and stress-related cortisol compared to a control group (Tang et al., 2007). T廿ese same students evidenced greater attention, self-regulation, and immunore- activity. Waelde et al.(2008) assessed changes in symptoms of depression, anxiety, and posttraumatic stress disorder among New Orleans mental health workers following an 8-week meditation inter- vention that began lo weeks after Hurricane Katrina. Although changes in depression symptoms were notfound, PTSD and anxiety symptoms significantly decreased afterthe 8-week intervention. Find- ings suggestthat meditation may serve a buffering role for mental health workers in the wake of a disaster. Other Benefits of Mindfulness for Therapists To date, one study has investigated the relationship between mindfulness and counseling self-efficacy. Greason and Cashwell (2009)found that counseling self-efficacy was significantly pre- dicted by self-reported mindfulness among masters-levelinterns and doctoral counseling students.In that study, attention mediated the relationship between mindfulness and self-efficacy, suggesting that mindfulness may contribute to the development of beneficial attentional processes that aid psychotherapists in training (Greason & Cashwell, 2009). Dreifuss (1990)interviewed six therapists who practiced one ofthree mindfulness meditation styles (Vipassana, Zen, and Vajrayana)for more than five years to examine the influence oftheir meditation practice on their work as therapists. Findings suggested thatlong-term mindfulness meditation practice can positively impacttherapists' ability to distinguish their own experience from their clients' experience, can enrich therapists' clarity in their work with clients, and may help develop therapists' self-insight. Other potential benefits of mindfulness include in- creased patience,intentionality, gratitude, and body awareness (Rothaupt & Morgan, 2007). Client Outcomes of Therapists Who Meditate While the research reviewed above points rather clearly to the conclusion that 山主ndfulness meditation offers numerous benefits to therapists and trainees, do these benefits translate to psychotherapy treatment outcomes? To date, only one study provides evidence.In a study conducted in Germany,randomly assigned counselortrainees who practiced ZCn meditation for nine weeks reported higher self- awareness compared to nonmeditating counselortrainees (Grepmair et al., 2007). Whatis more importantis that after 9 weeks oftreat- ment, clients oftrainees who 皿Cditated displayed greaterreductions in overall symptoms,fasterrates of change, scored higher on mea- sures of well-being, and perceived theirtreatmentto be more effective than clients of nonmeditating trainees. Despite these promising results,three other studies suggestthat the relationship between counselortrainees' mindfulness and cli- ent outcomes is not so encouraging. Stanley et al.(2006) studied the relationship between trait 皿士ndfulness among 23 doctoral-level clinical psychology trainees in relation to treatment outcomes of 144 adult clients in a university community clinic that used manu- alized, empirically supported treatments. Contrary to expectation, therapist 皿士ndfulness was inversely correlated with client out- come. This is consistent with otherfindings that suggest an inverse relationship exists between therapists' mindfulness and client out- comes (Bruce, 2006; Vinca & Hayes, 2007). Still otherresearch suggests that no relationship exists between therapist mindfulness and therapy outcome (Stratton, 2006). One ofthe difficulties with this small body ofresearch pertains to the accuracy oftherapist self-reported mindfulness.It could be that more mindful people are likely to score lower on a self-report measure of mindfulness because they are aware ofthe degree to which they are mindless. Conversely, people who are less mindful may notrealize it and therefore may be inclined to rate themselves higher on such measures. Also,itis noteworthy thatin the one study with positive findings regarding outcome (Grepmair et al., 2007), participants engaged in the practice of meditation rather than simply reporting their mindfulness.In the studies with neg- ative or nullfindings,there was no indication if participants had ever engaged in actual meditation. Thus,it may be that meditation is a better predictor of outcome tlian self-reported mindfulness (see Grossman, 2008 for a comprehensive summary oflimitations to mindfulness research). FurtherImplications Empirically Supported Relationships Many scholars have proposed thatthe development of skills and qualities in therapists who practice mindfulness meditation will strengthen the therapeutic relationship (Germer et