A research portfolio

Including an investigation of ‘Bringing mindfulness to the therapeutic relationship:

Towards a grounded theory’

Jacob Ellwood

Submitted in partial fulfilment of the degree of Practitioner Doctorate (PsychD) in Psychotherapeutic and Counselling Psychology

Department of PsychologyFaculty of Arts and Human Sciences

University of Surrey

October 2016

Statement of copyright

No aspect of this portfolio may be reproduced in any form without written permission

of the author, with the exception of librarians at the University of Surrey who are

empowered to reproduced the portfolio by photocopy or otherwise, and may loan

copies for academic purposes.

© Jacob Ellwood, 2016

2

Statement of anonymity and confidentiality

In order to ensure the confidentiality and anonymity of all clients and research

participants, pseudonyms have been used throughout the portfolio, and any identifying

information has been changed or omitted.

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Acknowledgements

I would firstly like to thank my fellow trainees, whom I have got to know and love

more deeply than I could have believed when starting the course. I would particularly

like to thank Damien Pearse, who has been with me every step of the way and who

has been incredibly generous with his support and encouragement.

The clients with whom I have worked during my placements have each made a

mark on me, and contributed enormously to my development as a counselling

psychologist. I would like to thank them also.

Linda Morison, who supervised my second and third-year research projects,

has been a great source of support, both for her support in helping me formulate ideas,

and for the encouragement she gave me. I would also like to thank Riccardo Draghi-

Lorenz, who supervised my first-year literature review and who was always a

stimulating and enjoyable presence in class.

I would also like to give profound thanks to my placement supervisors, Saira

Razzaq, Roger Lippin, and Becky Whitfield, for their guidance and support. So much

learning in this profession takes place ‘on the job’, and these three people helped me

develop professionally, academically, and personally.

I am grateful for the participation of the therapists and clients whom I

interviewed for my research projects. Their input was not only valuable for the

purposes of research, but also encouraged me to reflect upon my own therapeutic

practice.

Finally I would like to thank my family and friends. I consider myself very

fortunate to have recourse to such a wonderful support network. Without them I

wouldn’t have made it this far.

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Contents

Abstract 6

Research Dossier

Introduction to the research dossier 8

Literature review 9

Research project 1: Therapist and client experiences of joint mindfulness 51

Appendices 99

Research project 2: Bringing mindfulness to the therapeutic relationship:

Towards a grounded theory 106

Appendices 155

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Abstract

This is a portfolio of research work completed during my three years of training on the

PsychD in Psychotherapeutic and Counselling Psychology at the University of Surrey.

It comprises a literature review and two research reports. The literature review

explores some of the conceptual and empirical links between mindfulness and

attachment. The first research report is a qualitative enquiry into how therapists and

clients experience joint mindfulness practice within therapy sessions, and identifies

themes and superordinate themes relating to this experience. The second research

report employs a qualitative methodology to understand how therapists bring

mindfulness to the therapeutic relationship, and presents a theory of the processes

through which this is achieved.

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Research Dossier

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Introduction to the research dossier

This dossier comprises a literature review and two empirical research reports. The

literature review examines the conceptual and empirical links between mindfulness

and attachment, and includes discussion of some ways in which mindfulness has been

used to enhance interpersonal relationships. Although most of the literature

surrounding these subjects is quantitative, the implicit objectivist stance evinced by

these studies did not sit easily with me – although I believe attachment theory is a very

useful way of understanding childhood development and subsequent relational style,

following the literature review I was less sure about the existence of clear-cut

attachment ‘styles’. Equally, I conceptualise mindfulness as a stance, or a way of

being, and I do not believe that it lends itself readily to quantification. Therefore in my

second and third-year research reports, I adopted qualitative research methods that

focused on the subjectivity of individual experience and acknowledged the socially

constructed nature of knowledge regarding social phenomena. The second-year

research report uses interpretative phenomenological analysis (IPA) in a study of joint

mindfulness practice within individual therapy sessions. The third-year research report

adopts a constructivist grounded theory approach to investigate therapist perceptions

of how they bring mindfulness to the therapeutic relationship.

