Mindfulness as a way of addressing the deficits in clinical psychology training programs: A review
Pooja Hemanth, Paul Fisher
1 Department of Psychology, James Cook University Singapore, Singapore
2 Department of Psychological Sciences, Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich, United Kingdom
Address for correspondence
Postal: 149 Sims Drive, Singapore 387380
E-mail: [email protected]
Word count (exc. figures/tables): 7276
Running Head: MINDFULNESS IN CLINICAL PSYCHOLOGY TRAINING
MINDFULNESS IN CLINICAL PSYCHOLOGY TRAINING
Mindfulness as a Way of Addressing the Deficits in Clinical Psychology Training Programs: A Review
Keywords: mindfulness, clinical psychology training, trainees, self-care, professional development
Abstract
Research suggests that there is a lack of focus on developing trainees’ intrapersonal skills
or adequately fostering self-care. Mindfulness training may help address the gaps in
training programs. Quantitative and qualitative studies involving mindfulness training for
postgraduate trainees were reviewed. There is a need to explore different designs of
mindfulness training groups to ascertain what would be feasible and effective, given the
trainees’ existing time constraints. Furthermore, the current understanding is limited due to
the difficulties defining and operationalizing mindfulness. Qualitative research would help
to explore what mindfulness training means to trainees and how it impacts on their lives.
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Introduction
Clinical psychology training programs are required to foster trainees’ professional
development in psychotherapy knowledge and skills to help them work effectively with
clients (Bruce, Manber, Shapiro, & Constantino, 2010) and to create a culture of self-care
as trainees are vulnerable to stress and stress-related problems during training (Pakenham
& Stafford-Brown, 2012). Research has suggested a lack of a structured approach within
programs to develop trainees’ intrapersonal skills and foster trainees’ self-care, resulting in
a lack of adequately meeting these needs (Lambert & Simon, 2008; Myers et al., 2012).
This review explores these gaps between research and training in the professional
development of intrapersonal and self-care skills, and discusses the use of mindfulness to
bridge these gaps. Due to the small amount of research that is specific to clinical
psychology training and the application of mindfulness to this population, the reviewed
literature includes that of trainees in other mental health fields which involve
psychotherapy training, such as counselling psychology, counselling, and social work.
Literature Search Strategy
The PsycARTICLES database was searched using the ProQuest interface on 31
December 2011 for the period 1990 to 2012. The Web of Science database was searched
on 20 October 2012 for the period 1990 to 2012. The search terms were: clinical, clinical
psychology, psychologist, counselling, counsellor, psychotherapy, psychotherapist,
therapist, health care, mindfulness AND training, skills, stress, self-care. Other relevant
articles were also found individually by looking through reference lists of the relevant
journal articles. The articles provided information about the current gaps in the
professional development and self-care among trainees in postgraduate psychotherapy
training programs, and the use of mindfulness to fill this gap. In particular, given this
review’s focus on the use of mindfulness practices for postgraduate psychotherapy
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trainees, the findings from a number of quantitative and qualitative articles that researched
the use of mindfulness with this population were summarized and can be found in Tables 1
and 2.
Professional Development in Clinical Psychology Programs
Research suggests that clinical psychology training involves the professional
development of psychotherapy knowledge and skills (Lambert & Simon, 2008).
Psychotherapy knowledge, which refers to knowledge regarding theories, models,
concepts, and techniques of therapy (Kramer, Meleo-Meyer & Turner, 2008), is commonly
learnt through didactic teaching methods, manual-guided techniques, and application of
theory to supervised clinical work (Vakoch & Strupp, 2000). Clinical psychology training
also involves learning skills such as active listening, questioning, empathy, re-framing, and
confrontation (Ivey, Ivey, & Zalaquett, 2009). Some of these skills are more complex and
dynamic in nature; in addition to interpersonal components, they also have intrapersonal
dimensions pertaining to internal qualities and attitudes of the trainees (Gockel, 2010).
Research suggests that it is important for therapists to use their intrapersonal skills to create
therapeutic presence, which Gellar and Greenberg (2002) described as having three
components: an openness to the client’s experiences, openness to one’s own experiences
when working with the client, and the ability to interact with the client based on this
experience. Some examples of important intrapersonal skills that make up therapeutic
presence are in-session self-awareness, an internal attitude of empathy, affect tolerance,
and managing focused attention (Williams & Fauth, 2005; Fulton, 2005; Greason &
Cashwell, 2009). Thorne (1992) reported that therapeutic presence helps to cultivate
Rogers’ (1957) six core conditions, which are agreed upon by theorists from almost all
orientations to be important to strengthen the therapeutic alliance and promote positive
changes for clients during therapy (Norcross, 2002).
