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Mindfulness as a way of addressing the deficits in clinical psychology training programs: A review

Pooja Hemanth, Paul Fisher

1 Department of Psychology, James Cook University Singapore, Singapore

2 Department of Psychological Sciences, Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich, United Kingdom

Address for correspondence

Postal: 149 Sims Drive, Singapore 387380

E-mail: [email protected]

Word count (exc. figures/tables): 7276

Running Head: MINDFULNESS IN CLINICAL PSYCHOLOGY TRAINING

MINDFULNESS IN CLINICAL PSYCHOLOGY TRAINING

Mindfulness as a Way of Addressing the Deficits in Clinical Psychology Training Programs: A Review

Keywords: mindfulness, clinical psychology training, trainees, self-care, professional development

Abstract

Research suggests that there is a lack of focus on developing trainees’ intrapersonal skills

or adequately fostering self-care. Mindfulness training may help address the gaps in

training programs. Quantitative and qualitative studies involving mindfulness training for

postgraduate trainees were reviewed. There is a need to explore different designs of

mindfulness training groups to ascertain what would be feasible and effective, given the

trainees’ existing time constraints. Furthermore, the current understanding is limited due to

the difficulties defining and operationalizing mindfulness. Qualitative research would help

to explore what mindfulness training means to trainees and how it impacts on their lives.


Introduction

Clinical psychology training programs are required to foster trainees’ professional

development in psychotherapy knowledge and skills to help them work effectively with

clients (Bruce, Manber, Shapiro, & Constantino, 2010) and to create a culture of self-care

as trainees are vulnerable to stress and stress-related problems during training (Pakenham

& Stafford-Brown, 2012). Research has suggested a lack of a structured approach within

programs to develop trainees’ intrapersonal skills and foster trainees’ self-care, resulting in

a lack of adequately meeting these needs (Lambert & Simon, 2008; Myers et al., 2012).

This review explores these gaps between research and training in the professional

development of intrapersonal and self-care skills, and discusses the use of mindfulness to

bridge these gaps. Due to the small amount of research that is specific to clinical

psychology training and the application of mindfulness to this population, the reviewed

literature includes that of trainees in other mental health fields which involve

psychotherapy training, such as counselling psychology, counselling, and social work.

Literature Search Strategy

The PsycARTICLES database was searched using the ProQuest interface on 31

December 2011 for the period 1990 to 2012. The Web of Science database was searched

on 20 October 2012 for the period 1990 to 2012. The search terms were: clinical, clinical

psychology, psychologist, counselling, counsellor, psychotherapy, psychotherapist,

therapist, health care, mindfulness AND training, skills, stress, self-care. Other relevant

articles were also found individually by looking through reference lists of the relevant

journal articles. The articles provided information about the current gaps in the

professional development and self-care among trainees in postgraduate psychotherapy

training programs, and the use of mindfulness to fill this gap. In particular, given this

review’s focus on the use of mindfulness practices for postgraduate psychotherapy


trainees, the findings from a number of quantitative and qualitative articles that researched

the use of mindfulness with this population were summarized and can be found in Tables 1

and 2.

Professional Development in Clinical Psychology Programs

Research suggests that clinical psychology training involves the professional

development of psychotherapy knowledge and skills (Lambert & Simon, 2008).

Psychotherapy knowledge, which refers to knowledge regarding theories, models,

concepts, and techniques of therapy (Kramer, Meleo-Meyer & Turner, 2008), is commonly

learnt through didactic teaching methods, manual-guided techniques, and application of

theory to supervised clinical work (Vakoch & Strupp, 2000). Clinical psychology training

also involves learning skills such as active listening, questioning, empathy, re-framing, and

confrontation (Ivey, Ivey, & Zalaquett, 2009). Some of these skills are more complex and

dynamic in nature; in addition to interpersonal components, they also have intrapersonal

dimensions pertaining to internal qualities and attitudes of the trainees (Gockel, 2010).

Research suggests that it is important for therapists to use their intrapersonal skills to create

therapeutic presence, which Gellar and Greenberg (2002) described as having three

components: an openness to the client’s experiences, openness to one’s own experiences

when working with the client, and the ability to interact with the client based on this

experience. Some examples of important intrapersonal skills that make up therapeutic

presence are in-session self-awareness, an internal attitude of empathy, affect tolerance,

and managing focused attention (Williams & Fauth, 2005; Fulton, 2005; Greason &

Cashwell, 2009). Thorne (1992) reported that therapeutic presence helps to cultivate

Rogers’ (1957) six core conditions, which are agreed upon by theorists from almost all

orientations to be important to strengthen the therapeutic alliance and promote positive

changes for clients during therapy (Norcross, 2002).


