CHAPTER 5

MINDFULNESS- AND ACCEPTANCE-BASED THERAPY

Ruth A. Baer

Debra B. Huss

Mindfulness and acceptance have become topics of great interest to therapists of many theoretical persuasions and clinical backgrounds. Mindfulness is a way of directing attention that originates in Buddhist meditation practices. It was a relatively unfamiliar concept in much of Western culture until the past few decades when a small number of researchers and clinicians began developing interventions based on secularized meditation practices and related skills. These interventions are designed for use in Western settings with individuals who may have little interest in Buddhist belief systems or traditions. The general purpose of these interventions is to cultivate mindful awareness in the service of improved well-being, symptom reduction, and a life that feels more vital, meaningful, and satisfying. Interest in these approaches has expanded rapidly, and several mindfulness- and acceptance-based treatment approaches have accrued substantial empirical support.

Mindfulness and acceptance are closely related concepts. Mindfulness can be described as intentionally focusing your attention on the experiences occurring in the present moment in a nonjudgmental or accepting way (Baer & Krietemeyer, 2006). Present-moment experiences include the full range of observable internal stimuli (e.g., cognitions, bodily sensations, emotional states) and external stimuli (e.g., sights, sounds, smells). Mindfulness also includes attending to your current activity, rather than functioning on automatic pilot without awareness of your actions. Mindfulness can be contrasted with states of mind in which attention is focused elsewhere such as preoccupation with memories, plans, fantasies, or worries (Brown & Ryan, 2003). Thus, a person in a mindful state is observing or noticing the ongoing stream of internal and external stimuli as they arise with a stance of nonjudgmental acceptance.

Acceptance can be described as willingness to experience a wide range of unwanted or unpleasant internal phenomena (e.g., sensations, cognitions, emotional states, urges) without attempting to avoid, escape, or terminate them. Acceptance of negative experience becomes an issue when attempts to avoid or escape it would be harmful or counterproductive. Mindfulness- and acceptance-based approaches do not advocate tolerance of pain and distress when they can be reduced without maladaptive consequences. Rather, they suggest that unpleasant cognitions, emotions, and sensations are inevitably a part of life and cannot always be avoided and that skillful acceptance of these experiences may be important to mental health (Linehan, 1993b). Recent theory and research suggest that many forms of psychopathology and disordered behavior stem from counterproductive efforts to avoid negative internal experiences by engaging in maladaptive behaviors (e.g., substance abuse, dissociation, binge eating, self-harm, or situational avoidance). Laboratory studies in which individuals attempt to suppress negative thoughts and feelings suggest that suppression sometimes leads, paradoxically, to increased frequency and intensity of these experiences (Abramowitz, Tolin, & Street, 2001; Zvolensky, Feldner, Leen-Feldner, & Yartz, 2005). Thus, acceptance includes allowing reality to be as it is without maladaptive attempts to change or escape it. Terms such as friendly curiosity, interest, allowing, open-heartedness, and compassion are often used to describe the stance of mindful acceptance of present-moment experiences (Kabat-Zinn, 2003; Segal, Williams, & Teasdale, 2002).

The treatments covered in this chapter have developed many exercises for teaching mindfulness and acceptance skills. Some of these are formal meditation practices in which participants direct their attention in specific ways for periods of up to 45 minutes, usually while sitting quietly or lying down. Others are briefer exercises that do not necessarily involve meditation and may require bringing mindful awareness to routine activities of daily life, such as walking, eating, or washing dishes. Although mindfulness practices vary widely in form, several general instructions are common across most exercises. Participants are often encouraged to focus their attention on a particular class of stimuli (e.g., sounds that can be heard in the environment) or on an activity (e.g., breathing). Breathing is a common target of awareness because it is always present and ongoing. Participants are asked to observe their breathing carefully, noting associated sensations or movements. They are invited to notice that their attention is likely to wander into thoughts, memories, plans, fantasies, or worries and to recognize when this happens and gently return their attention to breathing. When bodily sensations or emotional states arise, they are encouraged to observe them carefully, noting how they feel, where in the body they are felt, and whether they are changing over time. If participants experience urges or desires to engage in behavior such as changing the body’s position or scratching an itch, they are asked to observe the urge without acting on it as best they can. If they decide to act on the urge, they are asked to do so with full awareness, noticing the intention to act, the process of acting, the sensations associated with acting, and any aftereffects. Brief, covert labeling of observed experience, using words or short phrases, is often encouraged. Participants might say “in” and “out” as they observe inhaling and exhaling, or “sadness,” “thinking,” “aching,” or “urge to move” as they observe internal phenomena. They are encouraged to bring an attitude of acceptance, openness, curiosity, willingness, and friendliness to all observed phenomena and to refrain from efforts to evaluate, change, or terminate them. Some approaches teach participants to bring awareness to their breathing while also observing an internal experience, a practice known as breathing with the experience (Segal et al., 2002).

This chapter provides a detailed overview of recently developed empirically supported treatments (ESTs) that incorporate the cultivation of mindfulness and acceptance through the practice of meditation or related skills. These interventions often have a treatment manual, a prescribed number of sessions, and a more or less specific agenda for each session. Their efficacy has been supported in randomized clinical trials. However, it should be noted that mindfulness practices and principles have influenced Western psychotherapy and intervention in a variety of ways and that scholarly discussion and clinical practice often integrate mindfulness and therapeutic work outside of the context of evidence-based approaches. For example, the relationship between Buddhist teachings and psychoanalytic or psychodynamic forms of therapy has been discussed for several decades. Early contributions to this literature include Zen Buddhism and Psychoanalysis (Fromm & Suzuki, 1960) and Psychotherapy East and West (Watts, 1961). More recent contributions include Psychoanalysis and Buddhism: An Unfolding Dialogue (Safran, 2003) and several books by Epstein (1995, 1998) that discuss psychodynamic psychotherapy from a Buddhist point of view. Germer, Siegel, and Fulton (2005) argue that mindfulness meditation and Buddhist psychology have interesting points of convergence with several approaches to psychotherapy, including psychodynamic, cognitive-behavioral, humanistic, family systems, and narrative approaches. They also note that mindfulness can be integrated into therapeutic work without teaching mindfulness skills to patients. Some therapists practice meditation to cultivate a more attentive, receptive, and compassionate presence during therapy sessions and to enhance their own peace of mind and well-being in ways that improve the therapy they provide. Others adopt theoretical frameworks based on principles of mindfulness or Buddhist psychology without teaching mindfulness to their patients (Kawai, 1996; Rosenbaum, 1999; Rubin, 1996). The interested reader is referred to the previous sources for comprehensive discussions of mindfulness, Buddhism, and psychotherapy that place less emphasis on empirical support through controlled trials.

The mindfulness- and acceptance-based interventions with the best empirical support include acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), dialectical behavior therapy (DBT; Linehan, 1993a, 1993b), mindfulness-based cognitive therapy (MBCT; Segal et al., 2002), and mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982, 1990). Acceptance and commitment therapy is a flexible approach that can be applied in individual or group format to a wide variety of populations and disorders. Dialectical behavior therapy is a comprehensive treatment program originally developed for borderline personality disorder (BPD) although applications for other problems are emerging. Mindfulness-based cognitive therapy is an 8-week group intervention designed to prevent relapse in individuals with a history of major depressive episodes. Mindfulness-based stress reduction is also an 8-week group intervention and was developed in a behavioral medicine setting for mixed groups of patients with a range of complaints, including pain, anxiety, and stress. These interventions are described in more detail in later sections.

As three of these interventions (all but MBSR) have their roots in cognitive-behavioral therapy (CBT), it is important to consider the relationship between these newer approaches and traditional CBT. As a group, mindfulness- and acceptance-based treatments have been described as the “third wave” of the cognitive-behavioral tradition (Hayes, 2004, p. 639). The first wave began with treatments based on laboratory studies of behavior and learning and was motivated by dissatisfaction with the psychoanalytic approaches to psychotherapy that prevailed in the 1950s. First-wave methods—including operant conditioning, skills training, and exposure-based procedures—are empirically well established and remain in widespread use. The second wave arose from the need to deal more directly with cognition and emphasized the role of cognitive processes in the development, maintenance, and treatment of psychological disorders. Landmarks in the second wave include Beck’s (1976) cognitive therapy and Ellis’s (1962, 1970) rational-emotive therapy. Both of these emphasize the identification and modification of distorted and irrational cognition. First- and second-wave approaches have been widely integrated, forming the large collection of treatments known as CBT.

Traditional CBT methods focus primarily on change. Clients are taught skills for changing the content of their thoughts, reducing their unwanted emotions, and modifying any undesirable behaviors. Third-wave approaches integrate the change-based methods of the first two generations with mindfulness- and acceptance-based concepts and strategies. The third wave has been prompted, in part, by treatment outcome findings that raise questions about how CBT leads to desired outcomes. Ilardi and Craighead (1994, 1999) note that much of the improvement in CBT for depression occurs early in treatment, often before the cognitive change procedures have been introduced. A large dismantling study of cognitive therapy for depression (Gortner, Gollan, Dobson, & Jacobson, 1998; Jacobson et al., 1996) found that the behavioral activation component of cognitive therapy is just as effective alone as when cognitive change procedures are added to it. Several mediational analyses have failed to support the idea that changes in the skills targeted by CBT lead to the observed improvements in outcome. Burns and Spangler (2001) found that, although participants in cognitive therapy for anxiety and depression improved significantly, changes in dysfunctional attitudes were not responsible for this improvement. Similarly, Morgenstern and Longabaugh (2000) found little evidence that increases in cognitive and behavioral coping skills accounted for the improvements seen in CBT for alcohol dependence. These data suggest a paradox: Although the efficacy of CBT for many problems is well documented, recent findings suggest that direct cognitive change may not be necessary for clinical improvement (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). These findings suggest that more work is needed to clarify how CBT methods lead to change.

Third-wave treatment approaches are exploring this issue by suggesting that beneficial outcomes are related to changes in the functions of psychological experiences (cognitions, sensations, emotions, urges) rather than to changes in their content or frequency. These treatments attempt to change clients’ relationships to unwanted internal experiences rather than necessarily changing the experiences themselves. For example, a traditional cognitive approach to a sad mood might include identifying the thought that triggered the sad mood, identifying the type of distortion that the thought exemplifies (e.g., catastrophizing or overgeneralization), examining the evidence for and against the thought, developing a more rational, balanced thought, and then noting whether thinking in this new way results in a reduction in the level of sadness. The goal is to change the emotional state by changing the content of thought. In contrast, a mindfulness-based approach to a sad mood might include noticing the sadness, carefully observing how it feels, where it is felt in the body and whether it is changing over time; noting or labeling its elements with words (e.g., “tightness in throat, heaviness in chest, urge to cry, thoughts of failure and loss”); directing awareness to the breath while observing the sadness; and bringing an attitude of openness, curiosity, friendliness, and compassion to the experience of the sad mood. Mindful observation and acceptance of the sad mood are not meant to keep the individual wallowing in sadness, but rather to facilitate a thoughtful choice of action to take, if any (e.g., engaging in an activity, taking constructive steps to address a problematic situation, or simply allowing sadness to run its natural course), without engaging in maladaptive escape and avoidance behaviors.

Mindfulness-based interventions differ in the extent to which they teach specific skills for taking action, when action is needed. Mindfulness-based stress reduction and MBCT tend to assume that if individuals bring mindful awareness and acceptance to their present-moment experiences they will be able to handle difficult situations with skills already in their repertoires. Segal et al. (2002) state that “… staying present with what is unpleasant in our experience… allows the process to unfold, lets the inherent ‘wisdom’ of the mind deal with the difficulty, and allows more effective solutions to suggest themselves” (p. 190). In contrast, Linehan’s (1993a) biosocial theory of BPD (described in more detail later) assumes that many individuals with BPD have grown up in severely dysfunctional environments in which they could not learn important skills. Because of deficiencies in many clients’ repertoires, DBT includes explicit instruction and training in a wide range of skills, including emotion regulation (through an integration of acceptance and change methods), interpersonal effectiveness, distress tolerance, problem solving, and behavioral analysis strategies.