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Despite the importance of intrapersonal skills to the therapy process, research
suggests that there is a lack of focus on inculcating the intrapersonal psychotherapy skills
in trainees (Greason & Cashwell, 2009; Fulton, 2005; Lambert & Simon, 2008). The
following reasons have been proposed for this shortcoming in training programs: over-
emphasis on teaching therapy models (Fulton, 2005), assumptions about the fact that
developing the intrapersonal skills would naturally follow the learning of discernible
interpersonal skills (Greason & Cashwell, 2009), and the presence of the widely-held belief
that intrapersonal attitudes, such as warmth and non-judgment, are difficult to teach
(Lambert & Simon, 2008). As a result, training programs have either failed to pay attention
to developing these intrapersonal skills or have depended on other means, such as the
therapist’s personal psychotherapy and sensitivity training, for the development of these
skills (Lambert & Simon, 2008).
Self-Care in Clinical Psychology Training Programs
Clinical psychology training has been associated with significant challenges to
trainees’ subjective well-being (Pakenham & Stafford-Brown, 2012). Trainee
psychologists report many stressors, including personal stressors (e.g. finances), academic
and evaluative aspects of training (e.g. being evaluated by supervisors), work-practice
stressors (e.g. time constraints, caseload), and challenges in clinical work (e.g. ambiguity,
ethical dilemmas; Nelson, Dell’Oliver, Koch, & Buckler, 2001; Pakenham & Stafford-
Brown, 2012). Existing studies show significant levels of stress among clinical psychology
trainees (Cushway, 1992; Myers et al., 2012). Trainees are also vulnerable to difficulties
such as burnout and vicarious traumatization, particularly when they are new to practicing
(Gockel, 2010; Adams & Riggs, 2010). There is no known published empirical research to
show that stress and other stress-related outcomes hinder or impair professional
functioning among trainee psychologists. However, research on populations such as
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trainee teachers and trainee engineers suggest that if these problems are not appropriately
addressed, there is a risk of trainees experiencing hindered or impaired professional
competence as a consequence of impediments to skills such as attention, concentration, and
decision-making (El-Ghoroury, Galper, Sawaqdeh, & Bufka, 2012).
Self-care refers to actions (e.g. seeking social support and exercise) which the
individual initiates to promote his or her own health and well-being (Bickley, 1998). Some
studies have found that self-care practices are associated with lower perceived stress levels
among trainees (McKinzie, Altamura, Burgoon, & Bishop, 2006; Myers et al., 2012;
Chrisman, Christopher, & Lichtenstein, 2009). Despite these positive findings, training
programs usually do not have a structured component for self-care in the core curriculum
(Christopher, Christopher, Dunnagan, & Schure, 2006). Furthermore, there is a lack of
communication regarding the need for self-care, and it is usually conveyed to trainees as
their individual responsibility (Munsey, 2006; Christopher et al., 2006). This approach is
considered ineffective as trainees may underestimate their susceptibility to mental and
emotional difficulties due to the mental health training they have undergone (Barnett,
2008).
Mindfulness as a Tool for Professional Development and Self-Care
Given all of the above challenges, recent research has considered mindfulness as a
means to addressing the challenges of professional development and self-care for trainees
in clinical psychology and related disciplines, such as counselling, counselling psychology,
and social work (Rimes & Wingrove, 2011). Researchers have noticed compatibility
between the challenges in professional development and self-care, and the aims and
outcomes of practicing mindfulness (Gockel, 2010; Bruce et al., 2010). In order to
understand this compatibility, it is useful to first understand the nature of mindfulness and
how it has been applied to clinical practice and training.
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The Historical Roots of Mindfulness
Mindfulness, a practice that stretches over 2500 years ago, is known for being
rooted in Buddhist religion and philosophy. Thomas William Rhys Davids, a Pali-language
scholar, has been cited as the person who translated the word Sati to the English word
mindfulness. Thich Nhat Hanh was one of the first teachers of mindfulness to the West and
his work paved the way for many others to bring mindfulness into the Western clinical
context. This included practices such as focusing on bodily felt sensations and body scans
(Gendlin, 1998; Cornell, 2013).