al., 2005; Hick & Bien, 2008; Shapiro & Carlson, 2009). Future research could profitably address how therapists' mindfulness contributes to crit- icalrelationship factors such as the formation and sustenance of the working alliance, counter-transference management, and the provision of unconditionalregard with difficult clients (Norcross, 2002). For example, one study (Wexler, 2006)found that both client and therapist perceptions ofthe working alliance were positively related to therapist self-reported mindfulness.In another study, however,the relationship between mindfulness and working alliance was not significant(Bruce, 2006). Again,it could be that meditation practice is a better predictor ofthe working alliance than self-reported mindfulness, although this awaits further study. With regard to countertransference management,itis plausible thatthe nonreactivity and cognitive flexibility fostered by mind- fulness should help therapists respond more freely and less defen- sively to their clients (Gelso & Hayes, 2007). To date, one study has investigated mindfulness and countertransference. Kholooci (2008) examined the relationship between self-reported mindful- ness and therapists' awareness of countertransference. Kholooci found a significantinverse relationship between mindfulness and countertransference awareness such thatthe more mindfulthera- pists perceived themselves to be,the less aware they were oftheir countertransference. In conclusion, while the psychological and physical health ben- efits of mindfulness meditation are strongly supported by research, the ways in which therapists' mindfulness meditation practice and therapists' mindfulness translate to measureable outcomes in psy- chotherapy remain unclear. Future research is needed to examine the relations between therapists' mindfulness,therapists'regular mindfulness meditation practice, and common factors known to contribute to successfultreatment outcome. Doing so willfoster understanding of how mindfulness meditation may enhance com- munication and relationship building skills within the context of psychotherapy. Practice and Clinical Supervision Germer et al.(2005) proposed that mindfulness can be inte- grated into psychotherapy through three means:therapist mindful- ness (therapists' own practice of meditation to be more "mindful" and present with clients), mindfulness-informed psychotherapy (i.e., applying Buddhist psychology and mindfulness theory to clinical work), and mindfulness-based psychotherapy (teaching clients skills through the application of mindfulness practices). Davis (2010) has proposed that mindfulness meditation also would benefit clinical supervision by enhancing supervisors' presence to their supervisees and enabling them to be less reactive to super- visees' anxiety. Table 3 expands on Germer et al.(2005) and Davis (2010) and provides practical examples and means ofintegrating mindfulness into psychotherapy. The old adage that people can guide another on a path only as far as they themselves have ventured also applies to therapists integrating mindfulness into psychotherapy and into clinical su- pervision (Davis, 2010).Introducing mindfulness approaches into psychotherapy necessitates engaging in a mindful practice our- selves as psychotherapists (Hick, 2008).It has been recently pro- posed thattherapists who introduce mindfulness interventions with clients may find it helpfulto explain mindfulness in terms of attention, avoiding jargon that may have unintended negative effects on clients (Carmody, 2009). Training Implications Mindfulness as a metacognitive skill has been proposed as a necessary component of psychotherapy training (Bruce, Manber, Shapiro, & Constantino, 2010; Fauth, Gates, Vinca, Boles, & Hayes, 2007; Vinca, 2009). As research on therapists' mindfulness continues to emerge, should therapists' mindfulness demonstrate a meaningfulrelationship with measurable outcomes in the thera- peutic relationship and treatment outcomes, psychotherapy train- ing could include mindfulness training. Given the push toward outcome-based education,training and credentialing as measured by training benchmarks and the acquisition of competencies (Kaslow et al., 2002), perhaps mindfulness could be measured in training programs as a necessary specific competency. Research supportis needed to influence policy changes and changes in psychotherapy training program requirements. Given that mind- fulness meditation is a means to develop mindfulness, both coun- selor education and continuing education programs could benefi- cially offer mindfulness meditation training. Table 3 Examples of Ways to Integrate Mindfulness in the Field of