Chapter 26 Mindfulness Practice

Ruth Baer, PhD

Department of Psychology, University of Kentucky

Definitions and Background

In the psychological literature, mindfulness is often described as a form of nonjudgmental attention to present-moment experiences; these include internal phenomena, such as sensations, cognitions, emotions, and urges, as well as environmental stimuli, such as sights, sounds, and scents. Mindfulness also includes awareness of current activity and is often contrasted with behaving automatically or mechanically with attention focused elsewhere. Establishing a consensus about a more precise definition of mindfulness has been difficult, in part because the term is used in a variety of interventions, each with its own theoretical foundations. The Buddhist roots of several current mindfulness-based methods, and attempts to describe contemporary mindfulness in ways consistent with foundational Buddhist teachings, have also contributed to lack of consensus about a definition; this problem is complicated by the variety of ways in which mindfulness is described within Buddhist texts (Dreyfus, 2011). Despite these difficulties, a perusal of contemporary psychological descriptions of mindfulness shows that many include two general elements that can be loosely characterized as what one does and how one does it. The examples of this shown in table 1 suggest that mindfulness is generally agreed to be a type of attention or awareness that is open, curious, accepting, friendly, nonjudgmental, compassionate, and kind.

Table 1. Contemporary psychological descriptions of mindfulness: what and how

Author	What	How
Kabat-Zinn, 1994, 2003	Paying attention, or the awareness that arises through paying attention…	…on purpose, in the present moment, and nonjudgmentally. …with an affectionate, compassionate quality, a sense of openhearted, friendly presence and interest.
Marlatt & Kristeller, 1999	Bringing one’s complete attention to present experiences…	…on a moment-to-moment basis, with an attitude of acceptance and loving-kindness.
Bishop et al., 2004	Self-regulation of attention so that it is maintained on the immediate experience…	…with an orientation characterized by curiosity, openness, and acceptance.
Germer, Siegel, & Fulton, 2005	Awareness of present experience…	…with acceptance: an extension of nonjudgment that adds a measure of kindness or friendliness.
Linehan, 2015	The act of focusing the mind in the present moment…	…without judgment or attachment, with openness to the fluidity of each moment.

A more technical and theory-based definition is found in acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012), which conceptualizes mindfulness as having four elements: contact with the present moment, acceptance, defusion, and self-as-context; each of these is defined in terms of ACT and relational frame theory (Fletcher & Hayes, 2005; see chapters 23 and 24 in this volume). Though conceptually rigorous, this approach to defining mindfulness is roughly consistent with the framework of what and how. Present-moment experiences, particularly thoughts and feelings, are observed in a particular way: with willingness to experience them as they are, recognition that they need not control behavior, and the understanding that they do not define the person who is experiencing them. Similar formulations are central to other mindfulness-based interventions (Segal, Williams, & Teasdale, 2013)

Many authors agree that both the what and the how are essential to a clear understanding of mindfulness. For example, a person in a sad mood might be intensely aware of feeling sad but might respond to the sadness by judging the sad mood as ridiculous; criticizing the self as weak and foolish for feeling sad; ruminating about how the sad mood arose and how to get rid of it; or attempting to suppress, avoid, or escape the sad feelings in harmful ways. These responses to sadness are inconsistent with mindfulness and increase the risk of a downward spiral into depression (Segal et al., 2013).

Mindfulness of sadness includes closely observing the associated sensations, including where in the body they are felt and whether they are changing over time. The mindful observer of sadness brings an attitude of openness, friendly interest, and compassion to the experience while allowing the sadness to be present. When ruminative thought patterns arise, the mindful observer gently redirects attention to the present-moment sensations. The purpose of mindfulness of sadness is to encourage wise choices about potentially adaptive responses: taking constructive steps to address a problem, engaging in an activity to lift mood, or simply allowing sadness to run its natural course without reacting to it in ways that cause harm or are inconsistent with longer-term values and goals.

Implementation

Mindfulness-based interventions (MBIs) have a growing body of support (for a recent meta-analysis, see Khoury et al., 2013). The MBIs with the strongest evidence base are ACT and its close cousin acceptance-based behavior therapy (Roemer, Orsillo, & Salters-Pednault, 2008); dialectical behavior therapy (DBT; Linehan, 1993, 2015); and mindfulness-based cognitive therapy (MBCT; Segal et al., 2013) and the closely related methods of mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982) and mindfulness-based relapse prevention (Bowen, Chawla, & Marlatt, 2011). Loving-kindness meditation and compassion-focused methods (Gilbert, 2014; Hofmann, Grossman, & Hinton, 2011) also have promising support. Each of these programs includes a variety of exercises and practices to cultivate mindfulness skills. Some involve formal meditation, while others encourage mindful awareness of routine daily activities.