HISTORY OF MINDFULNESS- AND ACCEPTANCE-BASED THERAPIES

Development of the mindfulness- and acceptance-based interventions covered in this chapter began in the late 1970s in independent academic and clinical settings with researchers and practitioners from varying backgrounds. Some had extensive direct experience with Eastern traditions that encourage the regular practice of meditation as a method for reducing suffering and cultivating positive qualities, such as awareness, insight, wisdom, equanimity, and compassion. Others initially had little or no experience with such traditions, and yet arrived at strikingly similar ideas about the relief of psychological problems. A brief outline of these histories is provided in the following sections.

History of Acceptance and Commitment Therapy

Acceptance and commitment therapy was developed by Steven Hayes and colleagues, beginning at the University of North Carolina at Greensboro in the late 1970s and subsequently at the University of Nevada at Reno. Acceptance and commitment therapy is rooted in radical behaviorism, but rarely discussed in those terms, because of frequent misunderstandings of this approach (Hayes & Strosahl, 2004). Instead, ACT articulates a philosophy known as functional contextualism that assumes that human actions are always situated in a context that includes both historical factors (prior learning history) and current environmental factors (situational antecedents and consequences, social norms, rules). Human actions, in this approach, include thinking and feeling, which are conceptualized as types of behavior. A context, in the language of ACT, is a set of contingencies. Human behavior always has functional relationships to environmental events or circumstances. Some of these influence the behavior of the individual, whereas others influence the cultural practices of a group or the survival of the species (Hayes, 1987).

Acceptance and commitment therapy acknowledges that various types of behaviors, such as thinking, feeling, and acting, often are functionally related. Thinking “No one likes me” can lead to feeling sad or anxious and withdrawing from a social situation. However, the occurrence of such a thought does not invariably predict social withdrawal. Hayes and colleagues argued that the apparent causal relationship between a particular thought (“No one likes me”) and a specific behavior (social withdrawal) requires a social/verbal context in which thoughts are believed to be true and important and to necessitate particular behaviors. In a context in which thoughts are seen as “just thoughts,” their influence on overt behavior might be greatly reduced. This would allow other factors such as important goals and values (e.g., cultivating a more active social life) to exert greater influence on behaviors. Hayes and colleagues developed a therapy known as comprehensive distancing (Hayes, 1987; Zettle & Hayes, 1986) that questioned the assumption that thoughts must necessarily control behaviors. Distancing, which refers to observing and identifying thoughts objectively and distinguishing between thoughts and external reality, had already been described by Hollon and Beck (1979) as the “first critical step” (p. 189) in cognitive therapy because it enabled clients to view their thoughts as ideas to be tested rather than truths. However, Hayes’s new therapy departed from cognitive therapy by not attempting to correct unrealistic or irrational thinking through cognitive restructuring. Instead, it proposed that distancing is the primary therapeutic process because it weakens the influence of thoughts on other behaviors. Comprehensive distancing encouraged participants to notice and identify their depressive thoughts and to engage in adaptive behaviors while having these thoughts. Homework assignments encouraged participants to engage in effective behavior in the presence of thoughts that previously would have prevented them from doing so (Zettle & Hayes, 1986).

Early studies of comprehensive distancing for depression (Zettle & Hayes, 1986; Zettle & Raines, 1989) showed promising results. Clinical trials then were discontinued while philosophical and basic science foundations for the new therapy were strengthened. A series of publications clarified the assumptions of functional contextualism (Biglan & Hayes, 1996; Hayes, 1993; Hayes, Hayes, & Reese, 1988), developed a theory of human language and cognition known as relational frame theory (RFT) that now has a substantial empirical base (Hayes, Barnes-Holmes, & Roche, 2001), proposed a model of psychopathology (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), and provided a book-length treatment manual (Hayes et al., 1999). The treatment’s name was changed to acceptance and commitment therapy to signify acceptance of thoughts and feelings as they are while choosing potentially effective behavior consistent with goals and values. Mindfulness exercises are incorporated to facilitate awareness and acceptance of thoughts and feelings. Clinical outcomes studies have resumed and are providing increasingly strong support for the efficacy of ACT (see Hayes et al., 2006, for a review). Adaptations for numerous populations and settings have been reported (Hayes & Strosahl, 2004). Professional training opportunities are offered through the Association for Contextual Behavioral Science (ACBS; see Web Site section in References). A more detailed history of ACT is provided by Zettle (2005).

History of Dialectical Behavior Therapy

Marsha Linehan began treating suicidal and self-injurious adult women in the late 1970s at the University of Washington, using well-established cognitive-behavioral methods to reduce their self-harm and other problematic behaviors. The clients, who typically had long histories of unsuccessful attempts to solve extremely painful problems, often perceived suggestions about behavior change as invalidating and became angry, which led to high rates of attrition (Linehan, 1997). However, if they did not work on behavior change, their lives remained chaotic and miserable. Many had endured intense emotional suffering for years. Linehan studied numerous historical and biographical accounts of intense suffering, looking for insights about why it appeared to strengthen some people while ruining the lives of others. The concept of acceptance, though not widely discussed in psychology at that time, was central to many descriptions of the experiences of holocaust survivors, torture victims, and others who had endured great suffering. Those who were able to accept the reality of their suffering without denial, suppression, or avoidance seemed more likely to experience personal growth (Linehan, 2002). To learn more about acceptance, Linehan studied Zen Buddhism (Butler, 2001). She began combining nonreligious acceptance-based strategies, including validation and mindfulness skills, with traditional cognitive-behavioral changes strategies. A dialectical philosophy that emphasizes the synthesis of opposing forces provided the conceptual foundation for the systematic integration of acceptance- and change-based methods.

Linehan (1994) found that many of her clients were unable or unwilling to engage in the lengthy meditation practices characteristic of Buddhist traditions and therefore developed a set of behavioral exercises for teaching the core skills of mindfulness and acceptance without requiring formal meditation. Incorporation of mindfulness and acceptance skills appears to facilitate clients’ ability to tolerate the inevitable discomfort associated with the difficult process of changing their behavior to build better lives. It also seems to improve their acceptance of painful aspects of their histories and current circumstances that cannot be changed. Moreover, it facilitates therapists’ acceptance of the difficulties involved in working with this challenging population (Linehan, 1993a, 1993b).

Dialectical behavioral therapy has been enthusiastically embraced by mental health professionals (Scheel, 2000; Swenson, 2000) looking for effective treatment for clients with BPD. Several hundred DBT programs in the United States are listed on the web site of Behavioral Tech, an organization providing consultation and training in evidence-based treatments for mental disorders (see Web Site section in References). Standard outpatient DBT generally includes individual therapy, group skills training, telephone consultation, and a therapist’s consultation group. Typical duration is 1 year, though shorter versions have been reported. Adaptations for a range of settings, including prisons, inpatient hospitals, and outpatient private practice are increasingly available (Robins & Chapman, 2004), and more than a dozen states in the United States now include some form of DBT in their mental health treatment systems (Carey, 2004). Versions of DBT for adults with substance abuse problems (Linehan et al., 1999), eating disorders (Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2001), and intimate partner violence (Rathus, Cavuoto, & Passarelli, 2006), for self-harming adolescents (Rathus & Miller, 2002), and for depressed older adults (Lynch, Morse, Mendelson, & Robins, 2003) have been described in the literature, and additional adaptations seem likely.

History of Mindfulness-Based Stress Reduction

Jon Kabat-Zinn began developing MBSR in 1979 at the University of Massachusetts Medical School (Kabat-Zinn, 1982, 1990). His goal was to make mindfulness meditation available and accessible in a Western medical setting while remaining true to the essence of Buddhist teachings (Kabat-Zinn, 2000). Mindfulness meditation is at the core of Buddhist practices designed to reduce suffering and increase happiness in human beings. Thus, it is not specific to any problem or disorder, but rather potentially applicable to all who feel pain or distress. Kabat-Zinn, who had practiced Buddhist meditation for some time, hoped to provide a resource for patients whose medical treatments had been unsatisfactory. He began offering a 10-week group program for patients with a wide range of chronic pain and stress-related conditions, who were referred by their physicians because they continued to suffer, although traditional medical treatment had nothing more to offer them. The program was based on intensive practice of several forms of mindfulness meditation and designed to help patients cultivate awareness and acceptance of present-moment experience. The program was called stress reduction because of concerns that meditation would not be seen as a legitimate activity for patients in an academic medical center at that time. The program eventually became known as MBSR, and in its standard form is now an 8-week group program for up to 30 participants, with 2.5-hour weekly sessions and an all-day session during week six. The stress reduction clinic is now part of the Center for Mindfulness (CFM) in Medicine, Health Care, and Society at the University of Massachusetts Medical School. The CFM offers MBSR to several hundred patients per year. The CFM also offers professional education and training, workplace programs, and outreach programs for corporations, nonprofit organizations, and educational institutions. It holds an annual conference and supports research on applications of mindfulness.

Numerous MBSR programs are available in North America and Europe (see Web Site section in References). Adaptations for a wide range of populations and settings have been reported, including patients with cancer (Carlson, Speca, Patel, & Goodey, 2003; Saxe et al., 2001), heart disease (Tacon, McComb, Caldera, & Randolph, 2003), fibromyalgia (Weissbecker et al., 2002), and chronic fatigue syndrome (Surawy, Roberts, & Silver, 2005), as well as stress in the workplace (Davidson et al., 2003), and relationship enhancement for couples (Carson, Carson, Gil, & Baucom, 2004), among others. In most published studies, the 8-week group format is maintained, although the content may be tailored to the population or condition under study. As most of the mindfulness practices are not specific to a particular population or disorder, extensive changes often are not necessary. An intervention that has modified MBSR more extensively than most is mindfulness-based eating awareness training (MB-EAT; Kristeller, 2003; Kristeller & Hallett, 1999), which incorporates mindful eating of several types of food, as well as guided meditations related to body shape and weight, hunger and satiety cues, and binge-eating triggers.

History of Mindfulness-Based Cognitive Therapy

Mindfulness-based cognitive therapy is an adaptation of MBSR designed to prevent relapse in individuals with a history of major depressive episodes. It was developed beginning in 1992 by Zindel Segal at the University of Toronto; John Teasdale at the Medical Research Council in Cambridge, England; and Mark Williams at the University of Wales at Bangor. Although depression can be treated successfully in many cases, it remains a significant social problem because of its prevalence and high rates of relapse in previously depressed individuals (Segal et al., 2002). Segal, Teasdale, and Williams recognized that standard cognitive therapy provides good protection against relapse, but that most patients are treated with antidepressant medication, which has a high risk of relapse when discontinued. Thus, their goal was to develop a cost-effective treatment that would teach the skills responsible for cognitive therapy’s efficacy in preventing relapse to people who had recovered from depression using medication.

Based on experimental and theoretical work on vulnerability to depressive relapse, they developed a model suggesting that cognitive therapy prevents relapse by implicitly changing people’s relationship to their negative thoughts, rather than by changing the content of thoughts. By examining thoughts to evaluate the accuracy of their content, cognitive therapy patients adopt a different perspective on thoughts, viewing them as passing mental events rather than as essential truths about themselves or reality. This perspective, known as decentering or distancing, was already recognized in cognitive therapy (Beck, Rush, Shaw, & Emery, 1979), but usually viewed as a step in the process of changing thought content, rather than as an end in itself. Segal, Teasdale, and Williams began considering methods for teaching the skills of decentering to groups of previously depressed patients. On the recommendation of Marsha Linehan, who had visited Teasdale and Williams on a recent sabbatical and had made a strong case for the utility of mindfulness training, they began to examine the work of Jon Kabat-Zinn, who was teaching mindfulness to large groups of patients. At that point, only Teasdale had experience with meditation, whereas Segal and Williams were skeptical or uncertain of its potential utility for previously depressed patients (Segal et al., 2002).