The Definition of Mindfulness
Gunarantana (2002) stated that it was difficult to define mindfulness because of its
subtle and non-verbal nature. Researchers have yet to come to a consensus for the
operational definition of mindfulness (Bishop et al., 2004). Kabat-Zinn’s (1994) widely-
cited definition is “paying attention in a particular way: on purpose, in the present moment,
and non-judgementally” (p. 4). Shapiro, Carlson, Astin, and Freedman (2006) built on
Kabat-Zinn’s (1994) definition by suggesting that mindfulness comprises three
components: intention, attention, and attitude. Kabat Zinn’s (1994) “on purpose” refers to
intention, “paying attention” refers to attention, and “in a particular way” refers to attitude
(Kabat-Zinn, 1994; Shapiro et al., 2006). Shapiro et al. (2006) proposed that these three
components lead to “reperceiving” (p. 2), which means a significant shift in an individual’s
outlook. Bishop et al. (2004) view mindfulness as comprising two components, self-
regulation of attention to present moment experience and the individual’s attitude to the
present moment experience, an attitude typified by an attitude of curiosity, openness, and
acceptance (Bishop et al., 2004). Although different operational definitions exist, the
definitions include similar fundamental components; the intention to focus one’s attention,
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controlling attention to the present moment, and adopting a particular attitude to one’s
experiences.
Mindfulness practices can be classified as formal and informal. Formal mindfulness
practices often include seated meditation, mindful yoga stretches and the body scan, which
involves systematically paying attention to sensations in each part of the body (Cigolla &
Brown, 2011). Informal mindfulness practices involve the application of mindfulness skills
in daily life, such as walking or eating (Cigolla & Brown, 2011). Through the cultivation
of mindfulness skills, one becomes more aware of thought patterns, detaches from these
patterns, and gains a new perspective of seeing the world (Baer, 2003). In this new
perspective, thoughts and feelings are no longer labelled “good” or “bad” and individuals
are empowered to accept what is happening in their present moment, instead of focusing
on what they feel should be happening instead (Germer, 2005).
Mindfulness in Clinical Practice
Mindfulness is also currently of interest to therapists of almost all theoretical
orientations, including psychoanalytic and humanistic approaches (Christopher & Maris,
2010). It is central to many contemporary intervention approaches such as Acceptance and
Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), Dialectical Behaviour
Therapy (DBT; Linehan, 1993), Mindfulness-Based Cognitive Therapy (MBCT; Segal,
Williams, & Teasdale, 2002), and Mindfulness-Based Stressed Reduction (MBSR; Kabat-
Zinn, 2003). Therapists can implement mindfulness interventions into sessions to help their
clients and clients can also be encouraged to practice mindfulness in their daily lives
outside therapy (Ryan, Saran, Doran, & Muran, 2012).
Mindfulness has also been increasingly promoted in therapeutic interventions to
help clients and patients with psychological, physiological and interpersonal difficulties. It
has been used in interventions for chronic pain, stress, depressive relapse, binge eating
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disorder, and cancer (Kabat-Zinn, 1984; Shapiro, Schwartz, & Bonner, 1998; Segal et al.,
2002; Kristeller & Hallett, 1999; Speca, Carlson, Goodey, & Angen, 2000). It has also
been used in clinical populations with mixed diagnoses and non-clinical populations
(Kabat-Zinn, 2003). It is associated with many positive psychological outcomes, such as
higher positive affect, life satisfaction, adaptive emotional regulation, and self-compassion
(see Keng, Smoski, & Robins, 2011 for a review). Mindfulness is also associated with
various positive physical outcomes, such as positive changes in immune system
functioning and increased physiological levels of melatonin (Davidson et al., 2003;
Massion, Teas, Herbert, Wertheimer, & Kabat-Zinn, 1995).
Mindfulness for Professionals
Interventions such as ACT, DBT, MBSR, and MBCT include mindfulness practice
for the therapist as an important aspect of implementing the intervention (e.g. Linehan,
1993). Many who are experienced in using mindfulness-based interventions have proposed
that therapists should have experiential exposure to mindfulness techniques, thereby
increasing their own knowledge and experience before using the interventions with their
clients (e.g. Segal et al., 2002). Mindfulness has also been suggested to be useful for
mental health professionals because it offers professionals a means of self-care (e.g. May
& O’Donovan, 2007; Shapiro, Astin, Bishop, & Cordova, 2005; Christopher et al., 2011)
and they can use mindfulness in their personal and professional lives (Rothaupt & Morgan,
2007; Cigolla & Brown, 2009).