Despite the importance of intrapersonal skills to the therapy process, research

suggests that there is a lack of focus on inculcating the intrapersonal psychotherapy skills

in trainees (Greason & Cashwell, 2009; Fulton, 2005; Lambert & Simon, 2008). The

following reasons have been proposed for this shortcoming in training programs: over-

emphasis on teaching therapy models (Fulton, 2005), assumptions about the fact that

developing the intrapersonal skills would naturally follow the learning of discernible

interpersonal skills (Greason & Cashwell, 2009), and the presence of the widely-held belief

that intrapersonal attitudes, such as warmth and non-judgment, are difficult to teach

(Lambert & Simon, 2008). As a result, training programs have either failed to pay attention

to developing these intrapersonal skills or have depended on other means, such as the

therapist’s personal psychotherapy and sensitivity training, for the development of these

skills (Lambert & Simon, 2008).

Self-Care in Clinical Psychology Training Programs

Clinical psychology training has been associated with significant challenges to

trainees’ subjective well-being (Pakenham & Stafford-Brown, 2012). Trainee

psychologists report many stressors, including personal stressors (e.g. finances), academic

and evaluative aspects of training (e.g. being evaluated by supervisors), work-practice

stressors (e.g. time constraints, caseload), and challenges in clinical work (e.g. ambiguity,

ethical dilemmas; Nelson, Dell’Oliver, Koch, & Buckler, 2001; Pakenham & Stafford-

Brown, 2012). Existing studies show significant levels of stress among clinical psychology

trainees (Cushway, 1992; Myers et al., 2012). Trainees are also vulnerable to difficulties

such as burnout and vicarious traumatization, particularly when they are new to practicing

(Gockel, 2010; Adams & Riggs, 2010). There is no known published empirical research to

show that stress and other stress-related outcomes hinder or impair professional

functioning among trainee psychologists. However, research on populations such as


trainee teachers and trainee engineers suggest that if these problems are not appropriately

addressed, there is a risk of trainees experiencing hindered or impaired professional

competence as a consequence of impediments to skills such as attention, concentration, and

decision-making (El-Ghoroury, Galper, Sawaqdeh, & Bufka, 2012).

Self-care refers to actions (e.g. seeking social support and exercise) which the

individual initiates to promote his or her own health and well-being (Bickley, 1998). Some

studies have found that self-care practices are associated with lower perceived stress levels

among trainees (McKinzie, Altamura, Burgoon, & Bishop, 2006; Myers et al., 2012;

Chrisman, Christopher, & Lichtenstein, 2009). Despite these positive findings, training

programs usually do not have a structured component for self-care in the core curriculum

(Christopher, Christopher, Dunnagan, & Schure, 2006). Furthermore, there is a lack of

communication regarding the need for self-care, and it is usually conveyed to trainees as

their individual responsibility (Munsey, 2006; Christopher et al., 2006). This approach is

considered ineffective as trainees may underestimate their susceptibility to mental and

emotional difficulties due to the mental health training they have undergone (Barnett,

2008).

Mindfulness as a Tool for Professional Development and Self-Care

Given all of the above challenges, recent research has considered mindfulness as a

means to addressing the challenges of professional development and self-care for trainees

in clinical psychology and related disciplines, such as counselling, counselling psychology,

and social work (Rimes & Wingrove, 2011). Researchers have noticed compatibility

between the challenges in professional development and self-care, and the aims and

outcomes of practicing mindfulness (Gockel, 2010; Bruce et al., 2010). In order to

understand this compatibility, it is useful to first understand the nature of mindfulness and

how it has been applied to clinical practice and training.


The Historical Roots of Mindfulness

Mindfulness, a practice that stretches over 2500 years ago, is known for being

rooted in Buddhist religion and philosophy. Thomas William Rhys Davids, a Pali-language

scholar, has been cited as the person who translated the word Sati to the English word

mindfulness. Thich Nhat Hanh was one of the first teachers of mindfulness to the West and

his work paved the way for many others to bring mindfulness into the Western clinical

context. This included practices such as focusing on bodily felt sensations and body scans

(Gendlin, 1998; Cornell, 2013).