Psychotherapy Ways mindfulness can be integrated into psychotherapy Professional avenues forintegration Therapist mindfulness @ Therapists' personal meditation practice @ Therapists' clinical work @ Training programs @ Clinical supervision @ Continuing education Mindfulness-informed psychotherapy Mindfulness-based psychotherapy Therapists' clinical work Training programs Clinical supervision Continuing education Therapists' clinical work Training Programs Clinical supervision Continuing education Mindfulness-based group therapy Practical examples "While others are speaking, practice letting go of your own thoughts,judgments, and analyzing, and return to listening receptively. Let yourlistening be wholehearted and attentive .... speak slowly enough to stay connected to your body and heart."'3 Apply me Buddhist principal of equanimity to a clientissue, such as: "What happens when you letthat need be there?"'4 Guide clients to: Close your eyes and with curiosity and non-judgment, allow whatever emerges in your awareness to be there, letting it come and go. Mentally label your experience, such as feeling, smelling, thinking, etc. as you sitforfew minutes.'5 13 (Deep Listening & Authentically Speaking, Surrey, 2005. p.110) 14 (Adapted from Welwood, 2002. p.190).15 (Adapted from Mindfulness, Morgan& Morgan, 2005). Important Next Steps in Research Future research holds tremendous potentialfor uncovering more aboutthe neurophysiological processes of meditation and the benefits oflong-teⅠ血 practice on the brain. Research on neuro- plasticity may help explain the relationship among length and quality of meditation practice, developmental stages of meditators, and psychotherapy outcomes. More research is needed to better understand how the benefits of meditation practice accumulate overtime. In addition, other means ofincreasing 皿づndfulness,in addition to meditation, need to be explored. G士ven that currentresearch does notindicate thattherapists' self-reported 皿エndfulness en- hances client outcomes, better measures of 皿士ndfulness may need to be developed or differentresearch designs that do notrely on self-report measures need to be used. Garland and Gaylord (2009) have proposed thatthe next generation of mindfulness research encompass four domains:1) performance-based measures of mindfulness as opposed to self-reports of 皿エndfulness, 2) scientific evaluation of notions espoused by Buddhisttraditions, 3) neuro- imaging technology to verify self-report data, and 4) changes in gene expression as a result of mindfulness. Research along any one or a combination ofthese lines is likely to enhance our under- standing of mindfulness and its potential benefits to psychother- apy. Given tlie empirical supportforthe benefits of mindfulness reviewed in this paper,research is needed on effective and prac- tical means ofteaching therapists 皿士ndfulness practices. While formaltraining is required to teach MBSR,theoreticalliterature focused on using a mindfulness-based curriculum and teaching mindfulness practices is beginning to emerge (e.g., McCown, Reibel, & Micozzi, 2010). Future research could include investi- gating realistic ways mindfulness practices and/orformal mindful- ness meditation could be integrated into trainees' practicum and clinical supervision. Given that MBSR is a structured formatthat has been successfully used with therapisttrainees (e.g., Shapiro et al., 2007), MBSR may be a simple way fortherapists,regardless of theoretical orientation,to integrate mindfulness practices into trainees' practicum class or group supervision. Future research questions could include: Does therapists" practice of mindfulness meditation in clinical supervision with their supervisees affectthe supervisory alliance, orrelational skills of supervisees? Does prac- ticing formal mindfulness meditation as a group in practicum or internship aid in group cohesion, self-care,relational skills, or measurable common factors that contribute to successful psycho- therapy? Given the limited research thus far on empathy, compas- sion, decreased stress and reactivity, more research is needed on how mindfulness meditation practice affects these constructs and measurable counseling skills in both trainees and therapists. For example, how does mindfulness meditation practice effect empa- thy and compassion for midcareer orlate-careertherapists who are already seasoned veterans? Shapiro and Carlson (2009) have suggested that mindfulness meditation can also serve as a means of self-care to help combat burnoutrates. Future research on not only how therapists' practice of mindfulness meditation helps facilitate trainee development and affects psychotherapy is