Mindfulness-integrated CBT E-Book

Bruno A. Cayoun

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 574

Veröffentlichungsjahr: 2011

Beschreibung

Mindfulness-integrated CBT: Principles and Practice represents the first set of general principles and practical guidelines for the integration of mindfulness meditation with well-documented and newly developed CBT techniques to address a broad range of psychological dysfunctions.

• The first book to provide a strong rationale and general guidelines for the implementation of mindfulness meditation integrated with CBT for a wide range of psychological difficulties
• Incorporates ancient Buddhist concepts of how the mind works, while remaining firmly grounded in well-documented cognitive and behavioural principles
• Provides new insights into established understanding of conditioning principles
• Includes a comprehensive list of frequently asked questions, week-by-week instructions for professionals to facilitate application of the therapy, along with case examples and the inspiring stories of former clients

Leseprobe

Table of Contents

Cover

Table of Contents

Title page

Copyright page

About the Author

Acknowledgments

Preface

Abbreviations

Introduction

Part I: Theoretical Foundation

Chapter 1 Operationalization of Mindfulness

Definition of MiCBT

Case Illustration with Generalized Anxiety Disorder

Western Understanding of Eastern Conceptualization

Changes in Western Clinical Psychology

Summary of Main Points

Chapter 2 The Co-emergence Model of Reinforcement: A Rationale for Mindfulness Integration

Integrating Essential Components of Behavior Change

Role and Phenomenology of the Four Functional Components

Widening the Scope of Learning Theory

A Dynamic Systems Explanation of Intrusive Thoughts

Maintaining Mental Illness

Recreating Balance in the System

Summary of Main Points

Part II: Internalizing Skills

Chapter 3 Suitability and Rationale for MiCBT: Practical Guidelines for Therapists

A Transdiagnostic Assessment

Contraindications

Assessing Motivation to Change: A Proposed Script

Developing and Delivering an Appropriate Rationale

An Experiential Rationale for Mindfulness with Breathing

Modeling Acceptance and Equanimity in the 1st Interview

Summary of Main Points

Chapter 4 Stage 1 of MiCBT – Part I: How to Generalize Metacognitive and Interoceptive Exposure

Set Up

Relaxation as a Preparatory Measure

Practice Overview: Description and Operationalization

Summary of Main Points

Chapter 5 Clinical Relevance

Confounding Factors

Relaxation and Equanimity

Summary of Main Points

Chapter 6 Stage 1 of MiCBT – Part II: Explaining Difficulties and Facilitating Shifts

Lost in Thoughts

Dealing with Pain

Other Typical Difficulties

Promoting Adherence

Completion of Stage 1

Summary of Main Points

Part III: Externalizing Skills

Chapter 7 Stage 2 of MiCBT: Mindful Exposure and Cognitive Reappraisal

Aim of Stage 2

Basic Notion of Graded Exposure in Behavior Therapy

Exposure in Imagination

Overcoming Imagery Limitations

“Bi-polar Exposure”

Basic Notion of Cognitive Restructuring in Cognitive Therapy

Some Limitations

The Concept of Irrationality

Cognitive Reappraisal as a Consequence of Mindfulness

Re-evaluating the Self-Concept

Summary of Main Points

Chapter 8 Stage 3 of MiCBT: Interpersonal Mindfulness

Social Identity Theory

Stage 3 and the Theory of Social Identity

Using Stages 1 and 2 to Understand Others

Summary of Main Points

Chapter 9 Stage 4 of MiCBT: Relapse Prevention with Grounded Empathy

Empathy as Part of the MiCBT Model

Consequences of Mindfulness

Empathy as a Function of “Egolessness”

Self-Esteem

Two Bases for Self-Acceptance

Training in Stage 4

Reappraising Relapse

Summary of Main Points

Part IV: The Benefits

Chapter 10 MiCBT with DSM-V Axis 1 and Axis 2 Disorders

Developmental versus Situational Causes of Psychopathology

Early Cue Detection versus Experiential Avoidance

Case Example 1: Social Phobia

Case Example 2: PTSD

Case Example 3: PTSD and Dysthymic Disorder

Case Example 4: PTSD and Major Depressive Episode

Case Example 5: PTSD and Gambling Addiction

Case Example 6: Chronic Pain

Case Example 7: Chronic Pain, Chronic Depression, OCD and Panic Disorder with Agoraphobia

Case Example 8: General Anxiety Disorder, Connective Tissue Disorder and Osteoarthritis

Case Example 9: Chronic Depression, General Anxiety, Binge Eating and Diabetes

Case Example 10: Borderline Personality Disorder

The Issue of Personality

Summary of Main Points

Chapter 11 Evaluation of Mindfulness Training

Measuring Efficacy of Mindfulness-based Treatments

Data Collection: A Non Diagnosis-Specific Analysis of MiCBT

Effects of MiCBT on Health Behavior of People with Type 2 Diabetes

Mindfulness and Western Therapies

Summary of Main Points

Part V: Teaching and Training

Chapter 12 Weekly Implementation Protocol

Expected Skills Acquired with the Program

Contact Hours for the 8- to 12-Week MiCBT Program

Structure of Facilitator Handouts

Summary of the 4-Stage Model

Concluding Comment

Follow-up Sessions

Outline for the MiCBT Follow-up Groups

Summary of Main Points

Chapter 13 Professional Training

The Importance of Therapist Variables

Effects of Mindfulness on Therapy Outcomes

The Importance of Professional Training

Case Example 1: Needle Phobia

Case Example 2: Pain, Gambling Addiction and Anxiety

Case Example 3: Pain

Case Example 4: Distressing Situation

Case Example 5: ADHD

Recommendations for Clinicians

Summary of Main Points

Chapter 14 Frequently Asked Questions

Common Questions about Mindfulness Meditation

Compatibility with Pharmacotherapy

Unexplained Experiences with the Practice

Adherence to Therapy

Trauma

Passion

Pain

MiCBT for Children

Conducting Groups

Contraindications

Summary of Main Points

References

Glossary

List of Appendices

Appendix A – Scripts

Mindfulness with Breathing Script (Stage 1)

Part-by-Part Body Scanning Script (Stage 1)

Script Example for Stage 4

Appendix B – Assessment Tools

Short Progress Assessment (SPA)/Pre-Assessment Form

Table of results

Appendix C – Client Forms

Home practice feedback

Hierarchical exposure to target events/subjective units of distress (SUDS)

DAILY SCHEDULE OF MINDFULNESS PRACTICE

DAILY RECORD OF MINDFULNESS PRACTICE

Interoceptive Signature

Interoceptive Signature – Pocket Form

Interoception Form(Front/Back)

Bi-polar Exposure/Exercise Form

What is MiCBT?

Index

This edition first published 2011

© 2011 John Wiley & Sons, Ltd, except for pages 272–277 and 280–286 © B. A. Cayoun.