The Definition of Mindfulness

Gunarantana (2002) stated that it was difficult to define mindfulness because of its

subtle and non-verbal nature. Researchers have yet to come to a consensus for the

operational definition of mindfulness (Bishop et al., 2004). Kabat-Zinn’s (1994) widely-

cited definition is “paying attention in a particular way: on purpose, in the present moment,

and non-judgementally” (p. 4). Shapiro, Carlson, Astin, and Freedman (2006) built on

Kabat-Zinn’s (1994) definition by suggesting that mindfulness comprises three

components: intention, attention, and attitude. Kabat Zinn’s (1994) “on purpose” refers to

intention, “paying attention” refers to attention, and “in a particular way” refers to attitude

(Kabat-Zinn, 1994; Shapiro et al., 2006). Shapiro et al. (2006) proposed that these three

components lead to “reperceiving” (p. 2), which means a significant shift in an individual’s

outlook. Bishop et al. (2004) view mindfulness as comprising two components, self-

regulation of attention to present moment experience and the individual’s attitude to the

present moment experience, an attitude typified by an attitude of curiosity, openness, and

acceptance (Bishop et al., 2004). Although different operational definitions exist, the

definitions include similar fundamental components; the intention to focus one’s attention,


controlling attention to the present moment, and adopting a particular attitude to one’s

experiences.

Mindfulness practices can be classified as formal and informal. Formal mindfulness

practices often include seated meditation, mindful yoga stretches and the body scan, which

involves systematically paying attention to sensations in each part of the body (Cigolla &

Brown, 2011). Informal mindfulness practices involve the application of mindfulness skills

in daily life, such as walking or eating (Cigolla & Brown, 2011). Through the cultivation

of mindfulness skills, one becomes more aware of thought patterns, detaches from these

patterns, and gains a new perspective of seeing the world (Baer, 2003). In this new

perspective, thoughts and feelings are no longer labelled “good” or “bad” and individuals

are empowered to accept what is happening in their present moment, instead of focusing

on what they feel should be happening instead (Germer, 2005).

Mindfulness in Clinical Practice

Mindfulness is also currently of interest to therapists of almost all theoretical

orientations, including psychoanalytic and humanistic approaches (Christopher & Maris,

2010). It is central to many contemporary intervention approaches such as Acceptance and

Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), Dialectical Behaviour

Therapy (DBT; Linehan, 1993), Mindfulness-Based Cognitive Therapy (MBCT; Segal,

Williams, & Teasdale, 2002), and Mindfulness-Based Stressed Reduction (MBSR; Kabat-

Zinn, 2003). Therapists can implement mindfulness interventions into sessions to help their

clients and clients can also be encouraged to practice mindfulness in their daily lives

outside therapy (Ryan, Saran, Doran, & Muran, 2012).

Mindfulness has also been increasingly promoted in therapeutic interventions to

help clients and patients with psychological, physiological and interpersonal difficulties. It

has been used in interventions for chronic pain, stress, depressive relapse, binge eating


disorder, and cancer (Kabat-Zinn, 1984; Shapiro, Schwartz, & Bonner, 1998; Segal et al.,

2002; Kristeller & Hallett, 1999; Speca, Carlson, Goodey, & Angen, 2000). It has also

been used in clinical populations with mixed diagnoses and non-clinical populations

(Kabat-Zinn, 2003). It is associated with many positive psychological outcomes, such as

higher positive affect, life satisfaction, adaptive emotional regulation, and self-compassion

(see Keng, Smoski, & Robins, 2011 for a review). Mindfulness is also associated with

various positive physical outcomes, such as positive changes in immune system

functioning and increased physiological levels of melatonin (Davidson et al., 2003;

Massion, Teas, Herbert, Wertheimer, & Kabat-Zinn, 1995).

Mindfulness for Professionals

Interventions such as ACT, DBT, MBSR, and MBCT include mindfulness practice

for the therapist as an important aspect of implementing the intervention (e.g. Linehan,

1993). Many who are experienced in using mindfulness-based interventions have proposed

that therapists should have experiential exposure to mindfulness techniques, thereby

increasing their own knowledge and experience before using the interventions with their

clients (e.g. Segal et al., 2002). Mindfulness has also been suggested to be useful for

mental health professionals because it offers professionals a means of self-care (e.g. May

& O’Donovan, 2007; Shapiro, Astin, Bishop, & Cordova, 2005; Christopher et al., 2011)

and they can use mindfulness in their personal and professional lives (Rothaupt & Morgan,

2007; Cigolla & Brown, 2009).