needed, butthe ways in which therapists' own practice of mindfulness meditation can help with burnout rates and other detrimental outcomes of work-related stress. In addition, despite abundanttheoretical work on ways to con- ceptually merge Buddhist and Western psychology to psychother- apy (e.g., Epstein, 2007,1995),there is a lack ofliterature on what itlooks like in session when a therapist employs Buddhist-oriented approaches (i.e., mindfulness-informed psychotherapy as termed by Germer, 2005)to specific clinicalissues and diagnoses. Given the numerous and rich clinical applications of mindfulness-based approaches to specific clinicalissues, more literature is needed on the ways mindfulness-informed psychotherapy differs from mindfulness-based psychotherapy in session with clients. In conclusion,the momentum within research on mindfulness holds promise for a potentialtransformation in ways to facilitate trainee and therapists' development, and means to affect change mechanisms known to contribute to successful psychotherapy. The field of psychotherapy could benefitfrom future research exam- ining cause and effectrelationships and/or mediational models to better understand the seemingly fruitful benefits of mindfulness and mindfulness meditation practice. References Adele, M. H., 及@ Peldman, G.(2004). Clarifying the construct of mindful- ness in the context of emotion regulation and the process of change in therapy. Clinical Psychology,11. 255-262. doi:10.1093/clipsy.bph080 Alken, G. A.(2006). The potential effect of mindfulness meditation on the cultivation of empathy in psychotherapy: A qualitative inquiry. Disser- tation Abstracts International, Section B: Sciences and Engineering, 67, 2212. Anderson, D. T.(2005). Empathy, psychotherapy integration, and med- itation: A Buddhist contribution to the common factors movement. Journal of Humanistic Psychology, 45. 483-502. doi:10.1177/ 0022167805280264 Baer, R. A.(2006). Mindfulness-based treatment approaches: Clinician's guide to evidence み口ごと and applications. Burlington, MA: Elsevier. Bames, S., Brown, K. W., Krusemark, E., Campbell, W. K., & Rogge, R. D.(2007). The role of mindfulness in romantic relationship satisfac- tion and responses to relationship stress. Journal of Marital and Family Therapy, 33. 482-500. doi:10.1111/j.1752-0606.2007.00033.X Bateman, A., & Fonagy, P.(2004). Mentalization-based treatment of bpd. Journal of Personality Disorders,18. 36-51. doi:10.1521/pedi. 18.1.36.32772 Bateman, A., & Fonagy, P.(2006). Mentalizing and borderline personality disorder.In L. G. Alien & P. Fonagy (Eds.), Handbook of meniallml'wn- based treatment(pp.185-200). Hoboken, NJ: Wiley, Ltd. Benjamin,I.(1990). An outline ofintersubjectivity: The development of recognition. Psychoanalytic Psychology. 7. 33-46. doi:10.1037/ h0085258 Birnbaum, L.(2008). The use of mindfulness training to create an "Ac- companying Place" for social work students. Social Work Education, 27, 837-852. doi:10.1080/02615470701538330 Bishop, S. R., Lau, M. A., Shapiro, S. L., Carlson, L., Anderson, N. D., Carmody, J.,.., Devins, G.(2004). Mindfulness: A proposed opera- tional definition. Clinical Psychology,11. 230-241. doi:10.1093/ clipsy.bph077 Block-Lemer, J., Adair, C., Plumb, J. C., Rhatigan, D. L., & 0丁sillo, S. M. (2007). T卜e case for mindfulness-based approaches in the cultivation of empathy: Does nonjudgemental, present-moment awareness increase capacity for perspective-taking and empathetic concern? Journal of Marital and Family Therapy, 33. 505-516. doi:10.111l/j.1752- 0606.2007.00034.X Bodhi, B.(2000). A comprehensive manual of Adhidhamma, Seattle: BPS Pariyatti. Brach, T.(2003). Radical Acceptance: Embracing yourlife with the heart of a Buddha. NヒW York: Bantam BooksⅠDell. Brown, K. W., Ryan, R. M., & CⅠeswell, J. D.(2007). Mindfulness: Theoreticalfoundations and evidence forits salutary effects. Psycholog- icalInquiry,18. 211-237. doi:10.1080/10478400701598298 Bruce, A., Young, L., Turner, L., Vander Wal, R., & Linden, W.(2002). Meditation-based stress reduction: Holistic practice in nursing educa- tion.In L. E. Young & V. E. Hayes (Eds.), Transforming health promotion practice: Concepts,issues, and applications (pp. 241-252). Victoria, British Columbia: Davis. Bruce, N.(2006). Mindfulness: Core psychotherapy process? The rela- tionship between therapist 仰こndfulness and therapist effectiveness (Un- published doctoral dissertation). PGSP-Stanford Consortium, Palo Alto, CA. Bruce, N. G., Manber, R., Shapiro, S. L., & Constantino, M. J.(2010). Psychotherapist mindfulness and the psychotherapy process. Psycho- therapy Tlieory Research Practice Training, 47. 83-97. doi:10.1037/ a0018842 Cahn, B. R., & Polich, J.