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Library of Congress Cataloging-in-Publication Data

 Mindfulness-integrated CBT : principles and practice / Bruno A. Cayoun.

p. cm.

 Includes bibliographical references and index.

 ISBN 978-0-470-97496-4 (cloth) – ISBN 978-0-470-97495-7 (pbk.)

 1. Mindfulness-based cognitive therapy. 2. Meditation–Therapeutic use. I. Title.

 RC489.M55C39 2011

 616.89′1425–dc22

2010047203

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDFs 9781119993179; Wiley Online Library 9781119993162; ePub 9781119996255

About the Author

Bruno Cayoun is Director of the MiCBT Institute, which trains, accredits, and supports MiCBT practitioners. He is also a Clinical Psychologist in private practice and Research Associate at the School of Psychology, University of Tasmania.

Dr Cayoun’s past research has involved the dysfunction of attentional systems and the human capacity for attentional and inhibitory control (two essential mechanisms in mindfulness training) in children with ADHD. Current research includes the efficacy of MiCBT in clients with complex co-morbidity, the effects of MiCBT on the experience of addiction and trauma, and the measurement of mindfulness mechanisms in clinical populations.

For the past 22 years, he has practiced Mindfulness meditation and participated in many intensive training courses in Vipassana centers in various countries (France, Nepal, India, and Australia). He is the principal developer of the MiCBT model, which integrates mindfulness skills training with well-established principles of traditional Cognitive Behavior Therapy.

Dr Cayoun provides continual training in MiCBT to various services and professional associations in Australia, New Zealand, and South East Asia. His mindfulness training CDs are used worldwide and he is the principal developer of two questionnaires, the Short Progress Assessment and the Mindfulness-based-Self Efficacy Scale, now translated in Portuguese and Dutch.

Acknowledgments

This book would not have seen the light of day without the invaluable teaching I received from my beloved teacher of mindfulness meditation, Satya Narayan Goenka, a celebrated teacher in the Burmese Vipassana tradition. His pragmatic teaching of mindfulness has paved the way to this integrated approach. In the early stage of writing, I greatly benefited from the precious encouragement and comments from my colleagues Vicki Sauvage, Dr Frances Martin, Dr George V. Wilson, Dr Christopher Williams, and Dr Christopher Walsh. I thank George Burns, Patrea O’Donoghue, and Tenzin Chönyi (Dr Diana Taylor) deeply for their comments and precious advice at a later stage of the manuscript. I also thank Professor J. Mark G. Williams for his encouragement and useful advice on the renaming of this therapy model a few years ago.

The advice and contribution of Dr Kathryn Elbourne was central in the production of MiCBT information sheets for clients (Appendix C), and I express my gratitude to Gabrielle Cayoun, Georgina Cooke, Linda Elliott, and Glenn Bilsborrow for their precious assistance with the design of client and therapist forms (Appendix C). My gratitude also goes to my dear and compassionate wife, Karen, whose support, patience, and suggestions have been invaluable. I express wholeheartedly my gratitude to the inspiring people who were once my clients for their willingness to include their moving and inspiring letters in this book.

Like other practitioners writing about the way of mindfulness, I stand on the shoulders of giants. I am especially indebted to one of the wisest men in history, Siddhartha Gautama, known as the Buddha, whose legacy continues to inspire humankind for peace and science, and whose teachings have enthused those involved in this domain of therapy and research.

Preface

This book has its origins in my first 10-day residential mindfulness meditation course in the Burmese Vipassana tradition, in March 1989. There, I began to informally conceptualize a model of information processing that integrates the Buddhist psychological system. It took another 12 years of daily personal practice, numerous intensive courses and study of cognitive and behavioral principles to formulate a model that integrates traditional mindfulness training with cognitive and behavioral principles for the purpose of addressing psychological distress. In the early days, this integration was called “Equanimity Training”.

In 2001, I proposed and began to introduce a four-stage model of “Mindfulness-based Cognitive Behavior Therapy” (MCBT) for crisis intervention to various mental health services in Tasmania (Australia). About a year later, the book Mindfulness-based Cognitive Therapy: A new approach for preventing relapse in depression by Dr Zindel Segal, Dr John Teasdale, and Prof Mark Williams (2002) was published and has been a major influence in the proliferation of the use of mindfulness-integrated models in modern Western therapy. The acronym for this approach is MBCT. In the four years which followed, the similarity of acronyms between MBCT and the MCBT model I and others were using created some confusion. Although there are inevitable overlaps between the two approaches, there are also important differences. Repeatedly, therapists and researchers had often used these acronyms interchangeably.

Following a conversation with Mark Williams, it became clear that the name of MCBT had to be changed. However, since many clinicians and researchers attended training in MCBT and used it professionally or in their research, it was important that they had a say and that the switch of label was made together, as a group. I invited 211 colleagues and members of the Mindfulness-based Therapy and Research Interest Group worldwide to help in this process, which took several months of brainstorming and deliberating. The democratic process was inspiring for all of us. Fifty-three propositions were obtained and then distilled down to just a few options. From these, the new name “Mindfulness-integrated Cognitive Behavior Therapy” (MiCBT) was coined to effectively represent the essence of the approach described in this book.

We were pleased with the new name. It kept the two essential approaches (Mindfulness and CBT) and their integration at all stages of the model. For example, we would use the so-called Socratic dialogue even at the very start with people who believe they cannot make time for practicing twice daily.

We were also satisfied with MiCBT because the notion of “theoretical integration” (rather than “technical eclectism”) has been our guiding principle from the start. MiCBT integrates numerous principles from both approaches. For example, in Stage 1, as will be described later, it uses the principles of operant learning, especially interoceptive conditioning and extinction to explain a number of experiences during body-scanning. It also uses neural network theory to explain thought intrusion (distractions) and deactivation during mindfulness of breath. It attempts to measure increased awareness of body sensations and explains it in terms of neuroplasticity. In Stage 4, it relates an aspect of Grounded Empathy practice (“Loving Kindness” towards all beings) to counter-conditioning principles.

Over the last seven years, writing this book has been a dynamic experience. My initial intention was simply to provide a comprehensive manual for postgraduate students and mental health professionals undertaking training in MiCBT. Smaller versions of this book, the “MCBT manual”, and later the “MiCBT manual”, have been used for several years by multidisciplinary clinicians in the field of mental health. Clinicians, researchers, and writers have referred to it on many occasions and expressed strong interest in its publication (e.g., Ivanovski and Malhi, 2007; Lindsay, 2007; Whitfield, 2006). I now feel that the “manual” has become a sufficiently comprehensive and reader-friendly guide for clinicians to integrate confidently mindfulness training with cognitive and behavioral skills and principles in a generic manner to address a wide range of conditions. I hope the reader will find it useful for this purpose.

Abbreviations

ACT:

Acceptance and Commitment Therapy.

ADHD:

Attention Deficit Hyperactivity Disorder.