Meditative Practices

Sitting meditation is a commonly used practice with strong roots in meditation traditions. In a posture that is comfortable and relaxed, yet awake and alert, participants direct their attention to a series of internal or external foci, often beginning with the sensations and movements of breathing. Without trying to control the breath, they simply observe as it enters and leaves the body at its own pace and rhythm. Before long, attention is likely to wander. When this happens, participants are encouraged to recognize that the mind has wandered, note briefly where it went (e.g., planning, remembering, daydreaming), and gently return their attention to breathing while letting go of judgments and criticisms about the wandering mind. As the practice continues, the focus of attention typically shifts sequentially to other present-moment experiences, including bodily sensations, sounds, thoughts, and emotions. These experiences are observed with gentle interest, acceptance, and compassion as they come and go, whether they are pleasant, unpleasant, or neutral. Brief, silent labeling of observed experience is sometimes encouraged. For example, participants might say “aching,” “self-critical thoughts are here,” or “a feeling of anger is arising” as they notice these phenomena.

The body scan is another widely used meditative practice. Participants sit or lie comfortably with their eyes closed and focus their attention sequentially on many parts of the body, noticing sensations with friendly interest. When their minds wander, which is described as inevitable, they notice this and gently return attention to the body while letting go of judgment and self-criticism. If pain arises, they observe its qualities as best they can. Urges to move are observed nonjudgmentally. If participants choose to act on an urge, they are invited to notice with friendly curiosity the intention to act, the actions themselves, and any aftereffects or consequences. The body scan cultivates several essential mindfulness skills, including directing attention in particular ways; noticing when it has wandered; returning it kindly to the present moment; and being nonjudgmental, curious, and accepting about observed experience, whether it is pleasant or unpleasant.

Movement-Based Practices

Several MBIs use gentle yoga and mindful walking to cultivate mindful awareness while moving or stretching the body. Participants are invited to observe their bodily sensations with compassionate awareness, to notice when their minds wander, and to gently return their attention to sensations. The goal is not to strengthen muscles, improve flexibility or balance, or increase physical fitness, although such changes may occur with consistent practice. The only goal is to practice mindful awareness and acceptance of the body and mind as they are in the moment.

Mindfulness of Routine Activities

Many MBIs invite participants to bring moment-to-moment, nonjudgmental awareness to daily activities, such as eating, driving, or washing dishes. As with the other practices, participants gently return attention to the activity when the mind wanders away and bring an attitude of acceptance, allowing, openness, curiosity, kindness, and friendliness to all observed experiences, even those that are unwanted or unpleasant. Mindfulness of breathing in daily life is another way to encourage ongoing present-moment awareness. The breath is a useful target of mindful observation because it creates continuous observable sensations and movements. Breathing does not require voluntary control and therefore provides individuals an opportunity to allow the observed experience to be as it is, without trying to change it. Moreover, qualities of breathing (pace, depth, rhythm) shift with emotional and bodily states. By observing these patterns, people can become more aware of the constant fluctuations of emotion and sensation they experience in daily life.

With children or developmentally delayed or cognitively impaired populations, other attentional anchors, such as the soles of the feet, are sometimes used (Singh, Wahler, Adkins, & Myers, 2003). This target can help participants learn to regulate disruptive behavior because they can pay attention to their feet on the playground or during social interactions.

Breathing Spaces

The breathing space, which originated in MBCT, is a three-step practice designed to encourage participants to apply mindfulness skills in daily life, especially in stressful situations. First, they bring attention to the inner landscape of thoughts, emotions, and sensations; they gently note these experiences and allow them to be as they are, as if they were weather patterns in the mind and body. Then they narrow attention to focus only on breathing, and then widen it again to include the whole body. The breathing space is taught as a three-minute exercise but can be practiced more quickly or slowly depending on situational demands. It is not an escape or distraction strategy but rather an opportunity to step out of automatic patterns, see more clearly what the present moment holds, and make wise choices about what to do next.