(2006). Meditation states and traits: Eeg, eip, and neuroimaging studies. Psychological Bulletin, 332,180-211. doi: 10.1037/0033-2909.132.2.180 Cahn, B. R., & Polich, J.(2009). Meditation (Vipassana) and the P3a event-related brain potential.International Journal ofPsychophysiology, 72. 51-60. doi:10.1016/j.ijpsycho. 2008.03.013 Carmody, J.(2009). Evolving conceptions of mindfulness in clinical set- tings. Journal of COgnitive Psychotherapy: An International 0りarterly, 23. 270-280. doi:10.1891/0889-8391.23.3.270 Carmody, J., & Baer, R. A.(2008). 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. doi:10.1007/sl0865-007-9130-7 Carson, J. W., Carson, K. M., Gil, K. M., & Baucom, D. H.(2006). Mindfulness-based relationship enhancement(MBRE)in couples.In R. A. Baer(Ed.), Mindfulness-based treatment approaches: Clinician's guide to evidence base and applications (pp. 309-331). Burlington, MA: Elsevier. Chambers, R., Gullone, E., & Alien, N. B.(2009). Mindful emotion regulation: An integrative review. Clinical Psychology Revi6W, 29. 560- 572. doi:10.1016/j.cpr.2009.06.005 Chambers, R., Lo, B. C. Y., & Alien, N. B.(2008). The impact ofintensive mindfulness training on attentional control, cognitive style, and affect. Cognitive Therapy and Research, 32. 303-322. doi:10.1007/sl 0608- 007-9119-0 Coffey, K. A., & H'artman, M.(2008). Mechanisms of action in the inverse relationship between mindfulness and psychological distress. Comple- mentary Health Practice Review,j3. 79-91. doi:10.1177/ 1533210108316307 Cohen, J. S., & Miller, L.(2009).Interpersonal mindfulness training for well-being: A pilot study with psychology graduate students. Teachers College Record,]]], 2760@2774. Rerrieved from http://www.tcrecord .org Corcoran, K. M., Farb, N., Anderson, A., & Segal, Z. V.(2010). Mind- fulness and emotion regulation: Outcomes and possible mediating mech- anisms.In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnositc approach to etiology and treatment (pp. 339-355). New York: Guilford Press. Davidson, R. J.(2000). Affective styles, psychopathology, and resilience: Brain 血Cchanisms and plasticity. American Psychologist, 55,1196- 1214. Davidson, R. J., Jackson, D. C., & Kalin, N. H.(2000). Emotion, plasticity, context, and regulation: Perspectives from affective neuroscience. Psy- chological Bulletin,126. 890-909. Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S. F., & Sheridan, J. F.(2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 66,149-152. doi:10.1097/01.psy.OOOOl16716.19848.65 Davis, D. M.(2010). Mindfulness and supervision: What psychotherapists need to know. Psychotherapy Bulletin, 45. 9-17. Dekeyser, M., Raes, F., Leijssen, M. Leyson, S., & Dewulf, D.(2008). Mindfulness skills and interpersonal behavior. Personality and Individ- ual Differences, 44,1235-1245. doi:10.1016/j.paid.2007.11.018 Didonna, F.(2009b). Mindfulness and obsessive-compulsive disorder: Developing a way to trust and validate one's internal experience.In F. Didonna (Ed.),(2009). Clinical handbook of mindfulness (pp.189-219). New York: Springer. Didonna, F.(Ed.).(2009a). Clinical handbook of ℡ムndfulness. New York: Springer. Dreifuss, A.(1990). A phenomenologicalinquiry of six psychotherapists who practice Buddhist meditation. Dissertation Abstracts International: Section B: Science and Engineering, 51. 2617. Epstein, M.(1995). Thoughts without a thinker. New York: Basic Books. Epstein, M.(2007). Psychotherapy withoutthe self: A Buddhist perspec- tive. New Haven: Yale University Press. Erisman, S. M., & Roemer, L.(2010). A preliminary investigation ofthe effects of experimentally induced mindfulness on emotionalresponding to film clips. Emotion,lo, 72-82. doi:10.1037/a0017162 Farb, N. A. S., Anderson, A. K., Mayberg, H., Bean, J., McKeon, D., & Segal, Z. V.(2010). Minding one's emotions: Mindfulness training alters the neural expression of sadness. Emotion,lo, 25-33. doi:10.1037/ a0017151.supp Farb, N. A. S., Segal, Z. C., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., & Anderson, A. K.(2007). Attending to the present: Mindfulness meditation reveals distinct neural modes of self-reference. Social Cog- nitive and Affective Neuroscience, 2. 313-322. doi:10.1093/scan/ nsm030 Fauth, J., Gates, S., Vinca, M. A., Boles, S., & Hayes, J. A.(2007). Big ideas for psychotherapy training. Psychotherapy: Theory, Research, Practice, Training, 44. 384-391. doi:10.1037/0033-3204.44.4.384 Fonagy, P., & Bateman, A.(2008). The development of borderline per- sonality disorder一一A mentalizing model. Journal of Personality Disor- ders, 22. 4-21. doi:10.1521/pedi.2008.22.1.4 Fulton, P. R.