CBT:

Cognitive Behavior Therapy.

CNS:

Central Nervous System.

DSM-V:

Diagnostic and Statistical Manual of Mental Disorder (5th edition).

EEG:

Electroencephalograph (measurement of brain waves).

FFMQ:

Five Facets of Mindfulness Questionnaire.

FMI:

Freiburg Mindfulness Inventory.

fMRI:

Functional Magnetic Resonance Imaging (photographing of the brain’s blood flow during mental tasks).

GP:

General Practitioner. In Australia, a GP is a Medical Doctor.

ICD-10:

International Classification of Diseases (10th edition).

ICS:

Interacting Cognitive Sub-Systems.

KIMS:

Kentucky Inventory of Mindfulness Skills

MBCT:

Mindfulness Based Cognitive Therapy.

MBSR:

Mindfulness Based Stress Reduction.

MRI:

Magnetic Resonance Imaging (structural photographing of the brain)

MSES:

Mindfulness-based Self-Efficacy Scale.

OCD:

Obsessive Compulsive Disorder.

PMR:

Progressive Muscle Relaxation, also called Jacobsonian relaxation.

PTSD:

Post-Traumatic Stress Disorder.

SMA:

Supplementary Motor Area. the frontal lobe part of the motor system which enables the programming of movement sequences.

SPA:

Short Progress Assessment.

SUDS:

Subjective Units of Distress.

Introduction

Much learning does not teach understanding.

Heraclitus

Training ourselves to improve our capacity to remain calm and collected while facing the vicissitudes of life has a long history, dating back at least twenty-five centuries. It was, and remains in some Eastern traditions, a central feature of the yogic training taught by Buddhism. Its systematic approach embodies both a cosmological and a psychological system for the understanding of mental processes and remediation of psychological pains, which clearly departs from traditional ritualistic and religious practices (Goleman, 1977). It was in the most unusual way that I first experienced some of these principles.

Although it was over 29 years ago, I still remember sitting on the edge of a hotel bed in southern Israel, with an excruciating toothache. I had left France, my country of origin, several months earlier to visit the Middle East. There, I suddenly found myself with next to no money in my pocket after having lost my wallet and all my identification papers. It was about 2pm on a hot Saturday and the few dentists in the area were not available. I could not afford painkillers and didn’t know anyone who could help. The pain was so paralyzing that I could not even walk to a hospital, several kilometers away.

I had minimal understanding of what was the problem and decided to think it through: “the nerve will not hurt me forever … it is just a matter of time before the infection kills the nerve and the pain will go away, so I just have to wait,” I thought. This is just what I did, sitting on the side of the bed, waiting for the pain to pass. I pondered what would be the way to calm my inner agitation in the meantime. I am not sure why, but I thought that focusing on the pain to monitor the change and “go with the flow” could potentially accelerate the process. I was expecting to spend the rest of the day and at least part of the night with intense suffering, but there was not much else I could do. How long a tooth infection would take to kill the nerve in the root canal was central to my concerns. As I paid attention to the centre of the pain, I felt it more intensely for a short period and then, to my great surprise, it very rapidly diminished. After about ten minutes, the pain had largely disappeared. It was clear to me that the relief I experienced was due to the way in which I paid attention to the pain sensations rather than the desensitization of the tooth by the infection.

Being untrained in meditation techniques and unaware of their potential, this experience was incredible to me. My interest in the resources of the mind grew stronger from then on. I later understood that I had inadvertently used a technique well known in ancient Buddhist meditation practice, the practice of equanimity, a central component in what is known as Mindfulness Meditation. I also realized that I underestimated the constructive powers of human suffering. After all, it was pain and the necessity to accept it that taught me one of the greatest lessons in life; things change, even the most painful experience.

Buddhist teaching suggests that we create suffering because of our expectations. While wanted things don’t often happen, unwanted things often do. When we do get wanted things, they soon change. Even if some wanted things don’t seem to change, we do! We become habituated to what we have and eventually not so interested, and soon dissatisfied, once again. Becoming mindful of this simple but far-reaching universal reality in a way that alleviates suffering is an important aspect of the way of mindfulness. The establishment of mindfulness at all levels of experience (originally called Satipatthana) constitutes the essence of the practical aspect of Buddhist teaching. The meaning of the term “mindfulness” (sati, in Pali language spoken in ancient India) is traditionally expressed by meditation teachers as a mental factor which serves to keep our minds on the chosen object of concentration (Taylor, 2010) and this with a deeper understanding of the object of concentration. As will be described in detail in Chapter 1, we can recognize elements of sustained attention.

In the West, mindfulness has been defined as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 1994, p.4). Well over a decade ago, Salmon, Santorelli and Kabat-Zinn (1998) already noted the fast growing interest for the mindfulness approach since its early integration with Western psychotherapy in 1979, with over 240 mindfulness-based programs implemented in North America and Europe. Researchers have proposed the formal integration of mindfulness-based approaches with existing cognitive, behavioral and other models of psychotherapy (e.g., Bennett-Goleman, 2001; Cayoun, 2003; Hayes, 2003; Hayes, Follette, and Linehan, 2004; Kutz, Borysenko, and Benson, 1985; Lau and McMain, 2005; Roemer and Orsillo, 2002; Shapiro and Carlson, 2009; Whitfield, 2006).

Proponents of this integration have proposed various operationalizations and rationales for the implementation of mindfulness-based therapy systems in accord with the theory of specific psychopathologies, guidelines for clinical interventions, and a description of the quality standards of the therapeutic approach (e.g., Kabat-Zinn, 1990; Kabat-Zinn, Lipworth, and Burney, 1985 [chronic pain and stress]; Carlson et al., 2001 [depression and stress]; Linehan, 1993 [Borderline Personality Disorder]; Orsillo, Roemer and Barlow, 2003 [Generalised Anxiety Disorder]; Kabat-Zinn et al., 1992 [Panic and other anxiety disorders]; Segal, Williams, and Teasdale, 2002 [depression]; Witkiewitz and Marlatt, 2006; Follette, Palm, and Pearson, 2006 [Post-Traumatic Stress Disorder]), and specific information processing issues (Breslin, Zack, and McMain, 2002; Teasdale, 1999; Teasdale and Barnard, 1993; Wells and Matthews, 1994).

Numerous authors, whose expertise varies from social categorization to cancer research, have demonstrated that the human capacity for mindfulness can be developed and put to good use in the process of health recovery (Grossman et al., 2004; Lindsay, 2007; Speca et al., 2000). There is evidence that including the principles of mindfulness in Western psychotherapy programs can be of benefit to a wide variety of conditions (e.g., Baer, 2003). In keeping with this trend, I have proposed a non-dualistic, integrative approach to cognitive and behavior modification founded on the combination of a traditional account of mindfulness, the well-established Western principles of operant conditioning and on the principles of “embodied cognition” and neural networks in information processing (Cayoun, 2005a).