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LITERATURE REVIEW

Mindfulness and attachment: A review

Abstract

Mindfulness and attachment have been linked conceptually and correlated empirically.

Secure attachment and high trait mindfulness are associated with more successful

interpersonal relationships, better control over cognitive processes, and optimal

functioning in terms of affect regulation and general wellbeing. However, there is only

one previous review of the literature exploring the relationship between mindfulness

and attachment, leaving much uncharted territory. This review seeks to unpack some

of the processes underlying this relationship, and examines some of the ways in which

secure attachment and mindfulness are transmitted from parent to child. The findings

suggest that there is a positive correlation between secure attachment and mindfulness,

and that the key processes through which this relationship functions are attention and

emotion regulation. Potential benefits and obstacles are considered for the

implementation of mindfulness techniques for insecurely attached people within the

therapeutic setting.

Keywords: Mindfulness, attachment, interpersonal, attention, affect regulation

Introduction

Researchers have begun to explore the links between mindfulness and attachment only

in the last 10 years or so, and it is still a relatively undeveloped field of study:

Literature searches on PsycINFO, PsycARTICLES, and Google Scholar for

‘mindfulness’, ‘attachment’, and ‘review’ returned only Snyder, Shapiro, and

Treleaven’s (2012) review, which focuses largely on parent-child relationships. The

current review also looks at how attachment security is established during childhood,

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and the role of mindfulness can play in facilitating this process, but is concerned more

with the significance of mindfulness in relation to adult attachment security.

John Bowlby (1988) referred to the primary caregiver as a safe haven or

‘secure base’. If a child is securely attached, she will feel able to explore her

surroundings in the knowledge that she can return to the sanctuary of her caregiver if

necessary. In a similar way, mindfulness allows a person to be curious about their

emotions, cognitions, and sensations – if these become too intense, mindful practice

allows the individual to use focused breathing as an anchor. Indeed, the word ‘anchor’

has been used to refer to both mindful awareness (Brown, Marquis, & Guiffrida,

2013) and the feeling of having someone on whom one can rely for safety and

validation (Rothchild, 2000). Mindfulness could perhaps, then, be a way of using the

self as a secure base.

Such a notion has already been suggested within the literature. Snyder et al.

(2012) note that nurturing one’s capacity for mindfulness is a way of developing a

secure attachment to the self, or in the words of Siegel (2009, p.145), ‘becoming your

own best friend’. Recent studies have also found that attachment security is related to

increased mindfulness (e.g., Shaver, Lavy, Saron, & Mikulincer, 2007; Walsh, Balint,

Smolira, Frederickson, & Madsen, 2009). Some of the strongest evidence for the link

is suggested by Pepping, O’Donovan, and Davis (2014), who used self-report

measures to explore the link between mindfulness and attachment in meditators and

non-meditators. Regular meditators scored higher on mindfulness, and most

significantly, lower attachment avoidance and anxiety accounted for 43.3% of this

variance.

The current paper seeks to elucidate the various dimensions of the link

between mindfulness and attachment: Interpersonal, affective, cognitive, and

neurobiological. Ultimately, the aim of such an endeavour is to find out whether

cultivating mindfulness can help those with an insecure attachment style to achieve

both interpersonal and intrapersonal attunement, and so the discussion then proceeds

to look at how mindfulness-type skills are passed on through attachment processes,

and what implications this has for the therapeutic relationship.

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Mindfulness

The word ‘mindfulness’ can refer to a psychological trait, a state of awareness, a

mental process, or the formal practice of cultivating mindfulness (e.g. mindfulness

meditation) (Germer, Siegel, & Fulton, 2005). Most frequently it is said to have its

roots in Buddhist philosophy (Kabat-Zinn, 2004), but parallels have also been drawn

with ancient Greek philosophy, phenomenology, existentialism, transcendentalism,

and humanism (Brown, Ryan, & Creswell, 2007).