May and O’Donovan (2007) found that among 55 mental health professionals, self-

reported mindfulness was associated with higher life satisfaction, the experience of more

frequent positive emotions and less frequent negative emotions, lower levels of burnout,

and higher job satisfaction. Shapiro et al. (2005) found that an 8-week MBSR intervention

led to a significant decrease in perceived stress and increase in self-compassion among 18


health care professionals, including psychologists and social workers, in comparison to a

wait-list control group of 20 participants. Aggs and Bambling (2010) found that, for their

sample of 47 mental health professionals, an eight-week mindfulness therapy training

program positively impacted on their knowledge about mindfulness, attitudes regarding

using mindfulness in their clinical work, ability to practice mindfulness, and reduced stress

and tension.

One long-term follow-up qualitative study was conducted on 16 practicing

counsellors who had undertaken a mindfulness training course during their graduate

training in counselling (Christopher et al., 2011). The participants had taken the course an

average of four years prior to the follow-up study (Christopher et al., 2011). The study

sought to understand the role of mindfulness in their personal and professional lives. The

participants’ accounts suggested that they found the course useful. Two themes emerged

pertaining to their personal lives: a) personal development/self-care and b) interpersonal

relationships. Three themes emerged pertaining to their professional lives: a) counselors’

experience of self while counseling, b) the therapeutic relationship, and c) clinical practice.

Two qualitative studies have been conducted on populations of registered mental

health professionals who had identified themselves as using mindfulness practices.

Rothaupt and Morgan (2007) interviewed six counsellors, four of whom were also

counsellor educators, to understand their application of mindfulness in their personal and

professional lives. Their analysis was conducted by constant comparative method and

found one overarching theme of the need and effort to live in the present moment. They

also found two other broad themes: a) using a variety of tools or methods to incorporate

mindfulness into their lives and b) the outcomes or results of their mindfulness. Cigolla

and Brown (2009) interviewed six therapists to find out how they understand the concept

of mindfulness and its role in their personal and professional lives. Using an interpretive


phenomenological analysis, they developed one major theme of mindfulness as a way of

being, and three subthemes: a) a way of being in personal life, b) a way of being in

therapy, and c) encouraging a way of being in others.

The relative paucity of research in this area suggests that mindfulness for health

care professionals is still an area which requires further study so as to establish its

usefulness. The existing research, although lacking in quantity, suggests that it offers many

useful benefits for self-care, and personal and professional development. While

mindfulness can be taught to mental health professionals while they are practicing, it is

also useful to explore how this teaching can be fostered before they qualify, so as to reap

these benefits as professionals later on in their careers.

Mindfulness for Mental Health Trainees

Research has investigated the use of mindfulness to address the gaps in clinical

psychology training. In line with the focus of the literature search strategy, empirical

research regarding the use of mindfulness for mental health trainees will be reviewed so as

to understand the current knowledge and therefore inform on future research directions.

Quantitative and Mixed-Method Studies Regarding Mindfulness for Trainees

Dispositional mindfulness. Dispositional mindfulness refers to an innate trait that

reflects an individual’s propensity to cultivate intentional awareness (Brown & Ryan,

2003). Table 1 lists two quantitative studies that have been conducted to study the

association between dispositional mindfulness and variables of interest among mental

health trainees. The research shows that dispositional mindfulness is positively associated

with qualities within the therapist, therapeutic alliance, and client’s interpersonal

functioning (Greason & Cashwell, 2009; Ryan et al., 2012). Dispositional mindfulness was

not associated with improvement in clients’ broader psychological problems and symptoms

of psychopathology; one reason that was put forth to explain this was that mindfulness may


be more related to interpersonal rather than broader psychological functioning (Ryan et al.,

2012).

Insert Table 1 Here

Mindfulness practices. Table 2 lists the quantitative studies that have been

conducted to study the impact of mindfulness practices for mental health trainees. Some of

the studies were also mixed method in nature, where qualitative responses were collected

from the participants (Stafford-Brown & Pakenham, 2012; Rimes & Wingrove, 2010,

Moore, 2008). The studies show that trainees who participate in mindfulness training

experience many increases in positive outcomes related to self-care (Shapiro, Brown, &

Biegel, 2007; Stafford-Brown & Pakenham, 2012; Rimes & Wingrove, 2010, Moore,

2008; Collard, Avny, & Boniwell, 2008) and stronger therapeutic alliance (Stafford-Brown

& Pakenham, 2012). Some studies did not find significantly improved outcomes in

domains such as stress, anxiety, depression, satisfaction in life, and positive affect (Rimes

& Wingrove, 2010; Moore, 2008; Collard et al., 2008). Researchers proposed that the

possible reasons for this were sampling and measurement issues (Rimes & Wingrove,

2010; Moore, 2008; Collard et al., 2008). This suggested that it has been difficult for

research to accurately ascertain the effectiveness of mindfulness for this population. Some

of these studies also obtained open-ended written feedback from the participants, and their

feedback suggested that the practices were helpful in various aspects of their personal and

professional lives (Rimes & Wingrove, 2010; Moore; 2008; Stafford-Brown & Pakenham,

2012).