Visits to Kabat-Zinn’s program led to a series of developments in which the new treatment evolved over several years. Initially, it was called attentional control training, because it emphasized attending to thoughts in a decentered rather than a ruminative way. However, experience showed that it was necessary to apply the concept of decentering to all internal experiences, including the entire range of emotional states and bodily sensations, rather than to thoughts alone. Experience also showed that the attitude brought to decentering was of critical importance. Decentering for the purpose of avoiding, terminating, or changing unpleasant inner states was ineffective. Rather, the experienced mindfulness practitioner adopts a stance of allowing, accepting, and even welcoming such states, without trying to “fix” them. The nature of this mindful stance can be difficult to teach to others without personal experience of it. Thus, it became clear to all of the developers that a personal mindfulness practice was essential to effective teaching of mindfulness, a principle also endorsed by MBSR instructors. Following completion of the first clinical trial (described later), the new treatment was renamed MBCT to reflect the incorporation of the decentering principles and practices from cognitive therapy into a mindfulness framework (Segal et al., 2002).

In its standard form, MBCT is an 8-session group program for up to 12 participants with previous depressive episodes who are currently in remission. Like MBSR, it includes 2 or 2.5-hour weekly sessions and an all-day session during Week 6. Professional training in MBCT is offered periodically in North America and the United Kingdom (see Web Site section in References). Recent data suggest that MBCT may also be effective for currently depressed patients (Kenny & Williams, 2007), and adaptations for other problems and populations are beginning to appear, in preliminary form. Examples include MBCT for children (Semple, Lee, & Miller, 2006) and MBCT for binge eating (Baer, Fischer, & Huss, 2005a, 2005b).

THEORIES OF PSYCHOPATHOLOGY, HEALTH, AND THE DEVELOPMENT OF DIFFICULTIES

Each of the interventions addressed in this chapter has its own theory about how difficulties develop and how mindfulness and acceptance may be helpful. These are summarized briefly and elements common to these theories are discussed.

Theory of Acceptance and Commitment Therapy

Acceptance and commitment therapy is based on RFT, a comprehensive behavioral account of human language and cognition that suggests ways in which normal cognitive processes lead to psychological difficulties. In particular, the social-verbal community in which human beings are embedded supports cognitive fusion and experiential avoidance. In cognitive fusion, thoughts and related emotions are seen as literally true and as causes of behavior that must be controlled before a satisfying life can be pursued. Worries about the future, for example, may be seen as accurate descriptions of what the future will necessarily hold (e.g., “If I go to the party, I’ll be rejected”), rather than merely thoughts about the future. Experiential avoidance is defined as unwillingness to experience unpleasant internal phenomena (e.g., feelings, sensations, cognitions, or urges) and taking action to avoid, escape, or eliminate these experiences, even when doing so is harmful. Acceptance and commitment therapy and RFT point out that societal language conventions seem to support several assumptions, including: (1) that negative internal experiences are valid causes of behavior (e.g., “I couldn’t go to the party because I was anxious”) and (2) that internal experiences must be controlled in order to obtain valued outcomes such as social interaction (e.g., “I can’t have a social life until I control my anxiety”).

Acceptance and commitment therapy and RFT contend that these assumptions are not essentially true but rather are maintained by the mainstream verbal community and that negative internal experiences (emotions, cognitions) are not inherently dangerous or harmful and therefore do not need to be controlled or eliminated. Thoughts and feelings are not viewed as problems to be solved. Instead, problems arise when these phenomena are taken literally (fusion) and seen as things that must be changed or removed (experiential avoidance) before a good life can be pursued. For example, individuals who strive to control their internal experiences, such as anxiety, may use counterproductive tactics such as thought suppression that paradoxically tends to increase the frequency of unwanted thoughts. They may engage in harmful behavior such as drug and alcohol abuse, binge eating, or dissociation. They also may avoid an ever-increasing range of situations that elicit anxiety, thereby constricting their lives in ways that prevent pursuit of their most deeply held goals and values, such as having satisfying relationships or doing good work. In these ways, ACT contends, many forms of psychopathology and disordered behavior are related to unnecessary and counterproductive efforts to avoid negative internal experiences.

In ACT, the alternative to cognitive fusion and experiential avoidance is psychological flexibility, a construct with the following six interrelated components (Strosahl, Hayes, Wilson, & Gifford, 2004). Acceptance and commitment therapy views mindfulness as a combination of the first four of these components (Fletcher & Hayes, 2005):

Obstacles to engaging in these behaviors usually take the form of negative thoughts and feelings. Acceptance, defusion, contact with the present moment, and self-as-context then become useful tools for overcoming these obstacles. Overall, then, ACT is a therapy approach that uses acceptance and mindfulness processes, and commitment and behavior change processes to produce greater psychological flexibility.

Theory of Dialectical Behavior Therapy

Dialectical behavior therapy is based on Linehan’s (1993a) biosocial theory of BPD, which states that BPD is a dysfunction of the emotion regulation system brought on by the transaction over time of an emotionally vulnerable temperament and an invalidating childhood environment. The emotionally vulnerable child is biologically predisposed to react quickly and intensely to emotional stimuli and to have long-lasting emotional reactions. The invalidating environment communicates to the child that her expressions of internal experience are wrong, bad, or inappropriate. Thus, these children have frequent intense emotions. They often are told that they shouldn’t feel what they feel and that they feel it for inappropriate or undesirable reasons such as a bad attitude, lack of discipline, overreacting, paranoia, or manipulativeness. The invalidating environment intermittently reinforces both emotional inhibition and extreme emotional display, thereby teaching the child to vacillate between these two styles of emotional expression without helping the child to learn adaptive emotion regulation skills. This environment also fails to teach the child normative labeling of private experiences or the ability to trust the validity of his or her thoughts and emotions. As a result, several problems develop. The child becomes fearful of emotions, which are seen as intense, confusing, and the cause of much trouble. Impulsive behaviors, including self-harm, are likely to emerge as maladaptive attempts to escape feared emotional states. Identity disturbance develops because the child is unable to recognize what he or she thinks and feels. That is, adults in the child’s environment consistently communicate to the child that his or her thoughts and feelings are invalid, and the child therefore looks to others for cues about how to think, feel, and act.

The biosocial theory implies that mindfulness and acceptance skills should be helpful in several ways. The practice of mindfulness involves sustained observation of internal experiences. This can be seen as an example of exposure, which should encourage the extinction of fear responses and reduce maladaptive avoidance behavior. Observing and applying descriptive labels to thoughts and feelings should encourage the understanding that they tend to be transient and are not inherently harmful. The practice of nonjudging should reduce self-criticism for having various thoughts and feelings and improve self-understanding. Nonjudgmental observation and description also may facilitate recognition of the consequences of behaviors and lead to more effective behavior change, including reduced impulsive behavior. Linehan (1993b) also suggests that the practice of mindfulness develops control of attention, a critical skill for individuals who have difficulty attending to important tasks or situations because they are distracted by negative emotions, worries, or memories.

Theory of Mindfulness-Based Cognitive Therapy

According to the theoretical model underlying MBCT, individuals who have experienced episodes of depression have developed associations between sadness and negative thought patterns. In these individuals, the ordinary sad moods of daily life trigger depressive thinking patterns similar to those present during their previous depressive episode(s). These patterns are likely to include global negative judgments about themselves and the world and a ruminative style of thinking in which problems and inadequacies are repeatedly analyzed in an attempt to find insights about how to address them. These negative thinking patterns tend to be self-perpetuating and may escalate into a new depressive episode.

Early descriptions of cognitive therapy for depression suggested that it reduces vulnerability to relapse by changing the content of dysfunctional thoughts and attitudes. However, the empirical literature has shown that antidepressant medications are equally effective in changing thought content (Barber & DeRubeis, 1989; Simons, Garfield, & Murphy, 1984), yet provide much less protection against relapse. These findings suggest that changing thought content is not the central ingredient in cognitive therapy’s beneficial effects on relapse rates. As noted earlier, more recent theorizing (Segal et al., 2002) suggests that cognitive therapy, in addition to changing the content of thoughts, also leads to a new perspective about thoughts known as distancing or decentering. This perspective enables individuals to see their thoughts as transitory mental events that do not necessarily reflect important truths about reality or worthiness and that do not necessitate specific reactions or behaviors. Traditional cognitive therapy is hypothesized to encourage decentering by asking participants repeatedly to observe and identify their thoughts. In the past, these tasks were seen as important because they led to evaluation, disputing, and changing of thought content. However, several authors have suggested that decentering alone may be the central ingredient in relapse prevention (Ingram & Hollon, 1986) and that changing thought content may be unnecessary.

Segal et al. (2002) distinguish between doing and being modes of mind. In doing mode, discrepancies between actual and preferred conditions are recognized and problem-solving strategies are generated for reducing the discrepancies. Many discrepancies can effectively be addressed in this manner, such as by making a plan to have a broken appliance repaired. However, discrepancies about inner states, such as wanting to feel less sad, can be worsened by analyzing causes of sadness and making plans to fix them. Sadness may not respond to such efforts, which can easily escalate into rumination. Being mode, in contrast, involves accepting and allowing whatever is present, without efforts to analyze, solve, or change it. The MBCT model conceptualizes mindfulness practice as a method for learning to disengage from doing mode and adopt the stance of being mode, especially at times when a sad mood has arisen. This facilitates decentering and prevents reactivated negative thinking patterns from escalating into rumination and depressive relapse. It also allows time for choosing more adaptive responses to the occurrence of a sad mood. In this way, depressive thinking is “nipped in the bud” and a relapse does not occur.

Theory of Mindfulness-Based Stress Reduction

Mindfulness-based stress reduction was developed outside the field of psychology and was based largely on Buddhist teachings (known as the Dharma) concerned with the nature of human suffering in general, rather than with specific psychological or medical disorders. Buddhist teachings suggest that suffering is ubiquitous in life (Kumar, 2002) and is caused by misperceptions of the nature of self, identity, and change and attachment to or craving of conditions that are not present or will not last (Marlatt, 2002). The path out of suffering includes acceptance of reality as it is, which can be cultivated through meditative practices that lead to insight, wisdom, and compassion. Mindfulness-based stress reduction provides a secular format in which individuals who would like to reduce their levels of suffering can learn these practices. Kabat-Zinn (1996) points out that MBSR differs from traditional medical and psychiatric models that advocate specific treatments for specific disorders. Mindfulness-based stress reduction groups accept individuals with a wide range of medical and psychological problems and provide essentially the same intervention for all. The classes focus on characteristics that participants have in common. Superficially, these include stress, pain, and/or illness, the primary reasons for seeking help through MBSR. More important, by virtue of being alive and human, participants share, according to Kabat-Zinn (1996):

an incessant flow of mental states, including anxiety and worry, frustration, irritation and anger, depression, sorrow, helplessness, despair, joy, and satisfaction, and the capacity to cultivate moment-to-moment awareness by directing attention in particular systematic ways. They also share, in our view, the capacity to access their own inner resources for learning, growing, and healing (as distinguished from curing) within this context of mindfulness practice. (pp. 164–165)

Common Elements of Foundational Theories

Although these four conceptual foundations were developed independently, they share several common elements. First is the explicit recognition of the need to synthesize acceptance and change. In ACT, clients are taught to accept internal experiences as they are, willingly and without efforts to change or escape them, in the service of changing their behavior in ways necessary to move toward important goals and values. Similarly, DBT includes explicit training in mindfulness and acceptance skills for managing situations and experiences that cannot be changed and integrates these skills with change-based strategies designed to help clients improve their behavior and build more satisfying lives. Mindfulness-based cognitive therapy and MBSR concentrate more heavily on the practice of mindfulness and acceptance skills, although it is clear that these skills may facilitate important changes, including new perspectives on experiences and new ways of responding when difficulties arise.