The current paper will take as its starting point Jon Kabat-Zinn’s (2003, p.145)

definition of mindfulness as ‘the awareness that emerges through paying attention on

purpose, in the present moment, and nonjudgmentally to the unfolding of experience

moment by moment.’ The value of this working definition is that it encompasses

several key facets that are universal in the literature on mindfulness: Intentional

awareness, focus on the present moment, and non-judgemental orientation towards

experience. Shapiro, Carlson, Astin, and Freedman (2006) summarised these core

elements as, respectively, intention, attention, and attitude. It is acknowledged within

the literature that different individuals have different levels of trait mindfulness. This

is not to claim that one’s capacity to be mindful is fixed, though. Buddhism has long

used various meditation approaches including mindful breathing and concentration

meditation to encourage present moment awareness and engagement with experience.

Since the inception of Kabat-Zinn’s mindfulness-based stress reduction

(MBSR) programme in 1979, such techniques have been employed as health

interventions, among clinical and non-clinical populations. The MBSR course

comprises eight weekly sessions of 2-2.5 hours, with a whole-day retreat between

weeks 6 and 7. The program takes place within a group setting and incorporates a

variety of meditation techniques, including a body scan exercise, sitting meditation,

mindful walking and yoga, along with a taught element that ‘shows the workings’ of

the process. Emphasis is placed on a non-goal orientation, and participants are

encouraged to view mindful living as an ongoing process and to continue practice

after the course has finished (Kabat-Zinn, 1994).

A meta-analysis of 17 MBSR studies found evidence that MBSR improves

mental health in both clinical and non-clinical populations, but the evidence was

inconclusive as to whether it could improve physical health (Fjorback, Arendt,

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Ørnbøl, Fink, & Walach, 2011). Breast cancer survivors, in an RCT conducted by

Lengacher et al. (2009) recorded significantly improved psychological wellbeing and

quality of life, compared to a treatment-as-usual group. MBSR interventions have also

been found to lower anxiety and depression symptoms, and raise self-esteem, in

individuals with social anxiety disorder, by Goldin & Gross (2010); although a lack of

a control group in this study limits the claims that can be made about these findings.

Mindfulness-based cognitive therapy (MBCT) combines a variety of

mindfulness techniques (body scan, sitting meditation, mindful movement) with an

approach to emotion and cognition that is informed by Aaron Beck’s cognitive

therapy paradigm. MBCT is recommended as a way of preventing depression relapse

(Fjorback et al., 2011; Galante, Iribarren, & Pearce, 2013). Encouraging findings have

also been made for MBCT as a way of relieving symptoms in patients with panic

disorder and generalized anxiety disorder: Kim et al. (2009) assigned participants to

MBCT or an eight-week anxiety disorder education program, finding significantly

greater improvement in the MBCT group on measures of anxiety and depression.

Other forms of therapy use the teaching of mindfulness skills as a central

component. Dialectical Behaviour Therapy (DBT; Linehan, 1993a, 1993b) is used to

treat borderline personality disorder and has a focus on acceptance and change. The

therapist works with the client to encourage acceptance of his self, his history and his

current situation, while looking at change strategies for behaviour and environment

with the aim of improving the client’s life. One on one therapy is supplemented by a

year-long weekly skills group, which addresses interpersonal skills, emotion

regulation, and distress tolerance. Mindfulness practice is considered an integral part

of the treatment, although frequency and length of practice is left for the client and

therapist to decide. DBT has also been explored as a potential treatment, with

promising results, for substance abuse (Linehan et al., 1999) and bulimia (Telch,

Agras, & Linehan, 2002).

Although it does not prescribe mindful or meditative practice, acceptance and

commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is considered to be a

mindfulness-based intervention (Baer, 2003) because of its focus on mindfulness

skills. ACT has been used as an effective treatment for anxiety and depression

(Forman, Herbert, Moitra, Yeomans, & Geller, 2007), and eating disorders (Sandoz,

Wilson, & Dufrene, 2013). As in mindfulness, cognitions are treated as mental events,

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and clients are taught how to nurture an ‘observing self’ that can address thoughts and

feelings at an emotional distance, as discrete phenomena. Rather than attempting to rid

the self of troubling thoughts or emotions, clients are encouraged to change their

relationship towards them.