Insert Table 2 Here

Qualitative Studies Regarding Mindfulness for Trainees

Christopher and Maris (2010) summarised five qualitative research studies

regarding the impact of mindfulness interventions on trainees’ personal and professional


lives. Four of the studies were conducted on postgraduate counselling trainees (Christopher

et al., 2006; Schure, Christopher, & Christopher, 2008; Crisman et al., 2009; Maris, 2009).

These studies revealed many themes that suggested mindfulness to be useful for trainees’

self-care and personal and professional development. Apart from the studies summarized

in the article by Christopher and Maris (2010), one other qualitative study regarding

mindfulness for trainees was found. McCollum and Gehart (2010) conducted a study on 13

marital and family therapy trainees to understand their experience of learning mindfulness

meditation to aid them in developing therapeutic presence. The analysis, conducted

through thematic analysis, was based on journal entries. The following themes were found:

being present, effects of meditation, shift in mode, and compassion and acceptance. Within

the theme of being present, the sub-themes were (a) attending to inner experience, (b)

aware of what happens with client, and (c) acting from awareness. Within the theme of

effects of meditation, the sub-themes were (a) calmer, (b) managing inner chatter, (c)

slowing down and (d) boundaries between sessions. Within the theme of shift in mode, one

subtheme of doing mode balanced by being mode was found. While the doing mode refers

to the idea that therapy is focused on doing activity, the being mode refers to finding times

to simply be with the client (McCollum & Gehart, 2010). Within the theme of compassion

and acceptance, the sub-themes were (a) toward self, (b) toward client, and (c) sense of

shared humanity.

Mindfulness for Trainees’ Professional Development

Having listed the broad findings of mindfulness for trainees, this review will now

consider, in depth, how mindfulness training can cultivate the intrapersonal skills

mentioned earlier in this review.

Firstly, mindfulness can be a way for trainees to manage in-session self-awareness

because mindfulness involves non-judgmental and flexible attention and awareness, and


might help trainees manage distracting self-focus (Nutt-Williams, 2008). Qualitative

research found that trainees find mindfulness helpful to manage awareness of their

experiences during sessions (Christopher & Maris, 2010). For example, trainees reported

feeling more confident in their ability to manage their distracting self-focused anxiety

about being a therapist and reported increased ability to react constructively when

experiencing countertransference reactions (Chrisman et al., 2009; Christopher & Maris,

2010; Schure et al., 2008).

Secondly, mindfulness has been proposed to help with empathy through decreasing

stress, increasing self-compassion, and learning to put aside one’s own subjective

perspective (Gehart & McCollum, 2008). Greason and Cashwell (2009) found a positive

association between mindfulness and empathy. While there have not been any other

quantitative studies directly studying the association between mindfulness and empathy

among mental health trainees, it has been found that mindfulness increases self-

compassion and reduces stress (e.g. Shapiro et al., 2007), which is in line with Gehart and

McCollum’s (2008) proposal of the link between mindfulness and empathy. Qualitative

research also found that trainees found mindfulness training helpful in increasing their

compassion towards clients (Christopher & Maris, 2010).

Thirdly, mindfulness can also help trainees develop their affect tolerance skills as

the trainee would be able to tolerate his or her own affect through mindfulness by

accepting the emotions as they arise and letting them pass (Safran & Reading, 2008;

Luoma & Villatte, 2012). This, in turn, can increase the trainee’s confidence in his or her

ability to hold a client’s affect in session (Safran & Reading, 2008). This would allow

clients a safe environment to fully express their feelings, and this can in itself be a positive

experience in therapy (Fulton, 2005; Safran & Reading, 2008). This also enhances the

client’s ability to build affect tolerance; this has been found to be important to improve


difficulties such as anxiety and addiction (Gockel, 2010). Qualitative research has shown

that mindfulness helps trainees tolerate their clients’ and their own affect, thus creating a

‘holding environment’ for the client’s feelings (Christopher & Maris, 2010).