May and O’Donovan (2007) found that among 55 mental health professionals, self-
reported mindfulness was associated with higher life satisfaction, the experience of more
frequent positive emotions and less frequent negative emotions, lower levels of burnout,
and higher job satisfaction. Shapiro et al. (2005) found that an 8-week MBSR intervention
led to a significant decrease in perceived stress and increase in self-compassion among 18
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health care professionals, including psychologists and social workers, in comparison to a
wait-list control group of 20 participants. Aggs and Bambling (2010) found that, for their
sample of 47 mental health professionals, an eight-week mindfulness therapy training
program positively impacted on their knowledge about mindfulness, attitudes regarding
using mindfulness in their clinical work, ability to practice mindfulness, and reduced stress
and tension.
One long-term follow-up qualitative study was conducted on 16 practicing
counsellors who had undertaken a mindfulness training course during their graduate
training in counselling (Christopher et al., 2011). The participants had taken the course an
average of four years prior to the follow-up study (Christopher et al., 2011). The study
sought to understand the role of mindfulness in their personal and professional lives. The
participants’ accounts suggested that they found the course useful. Two themes emerged
pertaining to their personal lives: a) personal development/self-care and b) interpersonal
relationships. Three themes emerged pertaining to their professional lives: a) counselors’
experience of self while counseling, b) the therapeutic relationship, and c) clinical practice.
Two qualitative studies have been conducted on populations of registered mental
health professionals who had identified themselves as using mindfulness practices.
Rothaupt and Morgan (2007) interviewed six counsellors, four of whom were also
counsellor educators, to understand their application of mindfulness in their personal and
professional lives. Their analysis was conducted by constant comparative method and
found one overarching theme of the need and effort to live in the present moment. They
also found two other broad themes: a) using a variety of tools or methods to incorporate
mindfulness into their lives and b) the outcomes or results of their mindfulness. Cigolla
and Brown (2009) interviewed six therapists to find out how they understand the concept
of mindfulness and its role in their personal and professional lives. Using an interpretive
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phenomenological analysis, they developed one major theme of mindfulness as a way of
being, and three subthemes: a) a way of being in personal life, b) a way of being in
therapy, and c) encouraging a way of being in others.
The relative paucity of research in this area suggests that mindfulness for health
care professionals is still an area which requires further study so as to establish its
usefulness. The existing research, although lacking in quantity, suggests that it offers many
useful benefits for self-care, and personal and professional development. While
mindfulness can be taught to mental health professionals while they are practicing, it is
also useful to explore how this teaching can be fostered before they qualify, so as to reap
these benefits as professionals later on in their careers.
Mindfulness for Mental Health Trainees
Research has investigated the use of mindfulness to address the gaps in clinical
psychology training. In line with the focus of the literature search strategy, empirical
research regarding the use of mindfulness for mental health trainees will be reviewed so as
to understand the current knowledge and therefore inform on future research directions.
Quantitative and Mixed-Method Studies Regarding Mindfulness for Trainees
Dispositional mindfulness. Dispositional mindfulness refers to an innate trait that
reflects an individual’s propensity to cultivate intentional awareness (Brown & Ryan,
2003). Table 1 lists two quantitative studies that have been conducted to study the
association between dispositional mindfulness and variables of interest among mental
health trainees. The research shows that dispositional mindfulness is positively associated
with qualities within the therapist, therapeutic alliance, and client’s interpersonal
functioning (Greason & Cashwell, 2009; Ryan et al., 2012). Dispositional mindfulness was
not associated with improvement in clients’ broader psychological problems and symptoms
of psychopathology; one reason that was put forth to explain this was that mindfulness may
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be more related to interpersonal rather than broader psychological functioning (Ryan et al.,
2012).
Insert Table 1 Here
Mindfulness practices. Table 2 lists the quantitative studies that have been
conducted to study the impact of mindfulness practices for mental health trainees. Some of
the studies were also mixed method in nature, where qualitative responses were collected
from the participants (Stafford-Brown & Pakenham, 2012; Rimes & Wingrove, 2010,
Moore, 2008). The studies show that trainees who participate in mindfulness training
experience many increases in positive outcomes related to self-care (Shapiro, Brown, &
Biegel, 2007; Stafford-Brown & Pakenham, 2012; Rimes & Wingrove, 2010, Moore,
2008; Collard, Avny, & Boniwell, 2008) and stronger therapeutic alliance (Stafford-Brown
& Pakenham, 2012). Some studies did not find significantly improved outcomes in
domains such as stress, anxiety, depression, satisfaction in life, and positive affect (Rimes
& Wingrove, 2010; Moore, 2008; Collard et al., 2008). Researchers proposed that the
possible reasons for this were sampling and measurement issues (Rimes & Wingrove,
2010; Moore, 2008; Collard et al., 2008). This suggested that it has been difficult for
research to accurately ascertain the effectiveness of mindfulness for this population. Some
of these studies also obtained open-ended written feedback from the participants, and their
feedback suggested that the practices were helpful in various aspects of their personal and
professional lives (Rimes & Wingrove, 2010; Moore; 2008; Stafford-Brown & Pakenham,
2012).