The integration of mindfulness and cognitive-behavioral principles is actually not new at all. Numerous Buddhist parables recount twenty-five century-old stories that illustrate ways of using what we consider to be cognitive and behavioral skills to address people’s suffering, as well as for teaching purposes.

In one such parable, a woman who could not have children for seven years finally gave birth to a boy. Unfortunately, the boy died of an illness at the age of two, leaving the mother distraught to the extent of carrying her child in the city streets as if nothing had happened, pretending that her child was fine, that he was only asleep and just needed help to wake-up. Of course, nobody from the dozens of neighbors she asked for help could wake the child. Touched by her disarray, an old man suggested she goes and speak with “Master Gautama at his ashram.” Desperate for a miracle, she followed this advice and approached Master Siddhartha Gautama, better known as the Buddha, holding the boy’s corpse in her arms: “My son is asleep and nobody can wake him up. Someone in town said you could help. Please sir, I will do anything …”

The Buddha saw that her emotional agony would not permit an understanding of the true cause of her suffering and she was not ready to be taught in the way of mindfulness. So he proposed what we would perceive as a “behavioral experiment” to initiate cognitive reappraisal using the following instructions: “Go to every household of the city and ask for five sesame seeds from each family and bring them to me, but you must accept the seeds only from families in which there has been no death.” So she went, relentlessly knocking door after door, asking for the magical seeds that would save her son from eternal sleep. The unfeasibility of her task became clearer after each failure to find a deathless household. Everywhere, someone had died. By the time she returned to the Buddha, she had come back to her senses and before he even spoke, she said: “I understand sir, everybody dies; this is not just my son, this is how it is everywhere.” The Buddha was pleased and thought she was ready for mindfulness training. As the story goes, she became a well-known and prominent teacher of mindfulness meditation, freed from what could have been deep-seated grief for much of her life.

Assuming this parable has historical correctness, it demonstrates one of the remarkably spontaneous and accurate ways with which the Buddha implemented behavior modification techniques within his mindfulness doctrine. In other parables, he integrates a questioning style that we would easily associate with what is known as the Socratic dialogue, bringing forward the inconsistency of certain thoughts and their underlying assumptions (see Axiom, 2002, for a collection of parables).

Sharing similar principles, the four-stage model of Mindfulness-integrated Cognitive Behavior Therapy (MiCBT) presented in this book is a sophisticated integration of mindfulness core principles and traditional Cognitive Behavior Therapy (CBT). It incorporates a set of evidence-based techniques to develop self-knowledge, a healthy sense of self-control and self-efficacy in multiple domains of living. These attributes are partly dependent upon the type of knowledge about ourselves from which we operate to solve problems.

Three Bases of Learning

According to Theravada teachings, which is believed by many to be the oldest Buddhist school of thought, there are three bases for self-knowledge: listening to and believing others (devotional, philosophical, religious, etc), rationalizing (one’s own intellectual problem-solving abilities), and experiencing (one’s own actual experience). This applies to how we learn about ourselves during therapy. We can think of these learning methods in terms of personal involvement dimensions, each offering information about ourselves from a narrow (passive listening) to a greater (experiencing) frame of reference.

Devotional Learning

During psychotherapy, the client may learn about himself or herself based on what we say as therapists, colored by our own view of the world and operational paradigm. Our client acquires self-knowledge based on someone else’s view, the therapist’s: “the client’s thought is irrational because it leads to emotional pain.” If this is the only level of involvement (faith in the clinician), symptoms may be alleviated for some time but the client’s sense of self-control and self-efficacy tends to remain poor and bound to the context and topic of the intervention. A potential danger is dependence on the clinician for approval or reassurance, leading to unnecessary long-term treatment.

Rational Learning

The next level of involvement for self-knowledge is problem-solving by making sense of the information. This requires further personal involvement in the processing of information. It requires semantic processing with which the meaning of information is actively and critically evaluated and compared against already learned information stored in memory. For example, making sense of how our belief systems or “core schemas” (basic assumptions about the self and the world) create our reality, pleasant or unpleasant, has proven to be a useful skill in the course of Cognitive Therapy. Verification of this understanding via behavioral experiment (testing the validity of an assumption) has also been shown to help change our view and often the corresponding emotional distress. However, understanding our schemas does not always suffice to change our behavior. Despite the skilful attempts of the therapist to enhance a client’s awareness of his/her unhelpful beliefs, the client may feel incapable of changing a view or habitual response. Below is a good example of the difference between rational realization and experiential realization, which is the next level of involvement.

In 1952, Donald Glaser, an expert in physics who was awarded the Nobel Prize, invented a machine called the “bubble chamber” to measure the rapidity with which subatomic particles composing the universe “arise and pass away” (Goenka, 1987). In liquid hydrogen maintained near its boiling point, ions produced by incoming energetic radioactive particles leave bubble tracks that can be photographed. He counted ion traces and calculated that the number of arising and passing ions equated 1022 Hz (cycles per second). In other words, Glaser discovered that subatomic particles arise and vanish 1022 times per second. This great discovery, demonstrating the dynamics of the transient nature of the physical universe, relied on a machine, an external means of measurement with which we can rationalize physical human nature.

Experiential Learning

It is astonishing that twenty-five centuries earlier, a man with only his introspective capacity to apply awareness and equanimity from moment-to-moment made a similar discovery at an experiential level. Siddhartha Gautama (Buddha) discovered that “the entire material structure is composed of minute (subatomic) particles which are continuously arising and vanishing. In the snapping of a finger or the blinking of an eye, he said, each one of these particles arises and passes away many trillions of times” (Goenka, 1985, cited in Hart, 1987, p.32). Since there was no previous description or name for these vibrating particles, Gautama created the word kalapa – smallest indivisible unit of matter. Hence, these men’s discovery was similar but the process and results of that same discovery were indescribably different. One man became free from worldly woes while the other grew old bound by the emotional afflictions of physical and mental decay.

MiCBT encompasses these three aspects of learning about ourselves, with an emphasis on experiential characteristics and their underlying neurobehavioral underpinnings. An increasing number of researchers and clinicians are considering the advantages of experiential paradigms and have already embraced the inclusion of mindfulness components in the cognitive-behavioral framework (Follette et al., 2006; Hayes, Stroshal, and Wilson, 1999; Salzman and Goldin (2010); Teasdale, 1999; Teasdale, Segal, and Williams, 1995; Wells and Matthews, 1994; Williams et al., 2000). This book is yet another reflection of the current thinking in psychotherapy, which considers that experiencing per se has significant therapeutic value.