The mindful stance in relation to cognition, then, is that of viewing thoughts as

mental events, rather than truths that define the self (Kabat-Zinn, 2004). Mindful

interventions encourage the client to visualise thoughts as leaves floating by on a

stream, or clouds passing through the sky (Williams, Teasdale, Segal, & Kabat-Zinn,

2007; Orsillo & Roemer, 2011). The common theme in such visualisation exercises is

that of motion; Irving, Dobkin, and Park (2009, p.62) characterise the mindful stance

towards cognitions as one of ‘fluid attention’. This is reflected in Baer’s (2003, p.125)

description of mindful awareness as involving ‘observation of constantly changing

internal and external stimuli as they arise.’

As such, mindfulness has been used as a way of reducing rumination (Deyo,

Wilson, Ong, & Koopman, 2009; Raes & Williams, 2010), and has been found to be

effective as treatment for other psychological conditions including anxiety (Kabat-

Zinn et al., 1992), stress (Shapiro, Schwartz, & Bonner, 1998), eating disorders

(Kristeller & Hallett, 1999), and depression relapse (Teasdale et al., 2000). Trait

mindfulness is associated with higher life satisfaction (Brown & Ryan, 2003), higher

sense of autonomy (Brown & Ryan 2003), lower social anxiety (Brown & Ryan

2003), lower experiential avoidance (Baer, Smith, & Allen, 2004), higher empathy

(Dekeyser, Raes, Leijssen, Leysen, & Dewulf, 2008), and higher self-esteem

(Rasmussen & Pidgeon, 2011).

Studies have also investigated the relationship between mindfulness and the

‘big five’ personality dimensions, with findings suggesting that highly mindful people

are more agreeable (Thompson & Waltz, 2007), conscientious (Giluk, 2009), and

open to experience (Giluk, 2009), and score lower in measures of neuroticism

(Dekeyser et al., 2008). In addition to the psychological benefits, mindfulness-based

interventions have also been used to treat physical conditions including chronic pain

(Kabat-Zinn, 1982; McCracken & Keogh, 2009; McCracken & Thompson, 2009) and

psoriasis (Kabat-Zinn et al., 1998), and have been linked with improved immune

function (Davidson et al., 2003; Creswell, Myers, Cole, & Irwin, 2009).

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Various measures of trait mindfulness have been developed. Among them are

the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) (with a single

underlying dimension: open/receptive awareness and attention), the Cognitive and

Affective Mindfulness Scale (CAMS; Hayes & Feldman, 2004), the Kentucky

Inventory of Mindfulness Skills (KIMS; Baer et al., 2004) (subscales: observing one’s

moment-to-moment experience, verbalizing experience, acting or participating with

awareness, and non-judgemental acceptance of one’s experiences), the Mindfulness

Questionnaire (Chadwick, Hember, Mead, Lilley, & Dagnan, 2005), the Five Factor

Mindfulness Questionnaire (FFMQ; Baer et al., 2006), and the Freiburg Mindfulness

Inventory (FMI; Buchheld, Grossman, & Wallach, 2001; Walach, Buchheld,

Buttenmuller, Kleinknecht, & Schmidt, 2006). Some studies (e.g. Arch & Craske,

2006) have used interventions such as focused breathing techniques to induce a state

of mindfulness. To measure state mindfulness in such a context, there is a state

version of the MAAS (Brown & Ryan, 2003), as well as the Toronto Mindfulness

Scale (Lau et al., 2006).

Questions have been raised over the validity of such measurement scales.

Grossman (2008, 2011), who co-authored the FMI, contends that existing measures of

mindfulness suffer from a number of limitations, some of which are particular to the

measurement of mindfulness and others of which could apply in a more general sense

to self-report measurement scales. These are that (1) there is no consensus on what

constitutes a mindful person, and as such there is no way to tell whether these scales

are measuring mindfulness, or something else; (2) they neglect important elements of

mindfulness as defined by Buddhist sources as well as by the literature on

mindfulness-based interventions; (3) the various scales diverge in their definitions of

mindfulness, and therefore do not correlate well with each other; (4) certain qualities

which the scales purport to measure, such as attentional lapses, are not amenable to

accurate self-rating. Meanwhile, respondents who are experienced in mindfulness

practice will be aware of the ‘desirable’ response, and eager to believe that the time

they have spent in practice has yielded tangible results; (5) respondent values may

influence response style, confounding valuations with mastery; (6) interpretation of

items will vary significantly according to familiarity with mindfulness teaching; (7)

most scales were developed with convenience samples (e.g. university students); (8)

certain scales (e.g. the MAAS) phrase items in the negative, suggesting that what is

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being measured is not presence of mindfulness, but absence of ‘mindlessness’ – which

are not the same thing; (9) there are doubts over the validity of a measurement

designed for adolescents (i.e. Brown, West, Loverich, & Biegel, 2011); (10) certain

scales are too abbreviated to capture the subtleties and complexity of mindfulness, and

are therefore reductive.