Insert Table 2 Here
Qualitative Studies Regarding Mindfulness for Trainees
Christopher and Maris (2010) summarised five qualitative research studies
regarding the impact of mindfulness interventions on trainees’ personal and professional
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lives. Four of the studies were conducted on postgraduate counselling trainees (Christopher
et al., 2006; Schure, Christopher, & Christopher, 2008; Crisman et al., 2009; Maris, 2009).
These studies revealed many themes that suggested mindfulness to be useful for trainees’
self-care and personal and professional development. Apart from the studies summarized
in the article by Christopher and Maris (2010), one other qualitative study regarding
mindfulness for trainees was found. McCollum and Gehart (2010) conducted a study on 13
marital and family therapy trainees to understand their experience of learning mindfulness
meditation to aid them in developing therapeutic presence. The analysis, conducted
through thematic analysis, was based on journal entries. The following themes were found:
being present, effects of meditation, shift in mode, and compassion and acceptance. Within
the theme of being present, the sub-themes were (a) attending to inner experience, (b)
aware of what happens with client, and (c) acting from awareness. Within the theme of
effects of meditation, the sub-themes were (a) calmer, (b) managing inner chatter, (c)
slowing down and (d) boundaries between sessions. Within the theme of shift in mode, one
subtheme of doing mode balanced by being mode was found. While the doing mode refers
to the idea that therapy is focused on doing activity, the being mode refers to finding times
to simply be with the client (McCollum & Gehart, 2010). Within the theme of compassion
and acceptance, the sub-themes were (a) toward self, (b) toward client, and (c) sense of
shared humanity.
Mindfulness for Trainees’ Professional Development
Having listed the broad findings of mindfulness for trainees, this review will now
consider, in depth, how mindfulness training can cultivate the intrapersonal skills
mentioned earlier in this review.
Firstly, mindfulness can be a way for trainees to manage in-session self-awareness
because mindfulness involves non-judgmental and flexible attention and awareness, and
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might help trainees manage distracting self-focus (Nutt-Williams, 2008). Qualitative
research found that trainees find mindfulness helpful to manage awareness of their
experiences during sessions (Christopher & Maris, 2010). For example, trainees reported
feeling more confident in their ability to manage their distracting self-focused anxiety
about being a therapist and reported increased ability to react constructively when
experiencing countertransference reactions (Chrisman et al., 2009; Christopher & Maris,
2010; Schure et al., 2008).
Secondly, mindfulness has been proposed to help with empathy through decreasing
stress, increasing self-compassion, and learning to put aside one’s own subjective
perspective (Gehart & McCollum, 2008). Greason and Cashwell (2009) found a positive
association between mindfulness and empathy. While there have not been any other
quantitative studies directly studying the association between mindfulness and empathy
among mental health trainees, it has been found that mindfulness increases self-
compassion and reduces stress (e.g. Shapiro et al., 2007), which is in line with Gehart and
McCollum’s (2008) proposal of the link between mindfulness and empathy. Qualitative
research also found that trainees found mindfulness training helpful in increasing their
compassion towards clients (Christopher & Maris, 2010).
Thirdly, mindfulness can also help trainees develop their affect tolerance skills as
the trainee would be able to tolerate his or her own affect through mindfulness by
accepting the emotions as they arise and letting them pass (Safran & Reading, 2008;
Luoma & Villatte, 2012). This, in turn, can increase the trainee’s confidence in his or her
ability to hold a client’s affect in session (Safran & Reading, 2008). This would allow
clients a safe environment to fully express their feelings, and this can in itself be a positive
experience in therapy (Fulton, 2005; Safran & Reading, 2008). This also enhances the
client’s ability to build affect tolerance; this has been found to be important to improve
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difficulties such as anxiety and addiction (Gockel, 2010). Qualitative research has shown
that mindfulness helps trainees tolerate their clients’ and their own affect, thus creating a
‘holding environment’ for the client’s feelings (Christopher & Maris, 2010).