About this Book

Rationale

Despite the growing number of research publications and excellent books on the use of mindfulness in therapy, most tend to orient their contents toward problem- or disorder-specific contexts (e.g., Baer, 2006; Williams et al., 2007). There is no current practical set of general principles and guidelines for the applied integration of mindfulness meditation and the well-documented, evidence-based, techniques from traditional CBT to address multiple difficulties. Not only would such general principles help the efficacy of program delivery in heterogeneous groups, they would also help address the problem of co-morbidity, as informally illustrated by the various letters from ex-clients collated in Chapter 11. The need for such general principles and standardized guidelines has prompted the undertaking of this book. Much like that of Stephen Hayes and his colleagues with regard to their integrative model (Acceptance and Commitment Therapy, 1999), this book presents a rationale and general guidelines for the implementation of mindfulness meditation (not just attitude) tightly integrated with well-researched evidence-based CBT methods for a broad range of psychological dysfunctions.

Structure

This book places each chapter in order of implementation of the MiCBT four-stage program, although some features can be flexibly interchanged with individual delivery according to the client’s condition and progress. This structure is based on nine years of piloting, implementation and standardization in various mental health services. Years of opportunities for modifications based on client feedback, supervision of students and experienced clinicians, and empirical data have led to the current structure and content of the program.

Chapters 1 and 2 present an operationalization of mindfulness and a robust theoretical framework for including mindfulness in psychological therapy. It offers a neurobehavioral account of the mechanisms of action through a detailed description of the co-emergence model of reinforcement, showing a clear interface between mindfulness training and CBT. There is also a summary of main points at the end of Chapter 2, which will help the reader recall the most important aspects of the concepts and skills. It will also help the reader to communicate the content of the program simply to clients and colleagues.

Chapters 3 to 6 explain the details of Stage 1 of MiCBT, which describes mindfulness-training skills to internalize attention in order to regulate attention and emotion. These chapters describe techniques to engage the client in the treatment plan using a combination of mindfulness and CBT skills (interoceptive exposure and Socratic questioning). The chapters describe some of the clinical relevance and implications of this particular integration of mindfulness and CBT, and provide a comprehensive description of the common difficulties and resolutions.

Chapters 7 to 9 describe how MiCBT externalizes newly acquired skills in Stage 1 (attention and emotion regulation) to equip clients with long-term cognitive and behavioral tools to address common stressors, avoidance mechanisms and interpersonal difficulties. This is achieved through strategies learned in Stages 2, 3 and 4. The rationale for the use of Loving-Kindness Meditation, in Chapter 9, will make much sense to cognitive behavioral therapists and scientists.

Chapters 10 and 11 discuss the benefits of MiCBT and the relevance of MiCBT to DSM-V Axis 1 and Axis 2 disorders. The view that problems due to a personality disorder cannot be changed is challenged. The notion of internal locus of reinforcement and the advantages of addressing maladaptive cognition and behavior at the experiential level are illustrated by case examples. The inspiring commentaries of ten of my ex-clients treated with MiCBT are included. The reader is also informed about useful measures of change produced by mindfulness approaches, emphasizing the notion of self-efficacy. An evaluation of mindfulness training based on Aaron T. Beck’s (1976) standards is included.

Chapter 12 provides a useful summary of the weekly implementation protocol for adult clients. Note that reference to the use of compact discs (CDs) is frequently made, should the clinician choose to use the CDs typically used with MiCBT to assist both clients and clinicians in their daily training (available online from the MiCBT Institute: www.mindfulness.com.au. The experience of most MiCBT practitioners is that both practice CDs (Stage 1 and Advanced Training) would complement the practical use of this book, and are advantageous when delivering the program.

Chapter 13 addresses the importance of professional training. It includes a short review of the research on therapists trained in Mindfulness skills and the structure of the Vocational Graduate Diploma in MiCBT offered by the MiCBT Institute, a course that is now nationally accredited in Australia.

Chapter 14 is a compilation of questions by clients, clinicians and researchers, addressed to me over the past nine years, which I answered to the best of my ability. Since the exchanges with clients and colleagues were in simple conversational language, this chapter preserves the same conversational style to provide questions and replies grounded in the complex reality of clinical work.

The appendices contain three scripts that can be used by clinicians who want to instruct clients personally, rather than using CDs, during group sessions or one-on-one consultations. There are also several forms which clinicians will find very helpful for the delivery of the program.

Style

Unfortunately, academic references to Eastern teachers and writers who devotedly provided the bases for mindfulness training are often ignored. In this book, references are made to traditional conceptualizations and implementation of mindfulness training, and to its originator, the historical Buddha. Of course, this does not make it a “Buddhist” book, but it seems important that the reader has an opportunity to relate current concepts in behavioral science to ancient, well-established Eastern wisdom.

Finally, while the writing style of this book is mostly conversational, some technical language remains necessary, especially since most researchers, mental health professionals and interns would be familiar with many of the non-elaborated concepts. The reader is encouraged to refer to the glossary of terms at the end of the book when necessary.

Part I: Theoretical Foundation

Chapter 1

Operationalization of Mindfulness

Therapeutic progress depends upon awareness;

in fact the attempt to become more conscious is the therapy.

Edward Whitmont

Definition of MiCBT

As a mental state, mindfulness is experienced as a heightened sensory awareness of the present moment, free from judgment, reactivity and identification to the experience. As a training, mindfulness requires deliberate sustained attentional focus on sensory processes with unconditional acceptance of the sensory experience. Mindfulness-integrated Cognitive Behavior Therapy (MiCBT) is a systemic therapy approach that integrates mindfulness meditation with core elements of cognitive and behavioral methods for the purpose of teaching clients to internalize attention in order to regulate emotion and attention, and externalize these skills to the contexts in which their impairment is triggered or maintained.

The 4-Stage Model of delivery

This integration can be applied flexibly within a 4-stage model.

Personal Stage

In stage 1, Mindfulness meditation training is taught to internalize attention in a way that promotes deep levels of experiential awareness and acceptance. The emphasis is on the internal context of experience to equip clients with an increased sense of self-control and self-efficacy in handling thoughts and emotions before addressing daily stressors. We learn to regulate attention and emotions.

Exposure Stage

Stage 2 is the first externalizing stage. It introduces various exposure procedures, first in imagery and then in vivo, to decrease avoidance and increase self-confidence. We learn to decrease reactivity to external situations.

Interpersonal Stage

Stage 3 requires externalizing attention further towards others by decentering attention from self to others. It includes mindfulness-based interpersonal skills to understand experientially others’ ways of communicating, combined with assertiveness and other social skills training to address the interpersonal context of psychological difficulties and help prevent relapse. We learn to prevent our reaction to others’ reactivity.

Empathic Stage

Stage 4 teaches empathic skills grounded in the bodily experience of the present moment. It includes developing ethical awareness and action, self-compassion and compassion towards others in a way that acts as a counter-conditioning method and helps prevent relapse. We learn to feel connected to ourselves and to others.

Case Illustration with Generalized Anxiety Disorder

Before diving into the science and theoretical aspects of MiCBT, looking at clients’ impression might be of interest. The example below is a good reflection of how most clients perceive the program. There are ten other cases discussed in Chapter 10, where people (ex-clients of the author) express their views and transformations.