Fourth, mindfulness practices have also been suggested as a way to learn how to

focus attention as they give students mastery experiences in attention skills (Greason &

Cashwell, 2009). Greason and Cashwell (2009) found that self-reported mindfulness was

positively associated with attention. Qualitative studies have also revealed that trainees use

mindfulness to be more attentive with clients (Christopher & Maris, 2010).

Mindfulness for Trainees’ Self-Care

Research also suggests the use of mindfulness practices as a self-care tool for

trainees. It has been suggested that mindfulness training can help with reducing stress and

stress-related psychological problems (Gockel, 2010). Empirical research which has used

mindfulness training with trainee samples found that the interventions led to improvements

in their self-care and psychological well-being. This included significant increases in self-

compassion (Rimes & Wingrove, 2008), positive affect (Shapiro et al., 2007), self-

kindness (Moore, 2008), life satisfaction (Stafford-Brown & Pakenham), increased

relaxation (Crisman et al., 2009), and increased calmness (Crisman et al., 2009). The

interventions were also associated with decreases in perceived stress (Rimes & Wingrove,

2008), work-related stress (Stafford-Brown & Pakenham), negative affect (Shapiro et al.,

2007), and rumination (Rimes & Wingrove, 2008). Furthermore, Shapiro et al. (2007)

found that increases in mindfulness mediated these benefits to self-care. Qualitative

research has also shown that mindfulness practices offer numerous benefits to trainees for

self-care (Christopher & Maris, 2010). Given all of this literature, there is strong evidence

to suggest that mindfulness practices offer a useful approach to self-care for trainees.

Mindfulness for Trainees’ Implementing Mindfulness-Based Interventions


As mentioned above, mindfulness is integral to therapeutic approaches such as

MBCT (Segal et al., 2002) and MBSR (Kabat-Zinn, 2003), and research suggests that it is

an effective intervention for many presenting difficulties (Keng et al., 2011). However, the

lack of exposure and knowledge about mindfulness interventions can prevent trainees from

using mindfulness as an intervention within therapy (McKenzie, Hassed, & Gear, 2012).

Research has found that receiving training in mindfulness helps increase trainees’

willingness and confidence to use mindfulness practices with clients (Moore; 2008;

McKenzie et al., 2012).

Impact of Trainees’ Mindfulness Practices on Client Outcomes

In addition to trainees’ outcomes for their own self-care and professional

development in intrapersonal skills and using mindfulness-based interventions, research

has also studied the relationship between trainees’ mindfulness and client outcomes.

Grepmair et al. (2007) found that the clients of trainees who participated in mindfulness

training experienced improved outcomes such as decrease in symptom severity and

increase in self-attunement, global functioning, subjective experience and interpersonal

functioning (Grepmair et al., 2007). These clients also had a better comprehension of the

goals of therapy, their own development, and optimism about their progress (Grepmair et

al., 2007). These were in comparison to clients of trainees who did not participate in

mindfulness training.

How to Develop Mindfulness in Trainees

Given the potential benefits of mindfulness, attention has been paid to different

ways of teaching mindfulness to trainees. Research suggests that mindfulness can be taught

to trainees through the use of mindfulness groups as a variety of designs have resulted in

increased mindfulness and other positive outcomes (Moore, 2008, Collard et al., 2008). It

has been noted that time constraints, such as for groups such as clinical psychology


trainees where there is a rigorous curriculum, may impede trainees’ ability to participate in

mindfulness programmes (Moore, 2008). This may be a reason for them to decline

participation or drop-out from participating (Carmody & Baer, 2009). It would be useful to

explore possibilities of administering mindfulness programmes which have less strict time

demands and which can be conducted without the guidance of an instructor who has been

formally trained (Carmody & Baer, 2009). To support the rationale of using shorter

formats, Carmody and Baer (2009) found that shortened versions of MBSR were no less

effective than the standard format in decreasing psychological distress. In line with

recommendations for shorter interventions, suggested intervention designs have included

shorter versions of MBSR or MBCT (Carmody & Baer, 2009) and brief experiential

exercises as a group during clinical training (Moore, 2008), and a student-led mindfulness

group (Myers et al., 2012). The content in these intervention designs can be typical of

those used in mindfulness-based programs such as MBSR or MBCT, but with a shorter

duration (Moore, 2008). This would allow for the implementation of these designs within

programs with rigorous curriculum and time constraints.