Other Mindfulness Exercises

Several interventions have developed other creative exercises designed to cultivate mindfulness skills. In DBT, for example, each person in a group might be given an object, such as a lemon or a pencil. After a few moments of closely observing its shape, size, color, texture, and markings, all objects are returned to the group leader, who then shuffles them, sets them in the middle of a table, and asks participants to see if they can find the one they just examined. Participants might also be invited to sing a song or play a game mindfully. A short and somewhat more meditative practice is the conveyor belt exercise from DBT. With eyes closed, participants are invited to imagine that the mind is like a conveyor belt that brings thoughts, emotions, and sensations into awareness. Each is observed nonjudgmentally as it appears, including negative thoughts (This is a waste of time.) and mind wandering. ACT includes a similar exercise known as cubby-holing. Participants briefly consider a list of categories, such as sensation, thought, memory, emotion, and urge; then they close their eyes for a few minutes and observe the experiences that arise, noting with a single word the category that each represents.

Loving-Kindness and Compassion Meditation

Loving-kindness meditation and compassion meditation are closely related to mindfulness and sometimes are included in MBIs. Typically, participants practice them while sitting still, often with the eyes closed. Participants extend goodwill toward themselves and a sequence of others by silently repeating short phrases, such as “May he [I, she, they] be safe,” “May he be healthy,” “May he be happy,” “May he be peaceful.” A recent review (Hofmann et al., 2011) concludes that such practices, though less extensively studied than mindfulness practices, may be useful in the treatment of a wide range of problems and disorders.

Empirical Support

In mental health contexts, mindfulness is not practiced purely for its own sake but because mindfulness skills appear to have beneficial effects on psychological symptoms and well-being. Indeed, systematic reviews of mediation studies (Gu, Strauss, Bond, & Cavanagh, 2015; Van der Velden et al., 2015) report that there is consistent evidence that MBSR and MBCT lead to significant increases in self-reported mindfulness skills and that the acquisition of these skills is strongly associated with improvements in mental health. The specific psychological processes through which mindfulness skills exert these benefits are less clear. Several theoretical models and summaries of relevant literature propose lists of potential mechanisms (Brown, Ryan, & Creswell, 2007; Hölzel et al., 2011; Shapiro, Carlson, Astin, & Freedman, 2006; Vago & Silbersweig, 2012). These include forms of awareness (body awareness or general self-awareness), forms of self-regulation (attention regulation, emotion regulation), and perspectives on the self and internal experience (meta-awareness, decentering, reperceiving). The remainder of this chapter discusses mechanisms with empirical support from mediation analyses in outcome studies of MBIs (see Ciarrochi, Bilich, & Godsell, 2010; Gu et al., 2015; and Van der Velden et al., 2015, for reviews). The mechanisms with the best support include changes in cognitive and emotional reactivity, repetitive negative thought (rumination and worry), self-compassion, decentering (also known as metacognitive awareness or meta-awareness), and psychological flexibility. A few studies have also examined the role of positive affect. These processes have been defined and operationalized within a variety of theoretical and empirical contexts, and several of them appear to overlap conceptually and functionally. They are summarized in the following sections.

Cognitive Reactivity

As originally defined, cognitive reactivity is the extent to which a mild dysphoric state activates dysfunctional thinking patterns (Sher, Ingram, & Segal, 2005). It is typically studied with a laboratory task, in which the experimenter induces a temporary dysphoric state by asking participants to dwell on a sad experience while listening to gloomy music, or similar procedures. Participants complete a measure of dysfunctional attitudes (e.g., happiness requires success in all endeavors, asking for help is a sign of weakness, personal worth depends on others’ opinions) before and after the mood induction. Cognitive reactivity is shown by increases in dysfunctional attitudes immediately following the induction. People with a history of depressive episodes show higher cognitive reactivity to the induced mood, even if they are in remission when tested. Higher scores for cognitive reactivity are also associated with greater susceptibility to future depressive episodes (Segal et al., 2013).