“Jo,” a physically active middle-aged lady, was severely anxious about receiving the confirmation of her physical condition. Assessments from several specialists pointed to a diagnosis of Multiple Sclerosis, but they needed to perform further tests. It seemed to her that they were waiting to see some aggravations before being able to ascertain the diagnosis. She had been a worrier for most of her life and had been experiencing clinical levels of generalized anxiety for over twenty five years. Her mood had been mildly depressed for several years, and became clinically low since the tentative diagnosis was made, about nine months prior to our first meeting. In addition to the unappealing prospect of such a severe illness, living in future uncertainty had become excruciating. Catastrophic thoughts about the future had taken over most of her waking hours. Her GP referred her for symptoms of anxiety and depression. Fortunately, her partner was very warm and supportive. The MiCBT intervention included nine sessions, after which we both felt confident that she would be able to withstand the uncertainty and the final diagnosis, and ultimately, prevent relapse.

Following an intake assessment, we discussed a “therapy contract” (see Chapter 12) and the four main delivery steps of the MiCBT program (also in Chapter 12). She benefited from practicing Progressive Muscle Relaxation in the first week, which helped reschedule her day to include a thirty-minute practice of mindfulness meditation twice daily in the forthcoming weeks (see Chapters 3 to 6). Stage 2 (see Chapter 7) started on the fourth week, Stage 3 (see Chapter 8) on the sixth week, and Stage 4 (see Chapter 9) started on the seventh week. The ninth week was a follow-up session. Below is a letter which she wrote to express her experience.

Seeking help from a psychologist wasn’t something I’d ever considered. After all, I didn’t really need to – did I? A few years ago I knew that, for apparently no particular reason, I was feeling a bit down. My relationship was solid, my home life was good, I knew that the conditions of my life were, comparatively, excellent. Of course, there were always ups and downs with work, as with the rest of life. Generally, however, I couldn’t complain.

Nearly 12 months ago I began having a health related issue which potentially may develop into a debilitating condition. I love being active – bike riding, surfing and bushwalking. I own a farm and breed horses. Not being able to do all these things, the things I love doing, was not part of my future life plan! I found it really hard to move my mind away from thoughts about the future – thoughts that were almost invariably negative. My moods were becoming increasingly dark as these thoughts occupied my mind, more and more. I know my partner was worried about my mental state. She had suggested seeing someone to try and work out some strategies to help a number of times. However, I’ve never been comfortable with the idea of ‘airing the laundry’ to a complete stranger, preferring instead to try and work things out myself.

Consequently it was some time before I agreed to see someone – a psychologist recommended by a personal friend. I was seeking some ideas, some things I could ‘do’ to be able to help myself break free of the dark cloud. After the third session of talk, a couple of relaxation CDs and a month of a ‘snap out of it’ rubber band strategy, nothing was really changing. I can, however, thank this person for referring me on to Dr Cayoun, suggesting that his MiCBT program could provide some answers for me.

I have worked with Dr Cayoun for nearly 3 months. So what has changed? Quite a lot really – everything from my daily routine to the way I perceive each minute of each day. Twice daily I spend at least half an hour learning about my mind, my body, sensations, emotions, feelings and the inter-relationships between each of these. As I began training with basic relaxation and breath mediation exercises I realized my mind was totally in control of my sensations. I was constantly fighting to keep random (usually negative) streams of thought from dominating my mindspace and I was living in the future and not for the present. Further into body scanning methods, I have been learning more and more about the connection between thoughts and body sensations, but importantly, living more in the present moment.

So, what does this mean for me? Even though the concerns about my health remain, my emotions do not dominate my life as they did previously. I can enjoy what I have now as I am more observant and aware of all my experiences, all my body sensations. I am able to see situations with increased clarity – like the dusting settling after the road train has passed! I have learnt to recognize destructive thought patterns early – early enough to control my reactions to body sensations that accompany them and halt the emotional dip that usually follows. This increased level of equanimity has benefitted all areas of my life. At work I can focus more easily and am more patient with people who I previously found it difficult to work with. At home my ever supportive partner says that I’m more positive and easier to get along with. I have upped my exercise regime as I live in the moment and enjoy my life as it is at present, even making plans for the future – something I haven’t been able to do for some time.

Whatever happens in the future, I know that Dr Cayoun’s program will continue to be an important part of my life.

Western Understanding of Eastern Conceptualization

The formal establishment of mindfulness (Satipatthana) has been traditionally initiated through a meditation technique called Vipassana, meaning “seeing objectively” or “Insight,” which is said to facilitate the shift of personality (Doshi, 1989; Fleischman, 1989). Elements of vipassana meditation, re-branded as “mindfulness,” have entered the field of cognitive-behavioral psychology in various ways (Solomon, 2006). In part, this is because both traditions present important overlapping features and are complementary in several ways.

Relationship between mindfulness and modern Learning Theory

In many ways, mindfulness is a state of heightened awareness of natural laws. As such, developing mindfulness has been traditionally conceptualized as the highest standard of studying ecology. For instance, when we are able to sit still and merely witness internal passing events (thoughts and body sensations) we witness the law of impermanence within.

In effect, we have been using the law of impermanence for almost a century in conditioning research, and later in behavior therapy. The change over time that we observe when, for example, a learned behavior is decreased, is called an “extinction” phenomenon. The practice of CBT relies heavily on reinforcement and extinction principles, from the behavioral analysis stage to the planning and implementation of treatment. We will briefly discuss some of these principles later, although the scope of this book does not permit an elaborate discussion of the traditional views of the ways in which human behavior is modified (see Corsini and Wedding, 2005, for a useful summary).

The traditional teaching of mindfulness includes an awareness of the power of reinforcement that comes from grasping at attachments and abhorrence with aversions. Learned behaviors, thoughts and emotions are thought to lose their strength when they are not reacted to (Goenka, 1987); a principle known as ‘extinction’ in Western behavioral science. Whereas Western Psychology has termed and investigated reinforcement and extinction principles for about a century, Eastern conceptualizations of behavior have included a sequence of mental events called the Law of Causation for well over twenty-five centuries. In these conceptualizations, interoception (i.e., the ability to feel body sensations) has prime importance in either strengthening or eradicating behavior (Solé-Leris, 1992; see also Woodward, 1939, for an accurate translation).

Hence, the notions of reinforcement and extinction were not only well understood twenty-five centuries ago, they were also used as a means of self-acceptance and psychological change to decrease human suffering.