Second, all of these theories point to the potential harm resulting from excessive experiential avoidance. Attempts to suppress, escape, terminate, or change internal experiences—including sensations, cognitions, and emotional states—often have maladaptive consequences, including paradoxical increases in the frequency or intensity of these states, dysfunctional behavior, and maladaptive avoidance of important situations and tasks. Experiential avoidance may reduce distress or discomfort in the short term, and Western culture seems to support the idea that negative thoughts and feelings should be eliminated whenever possible. However, the theories underlying these treatment approaches suggest that acceptance of unpleasant inner experiences with willingness, openness, curiosity, compassion, and a nonjudgmental stance often is more adaptive. Because acceptance of these experiences can be frightening and painful, practice is necessary to develop the required skills.

Third, the concept of decentering or defusion is critical to all of these approaches. The essential idea is that internal experiences can be viewed as transitory mental events, rather than as literal truths that must dictate behavior. It includes the idea that thoughts and feelings are not inherently harmful and can be allowed to pass through awareness, regardless of their content or how aversive they feel. The language of stepping back and observing the experience of the moment is often used to describe a decentered stance. Adopting this stance reduces the behavioral impact of thoughts and feelings because individuals come to see them as events to be noticed but not necessarily believed or acted on. Some authors describe decentering or defusion as a process of changing the stimulus functions of internal events, whereas others discuss changing individuals’ relationships to their inner events.

THEORY OF PSYCHOTHERAPY

In a book entitled Twenty-First Century Psychotherapies, it may seem paradoxical to include an intervention (MBSR) whose developer does not describe it as a form of psychotherapy. Kabat-Zinn (1996) notes that the orientation of MBSR is educational rather than psychotherapeutic and describes the program as a class rather than a form of psychotherapy. However, MBSR was among the first mindfulness-based interventions to be made available in Western settings and is well supported by a growing literature in medical and psychological journals (see later sections). Inclusion of MBSR in this chapter allows interesting perspectives on the current convergence of Eastern and Western approaches to the problems of human suffering.

Goals of Treatment

As a group, mindfulness- and acceptance-based treatments have several goals in common. Perhaps the most fundamental goal is increased awareness of present-moment experiences, including bodily sensations, cognitions, and emotional states, as well as stimuli in the environment. The cultivation of an accepting, nonjudgmental, and nonreactive stance toward these experiences is critically important. This stance includes curiosity about and openness to all experiences (pleasant or unpleasant) and a decentered perspective. For many people, a natural response to unwanted inner experiences is to attempt to avoid, suppress, or escape them, and these strategies often are used automatically or without conscious awareness. Thus, learning to see these strategies in operation and to replace them with a mindful approach to experience can be difficult and may require sustained and regular practice. As some inner states are intensely painful, accepting them as they arise without attempts to terminate them can require courage. Thus, an important goal of these treatments is the development of willingness to practice a mindful stance regardless of the particular experiences that arise.

In these treatments, mindful awareness is not practiced solely for its own sake, but is cultivated in the service of several broader goals, including symptom reduction, self-exploration and insight, improved quality of life, and the development of positive characteristics such as wisdom and compassion. Each of the interventions addressed in this chapter has its own approach to the identification of specific treatment goals. In ACT, which is applicable to a wide range of problems, goal setting is tailored to the individual client and is closely tied to a process of values clarification. Values are defined as chosen life directions, such as being a loving partner or a competent professional. Living in accordance with values is an ongoing process, rather than a task that can be completed. Goals, in contrast, are specific, attainable destinations along the path of your values, such as taking your spouse to a medical appointment or completing a professional training program. Acceptance and commitment therapy includes several exercises designed to help clients articulate their values. They may be asked to consider what they would like to have written on their tombstone, or to compose their own eulogy, clarifying what they wish to be remembered for. When values have been identified, goals and plans for moving toward them can be developed. This process is of central importance in ACT, which emphasizes that a satisfying and meaningful life usually entails consistently engaging in actions consistent with personal values. The specific values and goals are individual to each client, though many fall in the general categories of relationships, work, personal growth and learning, health, citizenship, or spirituality.

Dialectical behavior therapy takes a different approach to goal setting because of the severe impairments of many BPD clients, some of whom are at high risk for suicidal and self-harm behaviors. Dialectical behavior therapy includes a hierarchy of treatment targets, some of which are not negotiable if the client wishes to participate in the DBT program. Self-harm behavior is at the top of the hierarchy. Thus, the reduction of self-harm is the first goal of treatment for any client who is engaging in this behavior. Therapy interfering behavior (e.g., missing sessions, coming late, or failing to do homework) is next in the hierarchy and is always addressed if it occurs. Third in the hierarchy is behavior that interferes with quality of life. This very broad category includes most other problems, including those related to school, work, housing, finances, substance use, or relationships, as well as any Axis I disorders that might be present, such as depression, anxiety, or eating problems. Therapists and clients work collaboratively to determine treatment goals in this category. After these problems are addressed, other goals of treatment will be specific to each individual client, and may be related to broad issues such as happiness, spirituality, or self-respect.

In MBCT, the general goal is the prevention of recurrence of depression. Clients learn to apply mindful awareness and acceptance to their moment-to-moment experiences with the specific goal of recognizing when early signs of depression are arising, and then using skills learned in the group to prevent escalation into relapse. In MBSR, goals are usually described in very general terms, including self-discovery, self-development, learning, and healing (Kabat-Zinn, 1982). The program is designed to help patients learn to use their own inner resources to reduce suffering and to promote personal growth and well-being.

Assessment Procedures

Assessment procedures vary across these treatment approaches although each includes an initial assessment and some form of tracking throughout treatment. The initial assessment includes the nature and severity of the current symptoms and the ability and willingness to commit to the treatment program. Screening measures and/or an initial interview may be used to evaluate whether the potential client and the program are a good match. In MBSR, individuals with psychotic disorders are generally referred elsewhere, as are those early in treatment for substance use problems. Mindfulness-based stress reduction does not consider itself a substitute for psychotherapy and may accept individuals with posttraumatic stress disorder (PTSD), dissociative disorders, a current major depressive episode, or other problems only if they are also participating in psychotherapy. In DBT programs, a structured interview may be used to determine whether the potential client meets criteria for BPD. Acceptance and commitment therapy typically includes a general clinical assessment and a reformulation of the presenting problems in ACT-consistent terms (e.g., experiential avoidance, fusion).

Tracking of symptom levels, emotional states, and progress toward goals—either with in-session discussion, paper-and-pencil measures, or both—is quite common. Many self-report instruments can be used for these purposes. Monitoring of homework completion and reactions to mindfulness practice also is very common. Mindfulness-based cognitive therapy includes a weekly homework record form, and DBT uses a diary card for self-monitoring of skills practice and therapy targets. Posttreatment assessment of relevant medical or psychological symptoms using interview and questionnaire methods is commonly practiced. Useful instruments for measuring symptoms and distress include the Brief Symptom Inventory (BSI; Derogatis, 1992), Beck Depression Inventory (BDI-II; Beck, 1996), State-Trait Anxiety Inventory (STAI; Spielberger & Sydeman, 1994), or Profile of Mood State (POMS; McNair, Lorr, & Droppelman, 1971). Several researchers have argued that other outcomes should also be measured, including self-compassion (Neff, 2003), spirituality, or empathy (Shapiro, Schwartz, & Bonner, 1998).

Self-report instruments that measure levels of mindfulness and acceptance are beginning to appear in the literature. The Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith, & Allen, 2004) measures four facets of mindfulness: (1) observing, (2) describing, (3) acting with awareness, and (4) nonjudgmental acceptance. The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) measures the general tendency to be aware of and attentive to present-moment experiences in daily life. The Freiburg Mindfulness Inventory (Buchheld, Grossman, & Walach, 2001) assesses nonjudgmental observation and openness to negative experiences. The Acceptance and Action Questionnaire (Hayes, Strosahl, et al., 2004) assesses willingness to experience unpleasant internal events and ability to act constructively while having them. A factor analytic study of several of these measures (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) suggests that mindfulness can usefully be conceptualized as a multifaceted construct consisting of several component skills and that these can be assessed with the Five Facet Mindfulness Questionnaire. Future research with these instruments may help to clarify the nature of mindfulness and acceptance skills, the efficacy of mindfulness- and acceptance-based interventions in teaching them, and the extent to which learning these skills is responsible for symptom reduction and improved functioning.

Process of Treatment

Role of the Therapist and Therapeutic Relationship

Mindfulness- and acceptance-based approaches place strong emphasis on the common humanity of therapist and client and on interacting with clients in a genuine, open, equal, and sharing way. In MBSR and MBCT, group leaders are expected to be engaged in their own ongoing mindfulness practice and to teach from a basis in their own experience. This principle is expressed in several ways. Skillful instructors are said to embody a mindful stance to experience in their leading of sessions and interaction with group members. They engage in the mindfulness practices while leading them and participate in the discussion afterwards, disclosing some of their experiences. This helps to clarify that the variety of pleasant and unpleasant sensations, emotions, and cognitions that may arise during mindfulness practice are universally human, rather than specific to those seeking help. It should also illustrate that a mindfulness practice is a commitment to lifelong self-exploration, personal growth, and learning, rather than a skill that group leaders have mastered. Participants are more likely to make such a commitment for themselves when working with a group leader who is similarly committed.

Mindfulness-based stress reduction and MBCT group leaders listen closely and explore each participant’s experiences in an accepting and nonjudgmental way with curiosity about the details. This helps to create a safe environment for self-disclosure while conveying the attitude of mindfulness, acceptance, and careful observation that is being cultivated. Group leaders weave into the discussion the points that members’ experiences are likely to illustrate; for example, that the mind seems to have a life of its own, that everyone functions on automatic pilot much of the time, and that the nature of experience may change when we attend to it carefully. Instructors also facilitate understanding of how mindful awareness might help with the problems for which the clients sought treatment. The central idea is that bringing mindful awareness and compassion to difficult problems enables clients to refrain from counterproductive efforts to fix inner states, to see problems more clearly, and to work with them in skillful ways. However, MBSR and MBCT instructors tend not to engage in solution seeking about specific issues such as how to behave assertively with your spouse, conduct yourself in a job interview, modify diet or exercise behaviors, organize your time, and so on. Instead, these approaches emphasize the mobilizing of clients’ inner resources for addressing problems. In accordance with this stance, MBSR and MBCT leaders are more likely to describe themselves as mindfulness instructors than as therapists. The authors of MBCT describe how their experiences with MBSR led them to this perspective:

In our own training, we had been taught that, when faced with a difficult clinical problem we should collaborate with the patient on how best to solve it by seeing what thoughts, interpretations, and assumptions might be causing or exacerbating the problem…. Instead, it now appeared to us that the overarching structure of our treatment program needed to change from a mode in which we were therapists to a mode in which we were instructors. What was the difference? As therapists, coming as we did from the cognitive-behavioral tradition, we felt a responsibility to help patients solve their problems, “untie the knots” of their thinking and feeling, and reduce their distress, staying with a problem until it was resolved. By contrast, we saw that the MBSR instructors left responsibility clearly with the patients themselves, and saw their primary role as empowering patients to relate mindfully to their experience on a moment-by-moment basis (Segal et al., 2002, p. 59).

Dialectical behavior therapy and ACT also emphasize a genuine and egalitarian relationship with clients. In DBT, a strong, positive relationship is essential and may be the primary factor keeping the patient in therapy or even alive during a crisis (Linehan, 1993a). The relationship is described as both a means to an end and as an end in itself. A healthy relationship in which the therapist is compassionate, sensitive, flexible, and accepting stimulates the client’s innate potential for healing, learning, and growth. At the same time, the relationship enables the therapist to teach the client new skills and persuade the client to use them, even when she is resistant. In DBT, therapists are empathic, validating and genuine, and can also be irreverent at times. They are constantly engaged in the dialectic of accepting the client as she is and helping her to change. They are nurturing of the client while making compassionate and reasonable demands that she engage in constructive behaviors when she is capable of doing so. The therapist teaches any necessary skills that appear to be lacking in the client’s repertoire and functions as coach and cheerleader. A more detailed discussion of the therapeutic relationship in DBT can be found in Linehan (1993a).