Cognitive reactivity can also be assessed with the Leiden Index of Depression Sensitivity–Revised (LEIDS-R; Van der Does, 2002), a questionnaire that defines the construct more broadly as the tendency to show several maladaptive reactions to low mood, including rumination, avoidance of difficulties (neglecting tasks), aggressive behavior (sarcasm, temper outbursts), and perfectionism. LEIDS-R scores are consistently higher in previously depressed adults than in those who have never been depressed; scores also predict the amount of change in dysfunctional thinking following a negative mood induction. A recent study of a community sample found that MBCT led to significant decreases in reactivity, as assessed by the LEIDS-R, and that this effect was mediated by the extent to which participants had learned mindfulness skills during the intervention (Raes, Dewulf, van Heeringen, & Williams, 2009).

Emotional Reactivity

Several studies have shown relationships between mindfulness and reduced emotional reactivity to stress, specifically in recovery time following a negative mood induction or other unpleasant experience (see Britton, Shahar, Szepsenwol, & Jacobs, 2012, for a summary). In a randomized trial comparing MBCT to a wait-list control in adults with partially remitted depression, Britton and colleagues (2012) studied emotional reactivity with the Trier Social Stress Test (Kirschbaum, Pirke, & Hellhammer, 1993), administered before and after treatment. In the presence of a camera and judges, this test requires participants to make a five-minute speech and then to perform a difficult mental arithmetic task aloud. Emotional reactivity was measured with self-ratings of distress pretask, during the task, immediately following the task, and at forty and ninety minutes posttask.

Following the eight-week course, MBCT participants’ distress before and during the task were unchanged from before treatment. However, significant reductions in emotional reactivity were seen at the posttask, forty-minute, and ninety-minute assessment points, suggesting that after mindfulness training the task continued to elicit distress, but that participants recovered from it more quickly. Wait-list participants showed no change over the eight-week period, except that their pretask scores increased, suggesting that anticipatory anxiety was worse for their second experience with the task.

Although the study did not examine what treatment participants were doing during the posttask phase, MBCT teaches friendly acceptance of sensations and emotions while decentering from the content of thoughts and disengaging from ruminative thought patterns. It therefore seems plausible that after mindfulness training, participants were better able to refrain from several forms of reactivity to the stress associated with the task.

Repetitive Negative Thought

Several studies have examined the role rumination and worry may play in accounting for the therapeutic effects of MBIs on psychological symptoms, such as depression, anxiety, and stress. In their systematic review, Gu and colleagues (2015) found consistent evidence that reductions in repetitive negative thinking significantly mediate the effects of mindfulness-based treatment on outcomes. Van der Velden and colleagues (2015) report that evidence for rumination and worry as mediators of change in MBCT for depression is mixed. However, they note that while the frequency of rumination may not always decrease following treatment, the relationship between rumination and later relapse may change if participants develop skills for decentering from the content of negative thoughts.

Self-Compassion

According to Neff (2003), self-compassion has three components: self-kindness in the face of suffering, seeing one’s difficulties as part of a larger human experience, and “holding one’s painful thoughts and feelings in balanced awareness rather than over-identifying with them” (p. 223). Gu and colleagues (2015) found three studies of self-compassion as a mediator of the effects of MBIs, and results were conflicting. Two of the studies used nonclinical samples and found that MBSR led to significant increases in self-compassion, but that these increases did not mediate effects on anger expression or anxiety. However, the strongest of the three studies (Kuyken et al., 2010) compared MBCT with antidepressant medication for clients with recurrent depression and found that increases in self-compassion over the eight-week course of MBCT mediated reductions in the likelihood of a depressive episode over the next fifteen months.

Kuyken and colleagues (2010) also included in the study the cognitive reactivity task described earlier, finding that cognitive reactivity was unexpectedly higher in the MBCT group than the medication group at the end of the eight-week treatment. However, in the medication group, cognitive reactivity post-treatment predicted the likelihood of relapse over the following fifteen months, whereas in the MBCT group reactivity post-treatment was unrelated to later relapse. Self-compassion moderated this pattern, such that the toxic relationship between cognitive reactivity post-treatment and depressive relapse over the next fifteen months was absent for those who showed greater improvements in self-compassion. This finding suggests that a kind and nonjudgmental response to dysfunctional thoughts, when they arise, may weaken the link between such thoughts and the later onset of depressive episodes.