Mindfulness of human suffering

Mindfulness, as originally conceptualized in Theravada Buddhism, must serve to realize three central human conditions, one of which (Selflessness) will be discussed in more detail later. These are (a) the changing nature of all things, (b) the consequent substancelessness of the self (“Egolessness” or “Selflessness”), and (c) the suffering that springs from a lack of awareness of the impermanent nature of all phenomena, including the self and its aggregate components (Genther and Kawamura, 1975). From this perspective, being mindful facilitates this realization in all encountered internal and external events, knowing (not just thinking or hoping) that “this will also change.” Thus, as mentioned in the introduction of this book, the traditional conceptualization of mindfulness involves an increased ability to remain aware of a natural law, impermanence (i.e., the omnipresence of continuous and uncontrollable change), and its consequences in daily living (see Marlatt, 2002; Marlatt, Witkiewitz, Dillworth et al., 2004; for applications to treatment of addictive behavior). What is meant by “mindfulness” throughout this volume is precisely what this long-established tradition encompasses.

Paul Fleischman, a Psychiatrist and experienced mindfulness teacher in Northern America, pointed out that “Vipassana is a training in psychological culture” (Fleischman, 1999, p. 63). In terms of Kelly’s (1955) constructivist view of personality, undergoing traditional mindfulness-based training involves testing the hypothesis that all thoughts and physical sensations have the same characteristics of arising and passing away. By experiencing this law of perpetual change within ourselves, we learn to alter the self-construct by being a more objective, scientific observer producing more accurate analyses of ongoing events and making predictions that are more sensible and realistic, thus enhancing the sense of control over our life.

Attention regulation training

Yi-Yuan Tang, Michael Posner, and other experts of attention research have argued that mindfulness practice requires the recruitment of numerous brain networks that enable important functions of our attention systems. When we pay attention to our breath, for example, we teach ourselves three crucial attentional skills that are very familiar to attention researchers and clinicians working with attentional disorders (e.g., Cayoun, 2010; Tang et al., 2007). These are known as sustained attention, response inhibition and attention shifting. Observation and measurement of these three functions of attention are well established in the research literature, as reflected by the numerous tests of the so-called executive functions, which will be briefly discussed later, as they relate to mindfulness meditation skills.

Sustained Attention

First we train ourselves to sustain attention to a target, our natural, non-controlled breath (a script is provided in Appendix A). While we do our best to remain vigilant of our breath, we also learn to detect thoughts and other unwanted stimuli intruding into our conscious awareness. This task helps improve our vigilance and focus in daily activities. It also helps improve our objectivity and detachment. It is only when we can perceive a thought or body sensation arising in its own right that we can learn not to get lost in it, not to identify with it. We learn to differentiate our internal experiences from the sense of self.

Response Inhibition

As soon as we realize that a thought or body sensation has emerged in conscious awareness, we endeavor not to react to it in any way, whether mentally by producing a value judgment or otherwise. We “inhibit” our otherwise automatic reaction. This task leads to a progressive sense of being an agent of self-control and helps us learn to accept or tolerate the presence of unpleasant experiences and the absence of pleasant ones.

Response Re-Engagement

We learn not to grasp and “cling” to thoughts, which allows us to switch and reallocate attention to the intended target, in this case our breath. This is one of the most difficult attentional skills because it relies on both sustained attention and response inhibition. Research into the aetiology and maintenance of Attention Deficit Hyperactivity Disorder shows that people who are accurately diagnosed with this condition have some response inhibition deficits in some contexts and are most impaired in response re-engagement (e.g., Cayoun, 2010). Our ability to switch attention back to the experience of breathing or to other body sensations when a thought has emerged results in greater cognitive flexibility, which helps us “let go” of all sorts of unhelpful thoughts and emotions.

A few years ago, a team of North American and Canadian researchers met in an effort to produce an operational definition of mindfulness so that the mindfulness construct can be scientifically and efficiently measured (Bishop et al., 2004). Their conceptualization integrates (and is not limited to) these three functions of attention in a manner very similar to that mentioned above, with minor differences. Scott Bishop and his colleagues have termed this aspect of mindfulness training “attention regulation,” which effectively reflects the consequence of improving our ability to use these three skills simultaneously. Attention regulation, added to a non-judgmental and accepting attitude towards our whole experience, allows us to adopt a specific attitude called “equanimity.” As briefly discussed below and more in detail in the next chapter, equanimity is considered a core mechanism in the process of extinguishment of both implicit and explicit learned responses.

Equanimity: A core mechanism

The term “equanimity” loosely means balance, equipoise, composure, calmness, level-headedness, equilibrium and self-control. In the Abhidhamma (texts regrouping the Buddhist psychological system), it is referred to as “a mind which abides in the state of non-attachment, non-hatred, and non-deludedness coupled with assiduousness … Its function is not to provide occasions for emotional instability” (Pradhan, 1950, p. 6). It is the refusal to be caught in aversion or attachment (Taylor, 2010) and a “state of mind free from craving, aversion, ignorance” (Goenka, 1987, p.162). In the therapeutic context, equanimity may be defined as: the conscious and deliberate act of being non-reactive towards an event experienced within the framework of one’s body and thoughts as a result of non-judgmental observation. This implies that unless we are aware of an actual (internal) experience, we cannot be equanimous towards it. Thus defined, equanimity is a state of experiential acceptance that relies on awareness of thoughts and somatic sensations.

Interestingly, about fifty years ago, Russian behavior scientists reported on the importance of what was termed “interoceptive conditioning” (e.g., Bykov, 1957; Razran, 1960, 1961; Voronin, 1962). These studies, according to Yates (1970, p. 416), “are of critical significance for behavior therapists.” As will be discussed later in this and other chapters, interoceptive awareness and acceptance are central mechanisms in both mindfulness meditation traditionally taught in the Burmese tradition and in MiCBT, in which it is integrated.

In many ways, equanimity requires more objectivity about the event we are experiencing. The more able we are to be aware of thoughts and body sensations just as they are unfolding, the more equanimous we become. In that sense, we become more scientific about our own experiences. Our mind and body can be a little like our private laboratory, where our observations are significantly closer to scientific assessments than our usual judgmental evaluations. Hence, some resea­rchers and teachers of mindfulness have argued that mindfulness meditation is a science.

Neuroanatomically, it is proposed that equanimity relies on inhibitory neural networks in the temporal regions (inhibition of verbal responses in auditory cortex), right-prefrontal and limbic regions (inhibition of behavioral responses in emotional pathways, especially amygdala), and excitatory networks in the parietal regions (facilitation of neuroplasticity in somatosensory networks). Equanimity also seems to be associated with secretion of endorphins, whereas reactivity is related to secretion of adrenaline and cortisol. Equanimity is tied to activation of the parasympathetic nervous system and increased immune response (Davidson, Kabat-Zinn, Schumacher et al., 2003; Tang et al., 2007; Fan et al., 2010).

Overview of basic practice components

During formal training (i.e., sitting meditation), we learn to see a thought for what it is, just a thought, no matter what its content may be. Though content is acknowledged, we learn not to cling to it, give it importance, identify with it, or react to it. We learn to perceive an emerging thought more objectively as an arising and passing mental event. As such, the thought cannot truly affect us, the observer. The benefits gained through this process are obvious for depressed and anxious individuals, whose capacity to prevent ruminations are almost immediate (e.g., Ramel et al., 2004).