Acceptance and commitment therapy also emphasizes the commonality between therapist and client, in that both are subject to the same general “language traps” (Hayes et al., 1999, p. 267) of fusion and experiential avoidance. A strong bond between ACT therapists and their clients often develops. This requires that the therapist be willing to engage in a relationship that is open, accepting, and consistent with ACT principles. The therapist must be willing to defuse from literal language and to embrace uncomfortable feelings when necessary to remain present and work effectively with the client. If the therapist becomes confused during a session, ACT-consistent responses would include observation and nonjudgmental acceptance of feelings of anxiety and thoughts about incompetence, and refraining from maladaptive attempts to fend them off, while remaining present with the client. Therapists are not immune to fusion and avoidance. The critical issue is how they respond to these experiences when they occur.

In any of these approaches, it can be challenging for the therapist to remain mindfully present and aware and to refrain from efforts to rescue the client in distress from unpleasant thoughts or emotions. This may be particularly true for therapists accustomed to a problem-solving approach, who may feel tempted to begin cognitive restructuring or skills-training procedures when distress arises. In a mindfulness-based approach, clients in distress are encouraged to bring mindful awareness to the experience, feeling it fully as it is, accepting it with compassion and without judgment, perhaps breathing with awareness while feeling it, and sitting with it for a period of time before deciding what (if anything) to do about it. This facilitates the development of willingness to experience whatever is present and reduces impulsive, automatic reactions that may be counterproductive. It conveys confidence that the client can manage negative internal experience without harm or threat.

Typical Length of Therapy

The duration of therapy is highly variable across these approaches. Mindfulness-based stress reduction and MBCT, in their standard forms, are 8-week group programs, although variations in the number of weeks have been reported in the published literature. An adaptation of MBCT for binge eating was extended to 10 weeks (Baer et al., 2005b). Mindfulness-based cognitive therapy for children (Semple et al., 2006) increases the number of weekly sessions to 12, while decreasing the duration of each session from 2 hours to 90 minutes. Smith (2006) discusses potential advantages and disadvantages of extending MBCT to 10 sessions for older adults. More sessions may reduce cost-effectiveness but provide increased opportunity for practice and discussion of skills.

Standard outpatient DBT generally requires a commitment to participate in therapy for 1 year. Variations in duration have been reported in adaptations for different settings and populations. Adaptations for outpatients include a 6-month DBT program for veterans with BPD (Koons et al., 2001), a 12-week program for suicidal adolescents (Rathus & Miller, 2002), 20-week programs for women with eating disorders (Safer et al., 2001; Telch et al., 2001), and a 28-week program for depressed older adults (Lynch et al., 2003). Inpatient adaptations include a 3-month program for adult women with BPD (Bohus et al., 2004), an 18-month prison program for males with BPD traits (Evershed et al., 2003), and a 2-week program for self-harming adolescents (Katz, Cox, Gunasekara, & Miller, 2004).

Acceptance and commitment therapy has no set treatment length and can be adapted with great flexibility for many settings and populations. Individual outpatient therapy with adults is likely to include weekly sessions over a period of a few months. Many other formats and durations have been reported. Bach and Hayes (2002) described an ACT program for inpatients with psychosis consisting of 4 individual sessions occurring within approximately 12 days. Studies of ACT for stress reduction in the workplace (Flaxman & Bond, 2006) have used a “2+1” format in which groups participate in two 3-hour workshops 1 week apart, with a follow-up workshop 3 months later. Gifford et al. (2004) described an ACT program for smoking cessation with weekly group and individual sessions over 7 weeks, whereas Hayes, Bissett, et al. (2004) conducted single-day ACT workshops for the reduction of stigmatizing attitudes in drug abuse counselors.

Strategies and Interventions in Mindfulness-Based Stress Reduction

Each of the treatments addressed in this chapter has developed an array of practices and exercises designed to cultivate the skills of mindfulness and acceptance. The following sections provide a descriptive overview of the primary practices (for a more detailed account, see Baer & Krietemeyer, 2006).

Raisin Exercise

The raisin exercise is conducted during the first session, after group members have introduced themselves, and is the group’s first mindfulness meditation activity. The group leader gives everyone a few raisins and asks that they look at them, with interest and curiosity, as if they have never seen such things before. Then participants are guided through a slow process of observing all aspects of a single raisin, including its appearance and texture as well as the tastes, sensations, and movements of eating it. If thoughts or emotions arise, participants are asked to notice these nonjudgmentally and return attention to the raisin. This exercise provides an opportunity to engage mindfully in an activity often done without awareness. Many participants report that the experience of eating mindfully is very different from their typical experience of eating. Such comments illustrate that paying attention to activities that normally are done on automatic pilot can significantly change the nature of the experience. Increased awareness of experience can lead to increased freedom to make choices about what to do in a variety of situations.

Body Scan

Participants are asked to sit or lie down comfortably with their eyes closed. They are invited to focus their attention sequentially on numerous parts of the body, noticing the sensations that are present with openness and curiosity, but without trying to change them. If no sensations are present, they notice the absence of sensations. This exercise differs from traditional relaxation exercises in that participants are not instructed to relax their muscles, but rather to observe all sensations that are present. If they notice an ache or pain, they are asked to observe its qualities as carefully as possible. When their minds wander, which is described as inevitable, they are asked to notice this as best they can and gently to return attention to the body scan without self-criticism or blame. The body scan provides an opportunity to practice several important mindfulness skills, including deliberately directing attention in a particular way, noticing when attention has wandered off and returning it gently to the present moment, and being open, curious, accepting, and nonjudgmental about observed experience, regardless of its pleasantness.

Sitting Meditation

In sitting meditation, participants sit in a comfortable, alert, and relaxed posture with eyes closed or gazing downward. Attention is directed to the sensations and movements of breathing. When the mind wanders off, which may occur frequently, they gently return their attention to breathing. After several minutes, the focus of attention may be shifted to bodily sensations. Participants are instructed to notice these with acceptance, bringing an attitude of interest and curiosity even to unpleasant sensations. Urges to move the body to relieve discomfort are not initially acted on. Instead, participants are encouraged to observe the discomfort. If they decide to move, they are encouraged to do so with mindful awareness, noticing the intention to move, the act of moving, and the changed sensations that result. Sitting meditation also may include a period of listening mindfully to sounds in the environment. Next, the focus of attention may shift to thoughts. Participants are instructed to observe their thoughts as events that come and go in their field of awareness and to note thought content briefly without becoming absorbed in it. A similar approach is taken to emotions that may arise. Participants observe these, briefly note the type of emotion they are experiencing (anger, sadness, desire), and notice any thoughts or sensations associated with the emotion. In later sessions, sitting meditation may end with a period of choiceless awareness, in which participants notice anything that may enter their field of awareness (bodily sensations, thoughts, emotions, sounds, urges) as they naturally arise.

Hatha Yoga

Yoga postures cultivate mindful awareness of the body while it is moving, stretching, or holding a position. The postures are very gentle and are done slowly, with moment-to-moment awareness of the sensations in the body and of breathing. Participants are encouraged to observe their bodies carefully, to be aware of their limits, to avoid forcing themselves beyond their limits, and to avoid striving to make progress toward goals other than moment-to-moment awareness of the body. Thus, yoga is conceptualized as a form of meditation rather than physical exercise, although strength and flexibility may gradually increase. Participants sometimes report that during yoga practice they are better able to maintain a state of relaxed alertness than during the body scan and sitting meditation, which may induce boredom or sleepiness.

Walking Meditation

In walking meditation, attention is deliberately focused on the sensations in the body while walking. Attention is directed to the movements, shifts of weight and balance, and sensations in the feet and legs associated with walking. As in other meditation exercises, participants are encouraged to notice when their minds wander off and gently to bring their attention back to the sensations of walking. Although walking meditation often is practiced very slowly, it can be done at a moderate or fast pace. Participants typically practice by walking back and forth across a room to emphasize the absence of a goal to reach a destination. The goal is simply to be aware of walking as it happens.

Mindfulness in Daily Life

Participants are encouraged to apply mindful awareness to routine activities, such as washing the dishes, cleaning the house, eating, or driving. Cultivation of mindful awareness of each moment is believed to lead to increased self-awareness and ability to make adaptive decisions about handling difficult and problematic situations as they arise, as well as increased enjoyment of pleasant moments. Mindfulness of breathing in daily life also is encouraged. It complements the formal meditative awareness cultivated in sitting meditation by promoting generalization of self-awareness to the constantly fluctuating states experienced in daily life. Turning attention to the breath at any moment of the day is intended to increase self-awareness and insight and to reduce habitual, automatic, and maladaptive behaviors.

All-Day Meditation Session

During an all-day meditation session, which typically occurs during Week 6, participants engage in sitting and walking meditations, body scans, and yoga. Most of the day is spent in silence, except for instructions provided by the group leaders. Participants are encouraged not to speak to each other or to make eye contact. Although some participants may find the day enjoyable and relaxing, these are not the goals for the session. The goal is to be present with and accepting of whatever comes up during the day. Some participants may experience physical discomfort or pain from extended sitting meditation, whereas others may feel strong emotions that they usually attempt to avoid. Some may feel bored, anxious, or guilty about not accomplishing their usual tasks. The extended period of silence encourages intensive self-awareness and provides the opportunity to practice sustained nonjudgmental observation of experience, without engaging in habitual avoidance strategies such as doing tasks, talking to others, reading, or watching television. This experience can be stressful for some participants and enjoyable for others. Many report a mix of pleasant and unpleasant experiences during the day. Participants are encouraged to let go of expectations about how the day should feel and to remain mindfully aware of everything that unfolds. At the end of the day, a discussion of experiences is held.

Incorporation of Poetry

As the nature of mindfulness can be difficult to convey in ordinary language, many instructors include the reading of poetry in their weekly sessions. Poems by many different authors can be used to illustrate important elements of mindfulness. For example, “The Guest House,” by Rumi, a thirteenth-century Sufi poet, uses simple but expressive language to describe a welcoming stance toward all internal experience. Poems or readings by Rainer Maria Rilke, Mary Oliver, David Whyte, and others may be used to illustrate other important themes, such as awareness of moment-to-moment experience, recognition of internal wisdom, or experiencing life’s difficulties in a wider perspective.

Strategies and Interventions in Mindfulness-Based Cognitive Therapy

Mindfulness-based cognitive therapy incorporates all of the practices just described for MBSR, as well as several others that are summarized briefly here.

Three-Minute Breathing Space

This exercise encourages generalization to daily life of mindfulness skills learned in formal meditation practices. The breathing space allows participants to step out of automatic pilot at any time and reestablish awareness of the present moment. It consists of three steps, each practiced for approximately 1 minute. The first step is to focus awareness on the range of internal experiences currently happening. The participant notices any bodily sensations, thoughts, or emotional states that are present with a stance of nonjudgmental acceptance. The second step is to focus full attention on the movements and sensations of breathing, noticing each in-breath and out-breath as it occurs. The third step is to expand awareness to the body as a whole, including posture and facial expression, and to notice the sensations that are present. Although the breathing space may feel like a moment to relax or escape from a stressful situation, its purpose is to help participants recognize the difference between automatic reacting and skillful responding. Stepping out of automatic pilot facilitates bringing a wider perspective to any situation and choosing more skillfully how to proceed. In some problematic situations, the skillful response is to accept the inevitable unpleasantness, whereas at other times a skillful response might include taking action to change a situation. The breathing space encourages choosing with awareness, rather than reacting with automatic behavior patterns that may be maladaptive.

Bringing Difficulties to Mind in Sitting Meditation

Midway through the MBCT program, the instructions for sitting meditation are extended to include a period of deliberately calling to mind a difficult or troubling issue and noticing where in the body the associated sensations arise. Any tendency to push away or resist these feelings is noted, and participants then practice allowing themselves to feel whatever is present with willingness, openness, and a gentle, kindly awareness. It is often helpful to allow awareness to include both the difficult sensations and the breath, so that participants imagine “breathing with” the difficulties. The purpose of this exercise is to practice counteracting the usual tendency to resist difficult or painful feelings. A likely result is the realization that difficulties can be faced and worked with and that avoidance is unnecessary and may be maladaptive. Participants also may realize that their typical attitude toward negative experience is hostility rather than kindness. Because deliberately approaching problems that are usually avoided can be difficult, support from experienced group leaders is essential.