Much of Grossman’s critique relates to how mindfulness has been

operationalised, and methodological concerns over the development and testing of

measures; concerns that can be addressed in a relatively straightforward manner. More

intractable, perhaps, are the more general questions that have been raised about

contemporary understanding and application of the concept of mindfulness. Of

particular concern to some is the introduction of mindfulness into business contexts,

which jettisons the relational and ethical concerns of mindfulness and transplants

meditation to the world of private industry, where the bottom line is productivity and

profit – a world away from the non-striving attitude of its Buddhist roots (Kabat-Zinn,

2015). This seeming commodification of mindfulness has been termed

‘McMindfulness’ by concerned critics (Purser & Loy, 2013).

The rapid spread of mindfulness in the public consciousness has also led to

confusion about the meaning of mindfulness (even beyond the discrepancies in the

accounts of different authorities). A recent article in the Guardian (Foster, 2016)

referred to mindfulness as a ‘relaxation technique’; although relaxation may be an

outcome (or desired goal) of mindful practice, nowhere in the literature do its

proponents describe it as a ‘relaxation technique’. This confusion is not assisted by

apparent contradictions within the literature about what mindfulness meditation

entails. Even in a paper dedicated to establishing an operational definition of the

concept, Bishop et al. (2004) first state that mindfulness meditation involves a

concerted effort ‘to maintain attention on a particular focus, most commonly the

somatic sensations of his or her breathing’ (p.232) but also that ‘All thoughts, feelings,

and sensations that arise are initially seen as relevant and therefore subject to

observation.’ (p.233)

Meditating mindfully, then, involves two seemingly quite different activities –

attempting to maintain focus on the breath and engagement with the contents of

consciousness that arise when doing so. Brown and Ryan (2004) address this apparent

contradiction by noting that these two forms of meditation can be traced to two

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different traditions within Buddhism: concentration meditation and insight/awareness

meditation. Some traditions have established a stepped meditation program in which

the individual practises first concentration meditation (to sharpen attentional ability)

and then ‘graduates’ to insight meditation (Kapleau, 1980). In most contemporary

applications of mindfulness, the distinction between these two forms of meditation

appears to have been lost, which has perhaps contributed to confusion about what

mindfulness is.

This confusion also extends to the perceived status of mindfulness practice

such as meditation as solitary activities; such a perception may be reinforced by the

existence of silent retreats which proscribe interaction between attendees. In fact,

many authorities (e.g. Hanh, 1991; Kabat-Zinn, 2004; Williams & Penman, 2011)

argue that mindfulness is intimately engaged with interpersonal processes. The next

section will examine how the link between mindfulness and interpersonal

relationships has been conceptualised, tested, and employed in psychological

interventions.

Mindfulness and interpersonal relationships

Daniel Siegel, who has carried out work on the psychological and neurobiological

mechanisms of attachment, asserts that the neural circuitry activated and strengthened

by intentional and non-judgemental present moment awareness is also responsible for

engendering feelings of safety. This feeling of safety, along with activation of mirror

neurons that allow us to affectively understand (or ‘feel’) mental states in others is,

argues Siegel, the basis of compassion (Siegel, 2007, 2009).

Indeed, mindfulness has long been used as a method of improving

interpersonal relations. In Buddhism, mettā refers to loving-kindness, friendship, and

active interest in others. Within a contemporary psychological context, such practices

have been translated into ‘compassion meditation’, which has been found to increase

empathy (Hofmann, Grossman, & Hinton, 2011), social connectedness (Hutcherson,

Seppala, & Gross, 2008), and altruism (Kristeller & Johnson, 2005), all of which are

also linked with secure attachment (Mikulincer & Shaver, 2005).