Fourth, mindfulness practices have also been suggested as a way to learn how to
focus attention as they give students mastery experiences in attention skills (Greason &
Cashwell, 2009). Greason and Cashwell (2009) found that self-reported mindfulness was
positively associated with attention. Qualitative studies have also revealed that trainees use
mindfulness to be more attentive with clients (Christopher & Maris, 2010).
Mindfulness for Trainees’ Self-Care
Research also suggests the use of mindfulness practices as a self-care tool for
trainees. It has been suggested that mindfulness training can help with reducing stress and
stress-related psychological problems (Gockel, 2010). Empirical research which has used
mindfulness training with trainee samples found that the interventions led to improvements
in their self-care and psychological well-being. This included significant increases in self-
compassion (Rimes & Wingrove, 2008), positive affect (Shapiro et al., 2007), self-
kindness (Moore, 2008), life satisfaction (Stafford-Brown & Pakenham), increased
relaxation (Crisman et al., 2009), and increased calmness (Crisman et al., 2009). The
interventions were also associated with decreases in perceived stress (Rimes & Wingrove,
2008), work-related stress (Stafford-Brown & Pakenham), negative affect (Shapiro et al.,
2007), and rumination (Rimes & Wingrove, 2008). Furthermore, Shapiro et al. (2007)
found that increases in mindfulness mediated these benefits to self-care. Qualitative
research has also shown that mindfulness practices offer numerous benefits to trainees for
self-care (Christopher & Maris, 2010). Given all of this literature, there is strong evidence
to suggest that mindfulness practices offer a useful approach to self-care for trainees.
Mindfulness for Trainees’ Implementing Mindfulness-Based Interventions
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As mentioned above, mindfulness is integral to therapeutic approaches such as
MBCT (Segal et al., 2002) and MBSR (Kabat-Zinn, 2003), and research suggests that it is
an effective intervention for many presenting difficulties (Keng et al., 2011). However, the
lack of exposure and knowledge about mindfulness interventions can prevent trainees from
using mindfulness as an intervention within therapy (McKenzie, Hassed, & Gear, 2012).
Research has found that receiving training in mindfulness helps increase trainees’
willingness and confidence to use mindfulness practices with clients (Moore; 2008;
McKenzie et al., 2012).
Impact of Trainees’ Mindfulness Practices on Client Outcomes
In addition to trainees’ outcomes for their own self-care and professional
development in intrapersonal skills and using mindfulness-based interventions, research
has also studied the relationship between trainees’ mindfulness and client outcomes.
Grepmair et al. (2007) found that the clients of trainees who participated in mindfulness
training experienced improved outcomes such as decrease in symptom severity and
increase in self-attunement, global functioning, subjective experience and interpersonal
functioning (Grepmair et al., 2007). These clients also had a better comprehension of the
goals of therapy, their own development, and optimism about their progress (Grepmair et
al., 2007). These were in comparison to clients of trainees who did not participate in
mindfulness training.
How to Develop Mindfulness in Trainees
Given the potential benefits of mindfulness, attention has been paid to different
ways of teaching mindfulness to trainees. Research suggests that mindfulness can be taught
to trainees through the use of mindfulness groups as a variety of designs have resulted in
increased mindfulness and other positive outcomes (Moore, 2008, Collard et al., 2008). It
has been noted that time constraints, such as for groups such as clinical psychology
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trainees where there is a rigorous curriculum, may impede trainees’ ability to participate in
mindfulness programmes (Moore, 2008). This may be a reason for them to decline
participation or drop-out from participating (Carmody & Baer, 2009). It would be useful to
explore possibilities of administering mindfulness programmes which have less strict time
demands and which can be conducted without the guidance of an instructor who has been
formally trained (Carmody & Baer, 2009). To support the rationale of using shorter
formats, Carmody and Baer (2009) found that shortened versions of MBSR were no less
effective than the standard format in decreasing psychological distress. In line with
recommendations for shorter interventions, suggested intervention designs have included
shorter versions of MBSR or MBCT (Carmody & Baer, 2009) and brief experiential
exercises as a group during clinical training (Moore, 2008), and a student-led mindfulness
group (Myers et al., 2012). The content in these intervention designs can be typical of
those used in mindfulness-based programs such as MBSR or MBCT, but with a shorter
duration (Moore, 2008). This would allow for the implementation of these designs within
programs with rigorous curriculum and time constraints.
Critique of Mindfulness Literature
There are some limitations within the available literature regarding mindfulness for
mental health trainees. These limitations pertain to measurement and other methodological
issues.