Critique of Mindfulness Literature

There are some limitations within the available literature regarding mindfulness for

mental health trainees. These limitations pertain to measurement and other methodological

issues.

Limitations of Quantitative Studies Regarding Mindfulness for Trainees

In quantitative research, researchers determine the variables that will be studied

according to their interest (Christopher & Maris, 2010). Christopher and Marks (2010)

stated that within quantitative mindfulness studies, the variables of interest are usually

measured by questionnaires comprising a number of self-report items. This can result in

“an imposition by the researcher of his or her own framework of meaning that may miss or


distort the structures of meaning that the study participants would spontaneously generate

and employ on their own” (Christopher & Maris, 2010, p. 116). This is especially

pertinent for an experiential concept like mindfulness, for which researchers have yet to

attain consensus regarding its definition, operationalization and measurement (Cigolla &

Brown, 2011).

Different tools tend to differ in the aspects of mindfulness that they measure as well

as the way in which the aspects are measured (Hick, 2008). For example, the Mindfulness

Attention Awareness Scale (MAAS; Brown & Ryan, 2003), as used in the study by

Shapiro et al., 2007, measures attention and awareness but does not measure other

important aspects of mindfulness, such as openness to novel experiences and non-

judgmental attitude (Hick, 2008). One implication is that self-report questionnaires may

not be sensitive to the magnitude of change that participants experience (Moore, 2008). For

example, Myers et al. (2012) proposed that only those who engage in frequent formal

mindfulness practice obtain significant increase in trait mindfulness as measured by self-

report questionnaires.

The nature of mindfulness is also such that participants who are more mindful

might actually be more aware of the degree to which they are not mindful, and rate

themselves lower when completing self-reported questionnaires (Davis & Hayes, 2011).

Similarly, participants who are less mindful may not be fully aware of the degree to which

they are not mindful, thus overestimating their mindfulness (Davis & Hayes, 2011). They

may gain more insight during the post-course measures and the questionnaires may not be

a reliable indicator of change in mindfulness (Moore, 2008; Davis & Hayes, 2011).

Myers et al. (2012) suggested that an alternative to measuring mindfulness in self-

report questionnaires is to measure the frequency of mindfulness practice and find out how

this is associated with outcome measures. It is important to note that measuring the


frequency of mindfulness practice also has its limitations. Firstly, the meaning of engaging

in mindfulness practice may differ among individuals (May & O’Donovan, 2007). For

example, individuals may differ as to whether they view informal practices such as

labelling one’s feelings to be mindfulness practice. Secondly, the intention behind the

practice is also of concern (May & O’Donovan, 2007). For example, some individuals

might practice yoga with the intention to exercise rather than to cultivate mindfulness

(May & O’Donovan, 2007). This makes it difficult to quantify how much time an

individual spends engaging in mindfulness practice.

The available research also has many other methodological limitations. Firstly,

there are no randomized control groups in all studies. This means that the relationship

between the mindfulness interventions or courses and the changes in dependent variables

cannot be established as causal. The changes may be due to other factors such as trainees

adjusting to their professional roles over time. In all studies, the samples are self-selected.

This means that motivational differences such as being more open to learning about

mindfulness or perceiving the need for help may affect their choice to participate and affect

how they experience the interventions. These limitations of self-selection, participant

attrition during the intervention and evaluation, and demand effects as the participants may

be aware of the rationale of the intervention, can lead to bias with regards to confirming

the researcher’s hypotheses. Furthermore, the studies contain small sample sizes which

may affect statistical analysis and results. The nature of the student populations, that being

from specific courses in universities with different features (e.g. public or private

programs), also limits the generalizability of the results to the wider population.

Adopting a Qualitative Approach

Irving, Dobkin, and Park (2009) highlighted the lack of published qualitative

studies of mindfulness interventions with clinicians or trainees. Although research has


highlighted some emerging consistency in the definition of mindfulness (Bishop et al.,

2004; Shapiro et al., 2006), it was proposed that qualitative research in this area would help

explore experiences in an open-ended way and investigate aspects of change that have not

yet been captured in previous research (Christopher & Maris, 2010). This is done without

the use of operational definitions of mindfulness to guide the study, and Rubin and Babbie

(2009) offer three reasons to explain this. Firstly, the researcher does not want to predict

what the most salient variables will be (Rubin & Babbie, 2009). Secondly, the researcher

recognizes that his or her way of operationalizing a construct may not be the best way of

measuring the phenomenon (Rubin & Babbie, 2009). Thirdly, the researcher recognizes

that operational definitions may be limited because variables are measured by specific

observable indicators (Rubin & Babbie, 2009). A deeper understanding of mindfulness

could help inform operationalization in future quantitative or mixed-method studies

(Cigolla & Brown, 2009). Qualitative research can explore how trainees define, learn, and

experience mindfulness and mindfulness practices and the application of mindfulness in

their personal and professional lives as they train to become psychologists.