Cognitive Therapy Exercises

Mindfulness-based cognitive therapy does not include traditional cognitive therapy exercises designed to change thoughts, such as identifying cognitive distortions, gathering evidence for and against thoughts, or developing more rational alternative thoughts. However, it integrates exercises based on elements of cognitive therapy that emphasize a decentered approach to internal experience. In the thoughts and feelings exercise, participants are asked to imagine smiling and waving at an acquaintance on the street who appears not to notice and doesn’t respond. Thoughts and feelings that arise are used to illustrate the ABC model in which a situation (A) leads to a thought or interpretation (B) that leads to a feeling or emotion (C). Different thoughts at point B can lead to different emotions at point C. Because thoughts can have a strong influence on moods, it is important to cultivate awareness of them. Practicing mindfulness skills will help to develop this awareness. Mindfulness-based cognitive therapy also includes a discussion of automatic thoughts related to depression, such as “I’m no good” and “my life is a mess.” This discussion is designed to help participants recognize thoughts typical of depression and to see them as symptoms of depression rather than as true statements about themselves. Group leaders emphasize that the believability of these thoughts is high during episodes of depression but low during periods of remission, thus demonstrating that thoughts are mental events rather than representations of truth or reality. A third exercise illustrates that thoughts can be influenced by ongoing moods. In a happy mood, a particular event might trigger positive thoughts, whereas in a sad mood, the same event could trigger negative thoughts. In both cases, the thoughts seem believable and realistic. This exercise illustrates that although the tendency to believe thoughts as they occur is strong, thoughts vary so much with changing circumstances that they cannot be regarded as facts. Practicing mindfulness of thoughts cultivates this understanding.

Pleasure and Mastery Activities and Relapse Prevention Plans

As taking action can be critical to the prevention of depressive episodes, MBCT includes a discussion of pleasure and mastery activities. Pleasure activities are fun and enjoyable and mastery activities evoke a sense of accomplishment. Participants are asked to generate lists of such activities that they could engage in at times when their mood is low. They are also encouraged make lists of their “relapse signatures,” or signs that a depressive episode might be developing. Common examples include increased irritability, decreased motivation, social withdrawal, and changes in eating and sleeping habits. Participants then generate action plans to use when they notice these signs. The first step of a relapse prevention plan is always to take a 3-minute breathing space to reconnect with the present moment. The second step is to engage in one of the mindfulness activities they have learned in the group or to review the mindfulness principles they have learned and remind themselves of the points that have been most helpful. The third step is to choose actions from their lists of pleasure and mastery activities and to engage in them, even if they don’t feel like doing so. Strategies for counteracting the resistance they may experience when their mood drops are incorporated.

Mindfulness and Acceptance Strategies in Dialectical Behavior Therapy

Standard outpatient DBT typically includes an initial commitment to participate in therapy for 1 year. Dialectical behavior therapy is a complex treatment with many components, including weekly individual therapy sessions and a weekly skills training group. The skills training group includes four modules: (1) core mindfulness, (2) interpersonal effectiveness, (3) emotion regulation, and (4) distress tolerance skills. Clients work with their individual therapists on applying skills learned in group to their daily lives. Telephone consultation with the individual therapist for crisis intervention or skills coaching is available as needed (within each therapist’s personal limits for timing and frequency of phone calls). Dialectical behavior therapy can include a wide range of change-oriented procedures—including exposure-based strategies, cognitive modification, and contingency management—in addition to skills training. When appropriate, therapists may choose to incorporate other empirically supported and manualized treatments for problems such as panic attacks or binge eating into the course of individual therapy. More detailed information about the behavior-change strategies included in DBT can be found in Linehan (1993a, 1993b). The following paragraphs describe the mindfulness-based elements of DBT, including the core mindfulness module and the integration of mindfulness into emotion regulation and distress tolerance.

The mindfulness module begins with a rationale for practicing mindfulness skills. An important goal is to develop the ability to control the focus of attention. Without this skill, several problems are likely, including the inability to stop thinking about the past, the future, or current difficulties, and the inability to concentrate on important tasks. More generally, the goal of mindfulness skills in DBT is to develop wisdom, or the ability to see what is true and to act wisely. A useful metaphor is that life is like trying to move across a large room full of bulky furniture. It is easier to do this when our eyes are open. Developing mindfulness is like opening our eyes so that we can see what is truly there.

States of Mind

The mindfulness module describes three states of mind. First, the reasonable mind is the rational, logical part of the mind that thinks intellectually, knows facts, makes plans, and solves problems. Without it, we could not make grocery lists, complete schoolwork, or repair household items, nor would we have computers, skyscrapers, or medical advances. Second, the emotion mind is the state in which emotions control your thoughts and behaviors. It is difficult to be reasonable or logical while in the emotion mind. Perceptions of reality may be distorted to fit the ongoing emotional state. Emotion mind can motivate heroic behavior such as risking your safety to help others and can facilitate creative or artistic achievements. It includes being passionate about things, which may lead to important accomplishments and contributions. An imbalance in these states of mind can cause difficulties. For example, emotion mind can impel behaviors we later regret, such as angry outbursts. However, it is also possible to be too rational, as in offering only logical solutions to a troubled loved one who needs empathic understanding.

Third, the wise mind is described as the integration of reasonable mind and emotion mind. It balances and integrates both, synthesizing a dialectic involving emotion and reason. A wise mind can include knowledge of facts, but also includes intuitive forms of knowing. It is sometimes described as a “centered” or “grounded” type of knowing that includes both head and heart. In DBT, wise mind is conceptualized as a universal human capability. Practicing the mindfulness skills described next is a method for balancing reasonable and emotion mind and accessing wise mind.

Mindfulness “What” Skills

The three what skills specify what one does when being mindful, including observing, describing, and participating. First, observing refers to noticing, sensing, or attending to the experience occurring in the present moment, without trying to change or escape it. Targets of observation can include internal experiences (e.g., thoughts, bodily sensations, emotional states, urges) and stimuli in the environment (e.g., sights, sounds, smells). Participants are encouraged to notice that observing an event is distinct from the event itself. That is, observing thinking can be distinguished from thinking. In one exercise, participants imagine that the mind is a conveyor belt that brings thoughts, feelings, and sensations into awareness. Each is observed as it appears. Group leaders emphasize that anything that enters awareness while practicing this exercise can be observed, including wandering of the mind and negative thoughts. Rather than interpreting these occurrences as failures to do the exercise, group members simply practice observing whatever occurs.

Second, describing refers to labeling observed experience with words. This exercise can be applied to all observed experience and is especially useful when applied to thoughts and feelings. Labeling thoughts as thoughts encourages recognition that they are not necessarily true or important and may reduce the tendency to believe them or act on them in automatic, maladaptive ways. The same principle applies to emotions and urges. For example, a group member may feel bored while practicing a mindfulness exercise and wish to stop. Covertly describing this experience in words (“I’m feeling bored and wish to stop”) can lead to the important realization that feelings and urges do not have to control behavior. That is, a person can choose to engage in specific behaviors in spite of his or her feelings or urges.

Third, participating refers to attending completely to the activity of the present moment, becoming wholly involved with it, and acting with spontaneity and without self-consciousness. It can be practiced in group sessions by engaging in a group activity such as singing a song or playing a brief game. Participants are encouraged to throw themselves into the activity as completely as possible. If they have thoughts (“This is silly”) or emotions (embarrassment), they are asked to notice these briefly and return their attention to the activity. Afterwards, the difference between participating fully in the activity and being distracted by thoughts or feelings can be discussed. Group members also can be encouraged to find activities in which they can practice participating outside of sessions (e.g., exercise, dancing, yoga, music, arts or crafts, cooking). An important goal of mindfulness practice is to develop a generalized pattern of participating with awareness in daily life. Participating without awareness, or acting mindlessly, is seen as a characteristic of impulsive and mood dependent behavior.

Mindfulness “How” Skills

DBT includes three how skills: (1) being nonjudgmental, (2) being one-mindful, and (3) behaving effectively. First, being nonjudgmental means taking a nonevaluative stance toward experience in which the individual refrains from judging experiences as good or bad. Helpful or harmful consequences can be acknowledged, as can feelings of attachment and aversion, but all experiences are accepted as they are, just as a blanket spread out on the grass is equally accepting of rain, sun, leaves, and insects that land on it. Being nonjudgmental does not mean replacing negative judgments with positive ones, nor does it imply approval of experience. It also does not require abandoning negative reactions or dislikes. For example, disliking raisins is not a judgment. Rather, an aversion to raisins can be mindfully observed and accepted without judgment. Being nonjudgmental can be practiced in group sessions during any group activity. Participants are encouraged to notice any judgmental thoughts (“this is silly”) and then to observe and describe the facts of the situation (“we are eating raisins; I am feeling aversion”). Group members are encouraged to do the same in their daily lives.

Second, to be one-mindful is to focus undivided attention on one thing at a time. One-mindfulness may be atypical of many people’s daily experiences, which often involve attempts to do two or more things at once. One-mindfulness can be practiced in group sessions with numerous activities. For example, participants can be encouraged to devote their full attention to listening to others during discussions. Food can be brought to sessions for practice of eating one-mindfully. Group members can also practice being one-mindful with numerous behaviors of daily life, such as washing dishes, bathing, petting the cat, and so on.

Third, behaving effectively refers to doing what works or using skillful means. It includes being practical, recognizing the realities of a situation, identifying your goals in the situation, and thinking of effective ways to achieve them, in spite of personal preferences or opinions about how the situation should be. It sometimes refers to being political or savvy and includes doing this well.

Mindfulness Skills in Emotion Regulation and Distress Tolerance

The emotion regulation and distress tolerance modules of skills training also include many elements of mindfulness. In emotion regulation, identifying and labeling emotions is an essential component. This requires the application of the mindfulness skills of observing and describing. Clients are instructed in methods for observing and describing many aspects of an emotional reaction, including the event that prompted it, their interpretations of the event, their subjective experience of the emotion (including bodily sensations), action urges they felt, behaviors they engaged in, and the aftereffects of the emotion. Mindfulness of current emotions also is taught as a method for reducing the suffering associated with negative emotions. It includes experiencing emotions as they occur, without judging them or trying to suppress, change, or block them. The inevitability of negative emotions as a normal part of life is emphasized.

The distress tolerance module explains that pain is an unavoidable part of life and emphasizes the importance of learning to bear pain skillfully. Several of the skills taught are direct extensions of the core mindfulness skills. These emphasize acceptance of reality, even when it is unpleasant and unwanted, and willingness to experience life as it is in each moment. The concept of radical acceptance is introduced, in which painful realities are fully acknowledged and fruitless efforts to change the unchangeable are abandoned. Distress tolerance skills are intended for situations in which painful realities or feelings cannot be changed, at least for the moment. They allow survival of such situations without engaging in maladaptive behaviors that worsen problems or create new ones. Skills for accepting reality as it is include several exercises involving awareness of breathing, such as counting breaths or silently labeling in-breaths and out-breaths. Another approach to accepting reality involves engaging in simple behaviors, such as making tea or washing dishes, slowly and with full awareness, noting every movement. These exercises are adapted from mindfulness meditations described by Hanh (1976).