We learn to identify when and for how long the mind has wandered in thoughts. In doing so, we progressively develop an awareness of our ongoing thoughts as they manifest themselves in consciousness. This skill has been termed “metacognitive insight,” which is another important skill that helps address depression and anxiety symptoms (Teasdale, 1999).

We also learn to perceive a body sensation merely as a body sensation, regardless of its hedonic qualities (pleasant, unpleasant, or neutral). We train to remain as objective as possible and observe the transient characteristics of body sensations, how quickly or slowly they change, whether they are intense or feeble, acceptable or unacceptable. Often with stupefaction, we discover that, much like thoughts, body sensations arise and pass away and they are essentially impersonal phenomena.

Developing this kind of detachment has several advantages. For instance, consider hyperarousal-based disorders (e.g., panic, post-traumatic stress disorder [PTSD], impulse control disorder, etc), or even chronic pain. What would happen to your client with these kinds of symptoms if he or she could train to experience their intrusive thoughts and accompanying body states with more objectivity and acceptance, and “let them go”?

Changes in Western Clinical Psychology

In the last decade and a half, there has been a significant shift in our conceptualization of human cognitive and emotional processing. For example, John Teasdale and his colleagues led the way by claiming that emotions are produced by patterns of sensorily-derived information and are maintained by self-perpetuating mechanisms via feedback loops (Teasdale et al., 1995). Teasdale and Barnard’s (1993) Interacting Cognitive Subsystems (ICS) model of information processing integrates the various ways of human cognition and emotion with an ecological notion of self-organized systems. The ICS approach also emphasizes experiential aspects of cognition which have been insufficiently taken into account to explain how reinforcement is actually experienced.

Others have also widened the net of possible reinforcing factors in their view of learning principles. For instance, modern learning theory acknowledges that cognitive and other internal experiences can be involved in learning. Bouton, Mineka, and Barlow’s (2001) comprehensive review of basic conditioning research in relation to panic underscores these involvements. The authors propose that Panic Disorder develops because exposure to panic attacks causes the conditioning of anxiety to cues outside the person as well as cues experienced in the body. In line with the model presented here, Bouton et al., (2001) conceive that this process fundamentally involves emotional learning that is best explained by conditioning principles.

Moreover, Stephen Hayes and his colleagues proposed a “post Skinnerian” account of learning, through their Relational Frame Theory (RFT). This approach proposes that human language and the use of it to communicate or make sense of the world requires deriving relations among events, highlighting the important role of human language and cognition in human learning, see Hayes, Barnes-Holmes, and Roche (2001) for detailed account.

Current status in Western psychotherapy

It has been proposed that mindfulness is a common factor across various therapeutic orientations (Martin, 1997). The basis for this view is that the development of mindfulness promotes access to new perspectives and the disengagement from habitual response sets, including automatic thoughts and behaviors (Langer, 1989, 1992; Roemer, and Orsillo, 2002; Teasdale et al., 1995; Wells, 2002).

By itself, mindfulness training can provide us with opportunities to review our beliefs since we train daily not to buy into our thoughts. It allows us to challenge our own established views about ourselves, others, our values, our future, as well as the external world (Kabat-Zinn, 1982, 1990), without necessarily reviewing the deep-routed belief systems that we began to establish in childhood (our “schemas”) or involving exposure to specific triggers as implemented in traditional cognitive-behavioral approaches (e.g., Beck, 1976; Mahoney, 1974; Meichenbaum; 1977). Accordingly, it is understandable that some authors have expressed reservations regarding what exactly are the active ingredients in mindfulness training (e.g., McLaren, 2006; Pridmore, 2006).

Some authors indicated the lack of adequate control in several studies of mindfulness training, as taught in MBSR, for depression and anxiety disorders (Toneatto and Nguyen, 2007) and questioned the construct of mindfulness, the effectiveness of such programs, the mechanisms of action, and the methodology used for treatment outcome studies (Bishop, 2002). The recent proliferation of publications has clarified some of these questions (e.g., Allen, Chambers, Knight, and Melbourne Academic Mindfulness Interest Group, 2006), but the active mechanisms of mindfulness seem to remain unclear (Kostanski and Hassed, 2008).

During her research at the University of Canterbury, examining the effects of MiCBT on the health behavior of diabetes sufferers, Melanie Lindsay (2007) noted the following:

Within the context of Western psychology, mindfulness research for physical and psychological health is a fledgling field. The variety of ways in which mindfulness has been conceptualized reflects the lack of theoretical consensus (Bishop et al., 2004) and much of the research on mindfulness highlights the problematic process of capturing a definition of mindfulness (Baer, 2003; Brown and Ryan, 2003). There is potential for confusion in the use of the word mindfulness (Hayes and Wilson, 2003) because mindfulness may be described as a group of behaviours and represent an outcome (Baer, Smith, and Allen, 2004; Feldman, Hayes, Kumar, and Greeson, 2004), a practice (Thera, 1969), a therapeutic process (Germer, 2005), a technology (Hayes and Shenk, 2004; Linehan, 1993), a state and a trait (Bishop et al., 2004; Siegel, 2009a).

The following chapter attempts to address some of these questions using a model of reinforcement that does not rely on Cartesian dualism, by which the endorsement of a dichotomy of mind and matter has dominated Western Psychology for over a century. Rather, it proposes that mind and body cannot be separated during an experience. It is an integrative approach to behavior maintenance and change that rests on a neuro-behavioral model reinforcement.

Summary of Main Points

Mindfulness practice requires the development of cognitive and behavioral skills, including sustained sensory awareness, and unconditional experiential acceptance and response prevention; traditionally summarized by the term “equanimity.”MiCBT is a four-stage therapy model that integrates mindfulness meditation with core elements of cognitive and behavioral methods into a systemic approach to teach clients to regulate emotion and attention, and to externalize these skills to the contexts in which their impairment is triggered or maintained.There is a strong overlap between mindfulness principles and modern Learning Theory, both of which recognize the importance of reinforcement for the maintenance, enhancement and extinguishment of habitual reactions to stressors.In agreement with the traditional principles for the establishment of mindfulness in the East (Satipattana), the MiCBT therapy system proposes that equanimity is the principal mechanism of action for the transformative effect of mindfulness meditation. Other mechanisms of action include sustained attention, response inhibition to intrusive thoughts, response re-engagement (attention shifting), and non-identification with the experience.In the last fifteen years, there have been significant changes in the Western understanding of human cognitive and emotional processing. The notion of Cartesian Dualism has given way to the concept of embodied cognition, where mind and body cannot be separated during an experience. Numerous health clinicians have successfully used mindfulness training to address the experiential aspect of their patients’ conditions.