Limitations of Quantitative Studies Regarding Mindfulness for Trainees
In quantitative research, researchers determine the variables that will be studied
according to their interest (Christopher & Maris, 2010). Christopher and Marks (2010)
stated that within quantitative mindfulness studies, the variables of interest are usually
measured by questionnaires comprising a number of self-report items. This can result in
“an imposition by the researcher of his or her own framework of meaning that may miss or
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distort the structures of meaning that the study participants would spontaneously generate
and employ on their own” (Christopher & Maris, 2010, p. 116). This is especially
pertinent for an experiential concept like mindfulness, for which researchers have yet to
attain consensus regarding its definition, operationalization and measurement (Cigolla &
Brown, 2011).
Different tools tend to differ in the aspects of mindfulness that they measure as well
as the way in which the aspects are measured (Hick, 2008). For example, the Mindfulness
Attention Awareness Scale (MAAS; Brown & Ryan, 2003), as used in the study by
Shapiro et al., 2007, measures attention and awareness but does not measure other
important aspects of mindfulness, such as openness to novel experiences and non-
judgmental attitude (Hick, 2008). One implication is that self-report questionnaires may
not be sensitive to the magnitude of change that participants experience (Moore, 2008). For
example, Myers et al. (2012) proposed that only those who engage in frequent formal
mindfulness practice obtain significant increase in trait mindfulness as measured by self-
report questionnaires.
The nature of mindfulness is also such that participants who are more mindful
might actually be more aware of the degree to which they are not mindful, and rate
themselves lower when completing self-reported questionnaires (Davis & Hayes, 2011).
Similarly, participants who are less mindful may not be fully aware of the degree to which
they are not mindful, thus overestimating their mindfulness (Davis & Hayes, 2011). They
may gain more insight during the post-course measures and the questionnaires may not be
a reliable indicator of change in mindfulness (Moore, 2008; Davis & Hayes, 2011).
Myers et al. (2012) suggested that an alternative to measuring mindfulness in self-
report questionnaires is to measure the frequency of mindfulness practice and find out how
this is associated with outcome measures. It is important to note that measuring the
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frequency of mindfulness practice also has its limitations. Firstly, the meaning of engaging
in mindfulness practice may differ among individuals (May & O’Donovan, 2007). For
example, individuals may differ as to whether they view informal practices such as
labelling one’s feelings to be mindfulness practice. Secondly, the intention behind the
practice is also of concern (May & O’Donovan, 2007). For example, some individuals
might practice yoga with the intention to exercise rather than to cultivate mindfulness
(May & O’Donovan, 2007). This makes it difficult to quantify how much time an
individual spends engaging in mindfulness practice.
The available research also has many other methodological limitations. Firstly,
there are no randomized control groups in all studies. This means that the relationship
between the mindfulness interventions or courses and the changes in dependent variables
cannot be established as causal. The changes may be due to other factors such as trainees
adjusting to their professional roles over time. In all studies, the samples are self-selected.
This means that motivational differences such as being more open to learning about
mindfulness or perceiving the need for help may affect their choice to participate and affect
how they experience the interventions. These limitations of self-selection, participant
attrition during the intervention and evaluation, and demand effects as the participants may
be aware of the rationale of the intervention, can lead to bias with regards to confirming
the researcher’s hypotheses. Furthermore, the studies contain small sample sizes which
may affect statistical analysis and results. The nature of the student populations, that being
from specific courses in universities with different features (e.g. public or private
programs), also limits the generalizability of the results to the wider population.
Adopting a Qualitative Approach
Irving, Dobkin, and Park (2009) highlighted the lack of published qualitative
studies of mindfulness interventions with clinicians or trainees. Although research has
MINDFULNESS IN CLINICAL PSYCHOLOGY TRAINING
highlighted some emerging consistency in the definition of mindfulness (Bishop et al.,
2004; Shapiro et al., 2006), it was proposed that qualitative research in this area would help
explore experiences in an open-ended way and investigate aspects of change that have not
yet been captured in previous research (Christopher & Maris, 2010). This is done without
the use of operational definitions of mindfulness to guide the study, and Rubin and Babbie
(2009) offer three reasons to explain this. Firstly, the researcher does not want to predict
what the most salient variables will be (Rubin & Babbie, 2009). Secondly, the researcher
recognizes that his or her way of operationalizing a construct may not be the best way of
measuring the phenomenon (Rubin & Babbie, 2009). Thirdly, the researcher recognizes
that operational definitions may be limited because variables are measured by specific
observable indicators (Rubin & Babbie, 2009). A deeper understanding of mindfulness
could help inform operationalization in future quantitative or mixed-method studies
(Cigolla & Brown, 2009). Qualitative research can explore how trainees define, learn, and
experience mindfulness and mindfulness practices and the application of mindfulness in
their personal and professional lives as they train to become psychologists.