Mindfulness and Acceptance Strategies in Acceptance and Commitment Therapy

Acceptance and commitment therapy is also a complex treatment package with many components. It incorporates both behavior change strategies and mindfulness and acceptance strategies. Change strategies tailored to the individual needs of the client might include psychoeducation, problem-solving, skills-training, or exposure-based procedures. These strategies are not covered here. They are largely consistent with the cognitive-behavioral methods described elsewhere in this volume. Mindfulness and acceptance exercises in ACT are numerous and varied. Some are meditative, whereas others are not. More detailed information and many additional examples can be found in Hayes et al. (1999). One commonly used practice is the cubbyholing exercise. Participants briefly review a list of categories in which inner experiences might fall, including thought, image, memory, urge, emotion, sensation, and so on. Next, they close their eyes for several minutes and observe the experiences that arise, noting with a single word which category each represents. This exercise encourages contact with experiences occurring in the present moment and facilitates acceptance and defusion, as well as self-as-context. In an exercise known as leaves on the stream, participants close their eyes and picture themselves sitting beside a stream with leaves floating on its surface. As thoughts and other experiences arise, they imagine placing each one on a leaf and watching it float downstream. Another exercise teaches participants to say, “I’m having the thought that…” whenever a particular thought arises. Rather than saying, “I’m an idiot,” participants say, “I’m having the thought that I’m an idiot.” This exercise facilitates recognition that the self is separate from the thoughts and feelings that pass through awareness and reduces fusion with these experiences. This greatly reduces the potentially threatening quality of many internal experiences because the individual recognizes that he or she is capable of having a wide range of thoughts and feelings without being harmed by them and that these experiences tend to be transient and insubstantial. The observer exercise promotes this awareness by asking the client to close his or her eyes, observe internal experiences (memories, sensations, emotions, thoughts), and then to notice the aspect of him- or herself that does the observing (the observer self). Many clients can readily see that the observer self has been present throughout the client’s entire life, whereas emotions, cognitions, bodily sensations, and other internal experiences have continually come and gone.

Use of Metaphors

All of these treatment approaches make frequent use of metaphors. In MBSR and MBCT, participants may be encouraged to see themselves as explorers of new territory who take a great interest in everything they find, regardless of how pleasant it is. When practicing mindfulness of thoughts, it may be helpful to imagine that thoughts are actors who step onto a stage for a while and then exit. Thoughts and feelings can also be seen as images in a film that come and go, whereas the observer remains firmly planted in his or her seat. Some participants prefer to think of their minds as the sky, and inner experiences as clouds that pass by. Some clouds are small and pleasing, whereas others are large and threatening. In all cases, however, clouds are transient while the sky remains. In the mountain meditation, thoughts and feelings are seen as constantly changing weather around the mountain, whereas the mountain remains strong, grounded, and stable. Similarly, in the lake meditation, the surface may be agitated by wind and rain, whereas below the surface all is calm. A cascading waterfall might represent a torrent of negative thoughts, feelings, and sensations, while the participant is encouraged to stand behind it, watching them pass by without being dragged down.

Dialectical behavior therapy and ACT also offer numerous metaphors. Learning to manage strong emotions is like learning to surf. A person must skillfully guide the surfboard even though the waves cannot be controlled. Learning acceptance is like learning to love the dandelions that appear in the lawn each year in spite of efforts to get rid of them. Willingness is like playing the cards you are dealt. In ACT, a useful metaphor for understanding defusion is known as passengers on the bus. Negative thoughts and feelings are seen as unpleasant passengers who make threats, demands, and criticisms, whereas the driver maintains control of the bus’s direction regardless of what the passengers say. In the swamp metaphor, which illustrates willingness and commitment, the client imagines that he or she is on a journey to a beautiful mountain and discovers that the only path goes through a smelly, muddy swamp. Willingness to enter the swamp in the service of reaching the mountain represents acceptance of unpleasant experience in the service of committed action.

Typical Sequences in Intervention

Mindfulness-based stress reduction and MBCT are structured groups, usually including 8 sessions, with a clear though flexible agenda for each session. Mindfulness exercises are introduced in a logical sequence. For example, the first exercise is an eating meditation (raisin exercise) that may be helpful in clarifying that mindfulness applies to everyday life and in dispelling mistaken ideas that meditation is mystical or otherworldly. Similarly, the body scan’s focus on physical sensations may be somewhat easier for novice meditators than the later practices in which attention is focused on thoughts and emotions. Sitting meditation is also sequential in its duration, beginning with shorter periods of sitting (e.g., 10 minutes) and working up to 45 minutes. In MBCT, the sequence of skills taught culminates in the development of relapse prevention action plans in which patients integrate the skills they have learned into clear and specific strategies to use when depressive thoughts and feelings arise.

In DBT, skills group sessions are well structured with a clear agenda for each session. Within each module, skills are introduced in a logical sequence with prerequisite skills and concepts preceding more complex and difficult ones. In individual therapy sessions, the sequence in which issues are addressed is determined primarily by the hierarchy of targets, which dictates that self-harm behavior must be addressed first, followed by therapy-interfering behaviors if these have occurred. If they have not, the sequence of intervention is determined jointly by therapist and client based on the client’s needs and the therapist’s judgment about the sequence likely to be the most helpful.

Acceptance and commitment therapy is probably the most flexible of these interventions, prescribing neither a number of sessions nor a specific sequence in which goals are addressed. However, specific applications of ACT have developed sequences that are workable for their population and setting. For example, ACT for stress reduction in the workplace (Flaxman & Bond, 2006) begins with mindfulness exercises designed to cultivate an understanding of the costs of experiential avoidance and skills for observing thoughts and feelings nonjudgmentally. Values clarification exercises come later. These authors note that values clarification proceeds more smoothly if participants have already developed skills for reducing fusion with thoughts and feelings. However, Dahl and Lundgren (2006), in an ACT program for chronic pain, find it effective to introduce values clarification early in the treatment. Patients are encouraged to see how living in accordance with their values (e.g., meaningful work, satisfying relationships, or community involvement) has been put on hold, sometimes for years, while they struggle fruitlessly with unsuccessful efforts at pain management. Although emotionally challenging, this realization can motivate behavior changes leading to a more satisfying life, even if pain persists.

Typical Clinical Decision Process

In manualized treatment programs, a challenging aspect of clinical decision making is finding a balance between following the structure of the program (which may include an agenda for each session) and flexibly addressing the needs of a particular individual or group. In DBT, some of this issue is captured by a dialectic known as unwavering centeredness versus compassionate flexibility, which describes essential therapists’ skills. Unwavering centeredness includes faith in the treatment program and the client’s ability to benefit from it in the long run. It therefore includes remaining true to DBT principles and procedures, even when the client does not like them and may be resisting them strenuously and experiencing considerable short-term emotional pain. Compassionate flexibility is an apparently contrasting ability to revise your position or modify a procedure or goal; that is, to accommodate the client’s preferences, when doing so is compassionate and not harmful. The ability to synthesize this dialectic requires characteristics of mindfulness in the therapist, including clear observation of the client’s and therapist’s emotions and of the situational context without maladaptive reactivity.

Mindfulness-based stress reduction and MBCT sessions also require flexibility in the context of meeting an agenda. Group leaders must be sensitive to individuals’ responses to the practices and material by taking time for clarification, allowing active discussion to continue when it seems beneficial, shortening or lengthening an exercise, or substituting one exercise for another to meet the group’s needs of the moment. A strategy recommended in MBCT is to lead a 3-minute breathing space during a session if the discussion has become unfocused, has gotten stuck in depressive patterns of thinking, or has elicited strong feelings. The purpose of such a breathing space is not to get rid of the strong feelings but to see what happens if attention is deliberately returned to the present moment and feelings are observed with nonjudgmental awareness. Different ways of responding to an emotional state may begin to suggest themselves. In general, a mindful approach to the process of leading the group allows changing the plan for the session to respond skillfully to the group’s ongoing experience.

As noted earlier, ACT is a very flexible approach. Some applications have a clear agenda for each session, whereas others do not. In either case, clinical decision making is guided by the core principles of the approach. The primary basis for clinical decisions is whether the client is working toward the goals and values that have been identified. If this is not occurring, then factors interfering are identified. The ACT therapist fits the interventions used in each session to the needs of the client. If the client appears to be fused with maladaptive thoughts, a defusion exercise or metaphor that appears suitable to the situation is introduced or reviewed.

Homework

Homework is seen as essential to successful outcomes and is an integral part of the treatment for all of these approaches. In MBSR and MBCT, much of the homework involves lengthy meditation practices (up to 45 minutes) to be completed 6 days per week. Audio recordings to guide the primary practices are provided by the group leaders although participants are encouraged to practice without recordings after the first few weeks. Additional assignments include mindfully engaging in tasks of daily life (eating, washing), completing monitoring forms or worksheets (pleasant and unpleasant events, records of home practice), and engaging in 3-minute breathing spaces (MBCT). Every session includes a discussion of clients’ experiences in completing their homework during the preceding week. Instructors emphasize that benefits are likely to be much greater if homework is completed, that discipline is required to practice daily, and that making the time available to do so may be difficult. Regular practice is described as a challenge and an adventure rather than a chore. It can be helpful to recommend that participants suspend judgment about the value of meditation for the duration of the course and commit to doing the homework with an attitude of exploration and open-mindedness, regardless of whether they enjoy it or perceive immediate benefits. When participants report that they have not done their homework, instructors express interest in and curiosity about their experiences surrounding the homework. Acceptance of all experiences is modeled and encouraged, including boredom, emotional reactions, doubts about how meditation may help, and any other factors that may have interfered with homework practice. Instructors acknowledge the difficulty of engaging in regular practice and encourage participants to bring their own curiosity to bear on the situation so that they may find ways to engage in the homework more regularly. They are encouraged to acknowledge feelings of boredom, aversion, or doubt, while continuing with the homework practices. A punitive or critical attitude is avoided.

In DBT, clients are likely to have weekly homework assignments for both individual therapy and group skills training. Mindfulness skills are frequently assigned for homework practice. Dialectical behavior therapy uses a diary card on which practice of skills can be recorded each day. Clients are expected to bring their diary card to each session for review. If a client reports that she has done no homework, this problem is analyzed carefully. Factors interfering with motivation to complete homework are examined, and behavioral strategies to improve homework completion are explored, providing a good opportunity for therapists to teach principles of behavior management. Failure to complete homework is seen as a problem to be solved constructively, not as an opportunity for critical judgments (by therapist or client) about the client’s willpower or character. In the skills group setting, clients often do not wish to discuss their noncompletion of homework and may ask the group leader to move on to the next person. The DBT therapist typically does not comply with this request, instead gently insisting on helping the client analyze factors related to her noncompletion of homework. This provides an opportunity for the client to practice something that is constructive but feels unpleasant. The discussion also may be beneficial to other group members who have trouble with behavior management or problem-solving skills. The DBT therapist also avoids a punitive or critical attitude.

Included in ACT are a wide range of activities, exercises, and monitoring forms that are assigned as homework. These are described as opportunities to practice skills that help clients change their lives in the ways that most matter to them. Therapists emphasize that these exercises will bring them closer to their most important goals. For this reason, Eifert and Forsyth (2005) call these assignments experiential life enhancement exercises, noting that the term homework implies something imposed by someone else rather than freely chosen. Clients are told that ACT is very experiential and that their results will depend on how much they practice new activities and exercises. Unlike taking medications, which may reduce symptoms with very little effort, ACT is about building a life that feels rich, meaningful, and satisfying. This requires hard work and feels difficult and stressful at times. The purpose of home practice exercises is explained clearly and clients are encouraged to give them a fair chance in the service of improving their lives. Whether to do so is the client’s choice. When clients report not having done a home practice exercise, factors that interfered are examined. Usually these are internal experiences such as anxiety, doubts, or other negative thoughts. Strategies described previously then are used to work with these, such as defusion, mindfulness, and values clarification exercises. The therapist also considers whether the exercise was truly linked to the client’s goals and values, and whether the link was apparent to the client. A compassionate and validating stance toward noncompliance with home practice is adopted.