Conclusion

The available research on mindfulness for mental health trainees shows many

benefits for self-care and professional development, but the research designs comprise

many interventions which require substantial time requirements. This might not be feasible

for clinical psychology training programs to implement, given the rigorous curriculum and

time constraints. Future research should focus on designs which require shorter time

commitments so as to facilitate trainees’ participation.

The research pertaining to the outcomes of these interventions includes quantitative

studies which have many methodological limitations, especially that concerning the

operationalization and measurement of mindfulness using self-report questionnaires.


Qualitative research could offer a complimentary way to understand how trainees

experience mindfulness and its impacts on their personal and professional lives. Currently,

there is an overall dearth of qualitative studies and none focusing on the views of clinical

psychology trainees, who face unique challenges compared to other trainee populations.

Future research needs to focus on exploring clinical psychology trainees’ experiences of

mindfulness practices and the meanings attached to these experiences. This can contribute

to the clarity of understanding as to whether mindfulness practices foster the professional

development and self-care that training programs require for trainees. Understanding their

experiences will also help move towards forming guidelines that inform the development

of mindfulness training programmes for clinical psychology trainees.


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Acknowledgements

This research received no specific grant from any funding agency, commercial or not-for-

profit sectors.

Declaration of Interest

None.

Table 1Quantitative studies regarding dispositional mindfulness for traineesAuthor Sample Research

DesignVariables of Interest

Significant Findings

Greason & Cashwell, 2009

179 Master's and doctoral counseling trainees

Self-report questionnaire

Mindfulness, attention, empathy, self-efficacy

Positive associations between all four dependent variables: mindfulness, attention, empathy, self-efficacy

Ryan et al., 2012 26 therapist-client dyads, of which 20 therapists are clinicalpsychology trainees

Self-report questionnaire

Mindfulness, therapist self-affiliation, therapeutic alliance, patient’s global symptoms, patient’s interpersonal functioning

Positive association between therapist’s mindfulness and therapist self-affiliation, the therapist’s ratings of the therapeutic alliance, one aspect of the patient’s ratings of the therapeutic alliance, and improvements in the patient’s interpersonal functioning

Table 2Quantitative and mixed-method studies regarding mindfulness practices for traineesAuthor Sample Research

DesignTreatment Group after Dropout

Control Group after Dropout

Dependent Variables Significant Findings

Shapiro et al., (2007)

Counseling psychologytrainees

Prospective, non-random,cohort-controlled

n=22 in an 8-week MBSR intervention

n=32 in the twocontrol courses

Mindfulness, positive and negative affect, stress, state and trait anxiety, rumination, and self-compassion

Increase in mindfulness, positive affect, and self-compassion

Decrease in stress, negative affect, rumination, andstate and trait anxiety

Moore (2008) Clinical psychology trainees

Within-subjects

n= 10 in a 14 session, structured, mindfulness skillsgroup using short (10 min) practices

N/A Stress,mindfulness skills, self-compassion

Increase in mindfulness skills and in self-kindness aspect of self-compassion

Collard, Avny, & Boniwell, (2008)

Postgraduate counselling trainees

Within-subjects

n=15 in an 8-week MBCT course

N/A Mindfulness,satisfaction with life, positive affect and negative affect

Increase in mindfulness

Decrease in negative affectRimes & Wingrove (2010)

Clinical psychology trainees

Within-subjects

n=20 in an 8-week MBCT course

N/A Stress, anxiety, depression, mindfulness, self-compassion, and rumination.

Increase in self-compassion and mindfulness

Decrease in ruminationStafford-Brown & Pakenham, (2012)

Clinical psychology trainees

Prospective, non-random,cohort-controlled

n=26 in a 4-week ACT-informed intervention

n=28 in a waitlist control group

Work-related stress, psychological distress, life satisfaction, self-compassion, self-efficacy, and therapeutic alliance

Increase in life satisfaction, self-compassion, self-efficacy, and therapeutic alliance

Decrease in work-related stress and psychological distress

Changes maintained at 10-week follow-up

web viewin quantitative research, ... this is done without the use of operational definitions of...

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