(2005). Mindfulness as clinicaltraining.In C. K. G0rmer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 55-72). New York: Guilford Press. Garland, E., & Gay lord, S.(2009). Envisioning a future contemplative science of mindfulness: Fruitful methods and new contentforthe next wave ofresearch. Complementary Health Practice Review,14. 3-9. doi:10.1177/1533210109333718 Gelso, C. J., & Hayes, J. A.(2007). Countenransference and the thera- pist's inner experience; Perils and possibilities. Mahwah, NJ: Eribaum. Germer, C. K.(2005). Mindfulness: Whatis it? What does it matter? In C. K. Germer, R. D. Siege], & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 3@27). New York: Guiiford Press- Genner, C. K., Siegel, R. D., & Fulton, P. R.(2005). Mindfulness and psychotherapy. New York: Guilford Press. Goldin, P. R., & Gross, J. J.(2010). Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion,lo, 83-91. doi:10.1037/a0018441 Greason, P. B., & Cashwell, C. S.(2009). Mindfulness and counseling self-efficacy: The mediating role of attention and empathy. Psychother- apists Education and Supervision, 49(1), 2-19. Grepmair, L., Mietterlehner, F., Loew, T., Bachler, E., Rother, W., & Nickel, N.(2007). Promoting 皿二ndfulness in psychotherapists in train- ing influences the treatmentresults oftheir patients: A randomized, double-blind, controlled study. Psychotherapy and Psychosomatics, 76, 332-338. doi:10.1159/000107560 Grossman, P.(2008). On measuring 山主ndfulness in psychosomatic and psychologicalresearch. Journal of Psychosomatic Research, 64. 405- 408. doi:10.1016/j.jpsychores.2008.02.001 Grossman, P., Niemann, L., Schmidt, S., & Walach, H.(2004). Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57. 35-43. doi:10.1016/S0022- 3999(03)00573-7 Gunaratana, H.(2002). Mindfiilness in plain English. Somerville, MA: Wisdom Publications. Hanh, T. N.(1987).Interbeing: Fourteen guidelines for engaged Buddhism (3rd ed.). Berkley: Parallax Press. Hick, S. F.(2008). Cultivating therapeutic relationships: The role of mindfulness.In S. F. Hick & T. Bien (Eds.), Mindfulness and the therapeutic relationship (pp. 3-18). New York: Guilford Press. Hick, S. F., & Bien, T.(2008). Mindfulness and the therapeutic relation- ship. New York: Guiiford Press. Hill, C. E., & Castonguay, L. G.(Eds.).(2007).Insightin psychotherapy. Washington, DC: American Psychological Association. Hoffman, 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 Holzel, B. K., Ott, L)., Gard, T., Hempe], H., Weygandt, M., Morgen, K., & Vaiti, D.(2008).Investigation of 皿士ndfulness meditation practitioners with voxel-based moiphometry. Social Cognitive and Affective Neuro- science, 3. 55-61. doi:10.1093/scan/nsm038 Jha, A. P., Stanley, E. A., Kiyonaga, A., Wong, L, & Gelfand, L.(2010). Examining the protective effects of mindfulness training on working memory capacity and affective experience. Emotion,10. 54-64. doi: 10.1037/a0018438 Kabat-Zinn, J.(1990). Full Catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell. Kaslow, N. J., Borden, K. A., Collins, F. L., Forrest, L.,Illfelder-Kaye, J., Nelson, P. D., & Rallo, J. S.(2002). Competencies conference: Future directions in education and credentialing in professional psychology. Journal of Clinical Psychology, 60. 699-712. doi:10.1002/jclp.20016 Kholooci, H.(2008). An examination ofthe relationship between counter- transference and mindfulness and its potentialrole in limiting therapist abuse. Dissertation Abstracts International: Section B: The Sciences and Engineering, 68. 6312. Kingsbury, E.(2009). The relationship between empathy and mindfulness: Understanding the role of self-compassion. Dissertation Abstracts In- ternational: Section B: Science and Engineering, 70. 3175. Kostanski, M., & Hassed, C.(2008). Mindfulness as a concept and a process. Australian Psychologist. 43,15-21. doi:10.1080/ 00050060701593942 Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D. N., Treadway, M. T., & FischI, B.(2005). Meditation experience is associ- ated with increased conicalthickness. Neuroreport: For Rapid Commu- nication of Neuroscience. Research,16,1893-1897. doi:10.1097/01.wnr. 0000186598.66243.19 Leary, M. R., & Tate, E. B.(2007). The multi-faceted nature of mindful- ness. PsychologicalInquiry,18. 251-255. Lesh, T. V.(1970). Zen meditation and the development of empathy in counselors. The Journal of Humanistic Psychology,lo, 39-74. doi: 10.1177/002216787001000105 Lutz, A., Dunne, J. D., & Davidson, R. J.(2007). Meditation and the neuroscience of consciousness: An introduction.In P. D. ZCiazo, M. Moscovtich, & E. Thompson (Eds.), The Cambridge handbook of con- sciousness (pp. 499-551). New York: Cambridge University Press. Lutz, A., Slagter, H. A., Dunne, J. D., & Davidson, R. J.