Adaptation to Specific Presenting Problems

Several adaptations of these interventions to new problems and populations have appeared in the literature (Baer, 2006). A critical issue in the development of new adaptations is the articulation of a theoretical rationale for how mindfulness and acceptance skills are expected to be helpful for each new problem to which they are applied. Teasdale, Segal, and Williams (2003) argue that mindfulness training should not be applied indiscriminately as if it were a generic, all-purpose intervention. Rather, it should be based on a conceptual formulation of the nature of the problems to be treated. They make several points in favor of this argument. First, empirical findings show that mindfulness training is not helpful for everyone. For example, clinical trials with MBCT show that it has no effect on relapse rates for participants with fewer than three previous depressive episodes (Ma & Teasdale, 2004; Teasdale et al., 2003). This finding suggests that there may be subtypes of depression, or types of previously depressed patients, who might not respond to MBCT and who should be provided an alternative treatment. Teasdale et al. (2003) also note that successful applications of mindfulness-based treatments include sharing with the patient an explicit analysis of how mindfulness will help. In the absence of such a rationale, the practice of mindfulness skills may not be effective. They also point out that several processes may contribute to the efficacy of mindfulness training and that these may be differentially important, depending on the disorder to be treated. For example, exposure to bodily sensations to reduce fear and experiential avoidance may be critical in patients with anxiety disorders, whereas decentering from ruminative thought processes may be more important in managing depressed moods.

In spite of these cautions, Teasdale and colleagues acknowledge that mindfulness-based treatments may be broadly useful because they target processes that are common to many disorders. Experiential avoidance appears to be one such process. The evidence is growing that it is related to many problems and that ACT, in particular, exerts its beneficial effects, at least in part, by reducing this form of avoidance. Mediational analyses examining this question with other mindfulness and acceptance-based treatments have not yet appeared in the literature, but they are critically important to our understanding of how these treatments work and to what specific problems they could fruitfully be applied.

View of Medication

Mindfulness-based stress reduction is described as a complement to more traditional medical approaches, not as a substitute for them. Decisions about medication are not directly within the purview of the MBSR instructor in most cases. Issues about medication, such as unpleasant side effects or feelings about having to take them, may arise for some participants during meditation practices and may come up during discussions. Sensations, thoughts, and feelings related to medication are not inherently different from other such experiences and provide an opportunity to practice mindful awareness of whatever has arisen. Patients with specific questions about medications are referred to their prescribers.

Mindfulness-based cognitive therapy is designed to prevent depressive relapse in individuals who have recovered using medication but who are no longer taking it. It is described to participants as a method for preventing new episodes without continued use of medication.

Medication issues are more complex in DBT because many clients are taking one or more psychotropic drugs and because misuse of them is not uncommon. In standard outpatient DBT, pharmacotherapy is viewed as an ancillary treatment. The primary individual therapist generally does not prescribe, supervise, or manage these medications, but consults with the client on how to interact effectively with his or her prescriber and how to make optimum use of medication. Relevant skills include communicating effectively with medical personnel about the client’s needs and preferences regarding medication, obtaining information about risks, benefits, and side effects, and complying with instructions about how to use medication effectively, among others. Abuse of prescribed medication is a high priority target for treatment, especially if it is life threatening or self-harming, or interferes with the ability to benefit from therapy. More detailed information can be found in Linehan (1993a).

In ACT, the general view of medication is that it may be helpful for symptom reduction, but it may not contribute directly to building a meaningful and satisfying life. Symptom reduction may not last once medication has been discontinued, and some clients are unwilling to take medications over the long term. Others are willing, but may find that symptom reduction alone does not address their dissatisfactions with life. Therefore, ACT suggests that identifying deeply held goals and values and building a life consistent with them, at the same time learning to accept the inevitable occurrence of unpleasant thoughts and feelings is more effective in the long run because it provides lasting and meaningful benefits that medication probably would not provide. However, ACT therapists do not insist that clients discontinue medication use.

Curative Factors

Curative factors for mindfulness- and acceptance-based approaches have not been conclusively established. However, researchers have proposed several processes or mechanisms that may account for the benefits of these treatments. Some authors have suggested that mindfulness practice functions as an exposure procedure in which sustained nonreactive observation of unwanted internal experiences leads to reduced fear and avoidance of them in a process of desensitization (Kabat-Zinn, 1982; Linehan, 1993a). Participants learn that these experiences are not harmful and can be allowed to come and go without efforts to control them. As a result, maladaptive behaviors designed to avoid or escape them are reduced. Other authors emphasize the importance of decentering or defusion in which thoughts and feelings are recognized as transient mental events that are not necessarily true, important, or harmful, that do not reflect on the worthiness of the person experiencing them, and that do not necessitate specific behaviors. Segal et al. (2002) note that decentering leads to decreased rumination because individuals observe their thoughts coming and going, rather than becoming absorbed in their content. They also point out that a decentered perspective can be applied to sensations and emotional states, as well as thoughts. In more general terms, mindfulness practice has also been described as a method for improving self-management. By cultivating self-observation skills, mindfulness encourages better recognition of internal states and improved ability to apply a wide range of appropriate coping strategies before these states escalate into difficult or intractable conditions.

This is not an exhaustive discussion of possible curative factors. A rich variety of processes may be at work in individuals who practice mindfulness, and these processes can probably be described in several language systems, depending on the theoretical orientation of the author. Future conceptual and empirical work may help to clarify the nature of the curative factors. However, regardless of how its effects are explained, most experts would probably agree that the central curative factor in these treatments is practice. To benefit from one of these treatments, it is essential to practice the skills. Thus, a crucial task for therapists or group leaders is to find ways to encourage practice, both in sessions and between sessions.

The participant’s relationships with the therapist or instructor and with other participants in group treatments may also be curative factors. In most cases, a strong therapeutic relationship is probably necessary but not sufficient for beneficial outcomes. A strong relationship with an accepting and compassionate therapist or group leader provides an environment in which participants feel safe in disclosing their experiences and in allowing painful ones to be present. It is likely to enhance confidence in the program and encourage participants to practice skills, as well as to express doubts and confusions when they arise. Social support from other group members may serve similar functions. For all of these treatments, it is difficult to imagine success in teaching mindfulness and acceptance skills without strong relationships. However, an exception can be seen in a study of patients with psoriasis, a chronic skin condition for which the medical treatment involves standing alone and naked in a light box on multiple occasions, over the course of several weeks, to receive ultraviolet radiation. Kabat-Zinn et al. (1998) found significant decreases in time required for skin to clear in patients who listened to mindfulness meditation tapes while alone in the light box, but who did not attend group or individual sessions with a mindfulness instructor.

Special Issues

The importance of a personal mindfulness practice for therapists is an issue unique to this family of interventions. In MBSR and MBCT, the necessity of a personal meditation practice is clear and explicit. The Center for Mindfulness, where MBSR was developed, has published qualifications for MBSR providers that include a daily meditation practice for at least 3 years and at least two silent meditation retreats of 5 to 10 days duration in the Theravadan or Zen traditions, along with experience in yoga or other body-centered awareness practices, among other requirements. Similarly, the authors of MBCT state, “Our own conclusion, after seeing for ourselves the difference between using MBCT with and without personal experience of meditation practice, is that it is unwise for instructors to embark on teaching this material before they have extensive personal experience with its use” (Segal et al., 2002, p. 84). Dialectical behavior therapy does not stipulate that therapists must have an ongoing formal mindfulness practice. However, therapists must be thoroughly familiar with all the skills in the protocol, which requires personal experience in practicing them. It is common for DBT therapists to practice mindfulness together during consultation and supervision group meetings. Acceptance and commitment therapy does not stipulate that therapists must practice meditation per se. However, the successful ACT therapist recognizes that experiential avoidance and cognitive fusion pose threats to their own ability to engage in behavior consistent with their values. Therapists who have little experience with willingness to approach unpleasant experiences for the sake of valued outcomes are less likely to impart such willingness to clients.

Another issue that may be unique to these approaches is the counterintuitive nature of the primary recommendations. In Western society, the idea that unpleasant thoughts and feelings should be avoided or eliminated, and that this is necessary before a valued life can be pursued, is widespread. The notion that these experiences can be accepted or even embraced, and that a good life can include them, may strike clients as strange. The daily practice of meditation or other mindfulness exercises also may seem strange. Meditation looks suspiciously like doing nothing, at least to the casual observer, and Western society seems to value productivity, busyness, and constant doing (Kabat-Zinn, 2005). In addition, mindfulness is practiced with a seemingly paradoxical attitude of nonstriving in which participants are encouraged to observe and accept current conditions without trying to attain goals. As most patients have sought help because they wish to change problematic conditions, they may be very skeptical of the potential utility of such practices. They also may bring an attitude of striving to the practices themselves. For example, they may try to get more relaxed during the body scan or more flexible during yoga, or to have less mind wandering during sitting meditation, rather than observing current conditions nonjudgmentally. It can be helpful for both clients and therapists to cultivate willingness to experiment with new ways of conducting themselves and relating to experiences, with open-mindedness and curiosity.

Culture and Gender

Unfortunately, very little has been written on the effects of mindfulness-based approaches in diverse populations. Roth and Calle-Mesa (2006) describe a successful MBSR program with Spanish-speaking, low-income, inner-city medical patients. Adaptations included reduced use of written handouts for participants with low levels of education, provision of child care and transportation, and deliberate omission of the all-day session due to child-care difficulties. The program was led by a Spanish-speaking instructor, and Spanish-language audio recordings of meditation practices were provided. Many patients with traumatic histories were uncomfortable with lying on the floor or unable to sustain focus on the body for extended periods. Thus, the body scan was conducted in shorter intervals with many participants sitting in chairs. Although the authors were concerned about reactions to Eastern meditation practices in a largely Catholic population, their only adaptation for this concern was to substitute (in Spanish translation) the term gentle stretching for the word yoga. Very few patients reported conflicts with religious beliefs. In fact, many commented that mindfulness and meditation enhanced their religious practices.

EMPIRICAL SUPPORT

Support for Mindfulness-Based Stress Reduction

The empirical support for MBSR has been summarized in several recent review papers (Baer, 2003; Grossman, Neimann, Schmidt, & Walach, 2004; Salmon et al., 2004). Findings suggest that MBSR is potentially useful for a wide range of problems and disorders. Populations with the most encouraging data include chronic pain (Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985), stress in general medical and student samples (Astin, 1997; Reibel, Greeson, Brainard, & Rosenzweig, 2001; Williams, Kolar, Reger, & Pearson, 2001), and stress in cancer patients (Speca, Carlson, Goodey, & Angen, 2000). More randomized trials and analyses of the mechanisms or processes by which beneficial outcomes occur are needed.

Support for Mindfulness-Based Cognitive Therapy

Strong empirical support for the efficacy of MBCT in preventing recurrence of major depression is provided by two recent randomized trials (Ma & Teasdale, 2004; Teasdale et al., 2000). Both studied patients who had experienced two or more major depressive episodes and were in remission. All participants had discontinued medication at least 3 months before the studies began. They were randomly assigned either to treatment as usual combined with participation in MBCT or to treatment as usual alone and were followed for 1 year. In both studies, MBCT had no effect on relapse rates for patients with only two previous episodes. However, for patients with three or more previous episodes, MBCT reduced relapse rates by about half (36% to 37% for MBCT participants and 66% to 78% for those receiving treatment as usual).

Support for Dialectical Behavior Therapy

Outcome studies comparing DBT to treatment as usual suggest that DBT results in greater reductions in self-harm behavior and hospitalization, better retention in treatment, and greater improvements in symptoms such as anger, depression, hopelessness, dissociation, and impulsive behaviors (Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Verheul et al., 2003). Findings also show that many participants continue to score in the clinical range on some of these measures after 1 year, suggesting that continued treatment might be beneficial. Other problems and populations for which adaptations of DBT have shown better results than various comparison conditions include BPD with substance dependence (Linehan et al., 1999, 2002), binge eating and bulimia (Safer et al., 2001; Telch et al., 2001), elderly depressed patients (Lynch et al., 2003), and suicidal adolescents (Rathus & Miller, 2002).

Support for Acceptance and Commitment Therapy

A recent review of the ACT literature is provided by Hayes et al. (2006). Findings show superior outcomes for ACT over a variety of control conditions for a wide range of problems, including work stress, depression, smoking, polysubstance abuse, chronic pain, rehospitalization for psychosis, self-harm in BPD, and stigma and burnout in mental health professionals. The ACT literature includes several mediational analyses suggesting that decreases in experiential avoidance are probably responsible for the positive outcomes.

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