Decentering

Decentering is also known as meta-awareness or metacognitive awareness and is similar to defusion as defined in the ACT literature. Hölzel and colleagues (2011) describe a similar construct as a change in perspective in which the contents of consciousness are recognized as constantly fluctuating and transient experiences. Decentering is the term used in the MBCT literature, in which it refers to a perspective from which thoughts and feelings are recognized as temporary phenomena rather than as true or important reflections of reality or as essential aspects of oneself. A decentered perspective allows people to take their thoughts and feelings less literally and to be less driven by them. Decentering has been shown to mediate the effects of MBCT for depression (Van der Velden et al., 2015) and MBSR for generalized anxiety disorder (Hoge et al., 2015).

Psychological Flexibility

Psychological flexibility is the central theoretical construct in ACT and includes six components. Four of these, as noted earlier, are conceptualized as elements of mindfulness (contact with the present moment, acceptance, defusion, and self-as-context). The other two components (values and committed action) are behavior change processes. Psychological flexibility, therefore, is the ability to be mindfully aware of the present moment and to behave in values-consistent ways, even when difficult thoughts and feelings are present. ACT includes many exercises and practices designed to cultivate the components of mindfulness, as well as strategies for helping participants to identify their values and engage in values-consistent behavior. A large body of literature shows that increases in psychological flexibility mediate the beneficial effects of ACT in a wide range of adult samples, including people with anxiety and mood disorders, chronic pain, self-harming behavior, and health-related goals such as smoking cessation and weight management (Ciarrochi et al., 2010).

Positive Affect

A few studies suggest that mindfulness training increases daily experiences of positive affect, and that this may be an important mediator of the effect of MBCT on depressive symptoms and risk of relapse (Geschwind, Peeters, Drukker, van Os, & Wichers, 2011; Batink, Peeters, Geschwind, van Os, & Wichers, 2013). Although the processes through which this occurs are not well studied, a newly articulated mindfulness-to-meaning theory (Garland, Farb, Goldin, & Fredrickson, 2015) suggests that mindfulness leads to decentering from thoughts and emotions, which facilitates the reappraisal of adversity and the savoring of positive experiences, which in turn increases purposeful engagement with life. Additional study of this promising theory is needed.

Summary of Mindfulness Processes

As noted earlier, the literature on the mechanisms of mindfulness includes a variety of conceptual and theoretical perspectives, each with its own terms and constructs that are used in somewhat overlapping ways. In general, the literature suggests that the practice of mindfulness teaches participants to adopt a new perspective on, or relationship to, their own internal experiences (sensations, cognitions, emotions, urges). This perspective includes decentering or defusion; acceptance or allowing; friendly curiosity, kindness and compassion; and the understanding that thoughts and feelings are not facts, don’t have to control behavior, and don’t define the person who is having them. Adopting this perspective appears to reduce unhelpful reactions to stressful events and the uncomfortable thoughts and feelings associated with them. For example, mindful awareness of difficult experiences may prevent the onset of dysfunctional attitudes and rumination; alternatively, if these cognitive patterns arise, the person may be able to decenter or defuse from them more readily, with an attitude of kindness and compassion. This may facilitate quicker recovery from stress and pain, increased positive affect and savoring, clearer recognition of values and goals, and increases in values-consistent behavior. Figure 1 summarizes the current literature’s conclusions about how mindfulness may influence mental health.

Conclusions

For many years, cognitive and behavioral therapies focused primarily on methods of change. A large body of literature supports the efficacy of strategies for changing behavior, cognitions, emotions, and aspects of the environment. Until recently, fewer strategies have been available for managing painful realities that can’t readily be changed, or difficult thoughts and feelings that paradoxically intensify when attempts are made to change them. The introduction of mindfulness to the cognitive and behavioral therapies provides a set of principles and practices that help people develop the skills to manage such experiences. For this reason, mindfulness training is often described as an acceptance-based approach, but it does not promote passivity or helplessness. It cultivates the ability to see what is happening in the present moment and to make wise choices about how to respond.

Mindful awareness, therefore, may provide a foundation for the effective use of the skills and methods discussed in this volume. Mindfulness training seems to help clients recognize and acknowledge their internal experiences (thoughts, emotions, sensations, urges) and choose constructive ways to respond to them. In some circumstances, helpful responses might include change-based strategies, such as arousal reduction, cognitive restructuring, behavioral activation, problem solving, or interpersonal skills use. In other circumstances, defusion and acceptance skills may be more helpful. Responses that are self-compassionate and consistent with personal values and goals are likely to promote flourishing and well-being. Mindfulness, therefore, may be critical to a broad perspective on how to alleviate problems and help people thrive.

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