Conclusion
The available research on mindfulness for mental health trainees shows many
benefits for self-care and professional development, but the research designs comprise
many interventions which require substantial time requirements. This might not be feasible
for clinical psychology training programs to implement, given the rigorous curriculum and
time constraints. Future research should focus on designs which require shorter time
commitments so as to facilitate trainees’ participation.
The research pertaining to the outcomes of these interventions includes quantitative
studies which have many methodological limitations, especially that concerning the
operationalization and measurement of mindfulness using self-report questionnaires.
MINDFULNESS IN CLINICAL PSYCHOLOGY TRAINING
Qualitative research could offer a complimentary way to understand how trainees
experience mindfulness and its impacts on their personal and professional lives. Currently,
there is an overall dearth of qualitative studies and none focusing on the views of clinical
psychology trainees, who face unique challenges compared to other trainee populations.
Future research needs to focus on exploring clinical psychology trainees’ experiences of
mindfulness practices and the meanings attached to these experiences. This can contribute
to the clarity of understanding as to whether mindfulness practices foster the professional
development and self-care that training programs require for trainees. Understanding their
experiences will also help move towards forming guidelines that inform the development
of mindfulness training programmes for clinical psychology trainees.
MINDFULNESS IN CLINICAL PSYCHOLOGY TRAINING
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Acknowledgements
This research received no specific grant from any funding agency, commercial or not-for-
profit sectors.
Declaration of Interest
None.
Table 1Quantitative studies regarding dispositional mindfulness for traineesAuthor Sample Research
DesignVariables of Interest
Significant Findings
Greason & Cashwell, 2009
179 Master's and doctoral counseling trainees
Self-report questionnaire
Mindfulness, attention, empathy, self-efficacy
Positive associations between all four dependent variables: mindfulness, attention, empathy, self-efficacy
Ryan et al., 2012 26 therapist-client dyads, of which 20 therapists are clinicalpsychology trainees
Self-report questionnaire
Mindfulness, therapist self-affiliation, therapeutic alliance, patient’s global symptoms, patient’s interpersonal functioning
Positive association between therapist’s mindfulness and therapist self-affiliation, the therapist’s ratings of the therapeutic alliance, one aspect of the patient’s ratings of the therapeutic alliance, and improvements in the patient’s interpersonal functioning
Table 2Quantitative and mixed-method studies regarding mindfulness practices for traineesAuthor Sample Research
DesignTreatment Group after Dropout
Control Group after Dropout
Dependent Variables Significant Findings
Shapiro et al., (2007)
Counseling psychologytrainees
Prospective, non-random,cohort-controlled
n=22 in an 8-week MBSR intervention
n=32 in the twocontrol courses
Mindfulness, positive and negative affect, stress, state and trait anxiety, rumination, and self-compassion
Increase in mindfulness, positive affect, and self-compassion
Decrease in stress, negative affect, rumination, andstate and trait anxiety
Moore (2008) Clinical psychology trainees
Within-subjects
n= 10 in a 14 session, structured, mindfulness skillsgroup using short (10 min) practices
N/A Stress,mindfulness skills, self-compassion
Increase in mindfulness skills and in self-kindness aspect of self-compassion
Collard, Avny, & Boniwell, (2008)
Postgraduate counselling trainees
Within-subjects
n=15 in an 8-week MBCT course
N/A Mindfulness,satisfaction with life, positive affect and negative affect
Increase in mindfulness
Decrease in negative affectRimes & Wingrove (2010)
Clinical psychology trainees
Within-subjects
n=20 in an 8-week MBCT course
N/A Stress, anxiety, depression, mindfulness, self-compassion, and rumination.
Increase in self-compassion and mindfulness
Decrease in ruminationStafford-Brown & Pakenham, (2012)
Clinical psychology trainees
Prospective, non-random,cohort-controlled
n=26 in a 4-week ACT-informed intervention
n=28 in a waitlist control group
Work-related stress, psychological distress, life satisfaction, self-compassion, self-efficacy, and therapeutic alliance
Increase in life satisfaction, self-compassion, self-efficacy, and therapeutic alliance
Decrease in work-related stress and psychological distress
Changes maintained at 10-week follow-up
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