(2008). Attention regulation and monitoring in meditation. Trends in Cognitive Sciences, 12,163-169. doi:10.1016/j.tics.2008.01.005 Lutz, A., Slagter, H. A., Rawlings, N. B., Francis, A. D., Greischar, L. L., & Davidson, R. J.(2009). Mentaltraining enhances attentional stability: Neural and behavioral evidence. The Journal of Neuroscience, 29, 13418 -13427. doi:10.1523/JNEUROSCI.1614 - 09.2009 Lysack, M.(2005). Relational 町立ndfulness and dialogic space in family therapy.In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mind- fulness and psychotherapy (pp.141-158). New York: Guilford Press. Martin, J. R.(1997). Mindfulness: A proposed common factor. Journal of Psychotherapy Integration, 7. 291-312. doi:10.1023/B:JOPI .0000010885.18025.bc Masicampo, E. J., & Baumeister, R. F.(2007). Relating mindfulness and self-regulatory processes. PsychologicalInquiry,18. 255-258. McCown, D., ROibel, D., & Micozzi, M. S.(2010). Teaching mindfulness: A practical guide for clinicians and educators. New York: Springer. McKim, R. D.(2008). Rumination as a mediator ofthe effects of 皿エnd- fulness: Mindfulness-based stress reduction (MNSR) with a heteroge- neous community sample experiencing anxiety, depression, and/or chronic pain. Dissertation Abstracts International: Section B: The Sci- ences and Engineering, 68. 7673. Moore, A., & Malinowski, P.(2009). Meditation, mindfulness and cogni- tive flexibility. Consciousness and Cognition,18,176-186. doi: 10.1016/j.concog.2008.12.008 Morgan, S. P.(2005). Depression: Turning toward life.In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 130-151). New York: Guilford Press. Morgan, W. D., & Morgan, S. T.(2005). Cultivating attention and empa- thy.In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 73-90). New York: Guilford Press. Newsome, S., Christopher, J. C., Dahlen, P., & Christopher, S.(2006). Teaching counselors self-care through mindfulness practices. Teachers College Record, 308,1881-1990. Norcross, J. C.(2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford Uni- versity Press. Ortner, C. N. M., Kilner, S. J., & Zeiazo, P. D.(2007). Mindfulness meditation and reduced emotionalinterference on a cognitive task. Motivation and Emotion, 3], 271-283. doi:10.1007/s 11031-007-9076-7 Ostafin, B. D., Chawla, N., Bowen, S., Dillwonh, T. M., Witkiewitz, K., & Marlalt, G. A.(2006).Intensive mindfulness training and the reduction of psychological distress: A preliminary study. Cognitive and Behav- ioral Practice,13,191-197. doi:10.1016/j.cbpra.2005.12.001 Ramel, W. Goldin, P. R., Carmona, P. E., & McQuaid, J. R.(2004). The effects of mindfulness meditation on cognitive processes and affectin patients with past depression. Cognitive Therapy and Research, 28, 433-455. doi:10.1023/B:COTR.0000045557.15923.96 Rosenzweig, S., Reibel, D. K., Greeson, J. M.. Brainard, G. C., & Hojat, M. (2003). Mindfulness-based stress reduction lowers psychological dis- tress in medical students. Teaching and Learning in Medicine,15, 88 -92. doi:10.1207/S 15328015TLM 1502_03 Rothaupt,]. W., & Morgan, M. M.(2007). Counselors' and counselor educators' practice of mindfulness: A qualitative inquiry. Counseling & Values, 52. 40-54. Rybak, C. J., & Russell-Chapin, L. A.(1998). The teaching well: Experi- ence, education and counseling.International Journalforthe Advance- ment of Counseling, 20,131-139. Schure, M. B., Christopher, J., 及@ Christopher, S.(2008). Mind-body medicine and the art of self care: Teaching mindfulness to counseling students through yoga, meditation and qigong. Journal of Counseling and Development. 86. 47-56. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D.(2002). Mindfulness- み口占ed cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press. Shapiro, S, L., Astin, J. A., Bishop, S. R., 及@ Cordova, M.(2005). Mindfulness-based stress reduction for health care professionals: Results from a randomized trial.International Journal of Stress Management, 12.164-176. doi:10.1037/1072-5245.12.2.164 Shapiro, S. L., Brown, K. W., & Biegel, G. M.(2007). Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health oftherapists in training. Training and Education in Pro- fessional Psychology,1,105-115. doi:10.1037/1931-3918.1.2.105 Shapiro, S. L., & Carlson, L. E.(2009). The art and science of mindfulness: Integrating mindfulness into psychology and the れとlping professions. Washington, DC: American Psychological Association. Shapiro, S. L., Carlson, L. E., Astin, J. A., & Eてeedman, B.(2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62. 373- 386.doi:10.1002/jclp.20237 Shapiro, S. L., & Izett, C. D.(2008). Meditation: A universaltoolfor cultivating empathy.In S. F. Hick 及@ T. Bien (Eds.), Mindfulness and the therapeutic relationship (pp.161-175). New York: Guilford P丁ess. Shapiro, S. L., Schwartz, G. E., & Bonner, G.(1998). Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine. 21. 581-599. doi:10.1023/A: 1018700829825 Siegel, D. J.(2007a). Mindfulness training and neuralintegration: Differ- entiation of distinct streams of awareness and the cultivation of well- being. Social Cognitive and Affective Neuroscience, 2. 259-263. doi: 10.1093/scan/nsm034 Siegel, D. J.(2007b). The mindful brain: Reflection and attunementin the cultivation of well-サCing. New York: Norton, Siegel, D. J.(2009). Mindful awareness, mindsight, and neuralintegration. The Humanistic Psychologist, 37,137-158. Stanley, S., Reitzel, L. R., Wingate, L. R., Cukrowicz, K. C., Lima, E. N., & Joiner, T. E.(2006). Mindfulness: A primrose path fortherapists using manualized treatments? Journal of Cognitive Psychotherapy, 20. 327- 335. doi:10.1891/jcop.20.3.327 Stern, D. M.(2004). The present momentin psychotherapy and everyday life. New York: W. 及@ W. Norton & Company. Stratton, P.(2006). Therapist mindfulness as a predictor of client out- comes. Dissertation Abstracts International: Section B: Science は乃り Engineering, 66. 6296. Surrey, J. L.(2005). Relational psychotherapy,relational mindfulness.In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 91-110). New York: Guilford Press. Tang, Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q.,... Posner, M.1. (2007). Short-term meditation training improves attention and self- regulation. PNAS Proceedings ofthe National Academy of Sciences, USA ofthe United States of America,104,17152-17156. doi:10.1073/ pnas.0707678104 Thompson, E.(2001). Empathy and consciousness.In E. Thompson (Ed.), Between ourselves: Second-person issues in the study of consciousness (pp.1-32). Tトorverton, U.K.:Imprint Academic. Valentine, E. R., & Sweet, P. L. G.(1999). Meditation and attention: A comparison ofthe effects of concentrative and mindfulness meditation on sustained attention. Mental Health Religion & Culture, 2. 59-70. doi:10.1080/13674679908406332 Vestergaard-Poulsen, P., van Beek, M., Skewes, J., BjarkれⅢ, C. R., Stub- berup, M., Bertelsen, J., & Roepstorfi, A.(2009). Long-te工血 meditation is associated with increased gray matter density in the brain stem. Neuroreport: For Rapid Communication of Neuroscience Research, 20, 170-174. doi:10.1097/WNR.Ob013e328320012a Vinca, M. A.(2009). Mindfulness and psychotherapy: A mixed methods investigation (Unpublished doctoral dissertation). Pennsylvania State University, University Park, PA. Vinca, M. A., & Hayes, J. A.(2007. June). Therapist 椛七ndfulness as predictive of empathy, presence and session イビクth. Presentation atthe annual 皿0eting ofthe Society for Psychotherapy Research, Madison, WI. Wachs, K., & Cordova, J. V.(2007). Mindfulrelating: Exploring mind- fulness and emotion repertoires in intimate relationships. Journal of Marital and Family Therapy, 33. 464-481. doi:10.1111/j.l752- 0606.2007.00032.X Waelde, L. C., Uddo, M., Marquett, R., Ropelato, M., Freightman, S., Pardo, A., & Salazar, J.(2008). A pilot study of meditation for mental health workers following hurricane Katrina. Journal of Traumatic Stress, 21. 497-500. doi:10.1002/jts.20365 Wallace, B. A.(2001).Intersubjectivity in Indo-Tibetan Buddhism. Jour- nal of Consciousness Studies, 8. 209-230. Wallin, D. J.(2007). Attachmentin psychotherapy. New York: Guilford Press. Walsh, R., & Shapiro, S. L.(2006). The meeting of meditative disciplines and western psychology: A mutually enriching dialogue. American Psychologist, 61. 227-239. doi:10.1037/0003-066X.61.3.227 Wang, S. J.(2007). Mindfulness meditation:Its persona] and professional impact on psychotherapists. Dissertation Abstracts International: Sec- tion B: Science and Engineering, 67. 4122. Way, B. M., Creswell, J. D., Eisenberger, N. L., & Ueberman, M. D, (2010). Dispositional 皿士ndfulness and depressive symptomatology: Cor- relations with limbic and self-referential neural activity during rest. Emotion.10,12-24. doi:10.1037/a0018312 Welwood, J.(2000). Toward a psychology of awakening: Buddhism, psychotherapy, and the path of personal and spiritualtransformation. Boston: Shambhala Publications. Wexler, J.(2006). T甘e relationship between psychotherapist mindfulness and the therapeutic alliance. Dissertation Abstracts International: Sec- tion B: Science and Engineering, 67. 2848. Williams, J. M. G.(2010), Mindfulness and psychological process. Emo- tion,lo,1-7. doi:10.1037/aOOl 8360 Young, S.(1997). The science of enlightenment. Boulder, CO: Sounds True. Received April19. 2010 Revision received June 7. 2010 Accepted June 8. 2010