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Dekeyser et al. (2008) explored the links between the four factors of the

Kentucky Mindfulness Scale and interpersonal behaviour. All dimensions were

positively related to expressing oneself in social situations. Mindful observing, acting

with awareness, and non-judgemental acceptance were associated with a higher

capacity for identifying and describing emotions, and lower social anxiety, with

mindful observing also correlated with empathy.

Such interpersonal skills bestow significant social advantages on the mindful

individual, and it is perhaps unsurprising that, for example, trait mindfulness is

positively correlated with marital satisfaction (Burpee & Langer, 2005; Barnes,

Brown, Krusemark, Campbell, & Rogge, 2007; Wachs & Cordova, 2007). Jones,

Welton, Oliver, and Thoburn (2011) found that this link is partially mediated by

spousal attachment, and, like Siegel (2007, 2009), suggest that mindfulness can

promote the strengthening of neural pathways linked to feelings of security and

positive affect. Accordingly, mindfulness has been incorporated into relationship

therapy, with a focus on empathy and acceptance as a way of improving outcome in

couple and family therapy (Block-Lerner, Adair, Plumb, Rhatigan, & Orsillo, 2007;

Gehart, 2012).

The last few years have seen a rapidly increasing interest in using mindfulness

techniques to help mothers become more attuned to their children, with the stated aim

to improve bonding between caregiver and infant, and reduce the stress associated

with raising a child. So called ‘mindful parenting’ involves listening with full

attention to the child, cultivating emotional awareness and self-regulation in the

parent, and approaching parent-child interactions with non-judgement and compassion

(Bögels & Restifo, 2015).

In an RCT with 65 families, Coatsworth, Duncan, Greenberg, and Nix (2010)

modified an existing parenting program to include a mindfulness element, leading to

reduced negative affect and increased positive affect among adolescents, and

improved parent-child relationships compared to the original program. Mindfulness is

also indicated as a potential intervention in those cases where attachment difficulties

may arise due to the presence of psychological, neurobiological, or developmental

disorders in the child: Trait mindfulness has been found to predict higher involvement

in parental tasks among fathers of children with intellectual disabilities (MacDonald &

Hastings, 2010), while positive effects of mindfulness training have been reported by

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parents of children with attention deficit hyperactivity disorder (Van der Oord,

Bögels, & Peijnenburg, 2012).

As noted in the introduction, one of the most intriguing relational aspects of

mindfulness is the proposed link with attachment processes. The next section will

provide a brief overview of attachment theory, and will begin to describe some of the

proposed links between the concepts of mindfulness and attachment.

Attachment

Bowlby’s (1958, 1988) attachment theory grew out of an attempt to understand

parent-child bonding in evolutionary terms. At times of threat or stress, a child’s

attachment system will be activated, and she will seek the comfort and safety provided

by her caregiver, until the threat has passed. Bowlby referred to this phenomenon as

‘attachment behaviour’, and believed its biological function to be protection from

predators (Howe, 2011). For Bowlby, attachment theory was not only applicable to

early childhood, stating that attachment behaviour can re-emerge at critical times

throughout the lifespan (Bowlby, 1969).

Attachment theory was further developed with the work of Mary Ainsworth,

who conceived of the ‘strange situation’ as a way of studying attachment behaviour in

infants. The child was separated from his or her mother for a short period of time, and

his or her behaviour studied during the separation period and after the mother’s return.

From the researchers’ observations, Ainsworth then classified each child as

conforming to one of four attachment styles: Secure, avoidant, ambivalent, and

disorganised (Ainsworth, Blehar, Waters, & Wall, 1978). Subsequent studies have

found attachment style to be predictive, not only of functioning during childhood, but

also through adolescent life and beyond (Grossmann & Grossmann, 1991; Sroufe,

2005).

Attachment theory is not just concerned, however, with behaviour. Bowlby

believed that early bonding experiences with caregivers shape a child’s understanding

of the relationship of the self to others, and that this will shape future attachment

behaviour. He called this the ‘internal working model’, a concept that is comparable to

the schemas of cognitive therapy or object relations of psychodynamic theory. For

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secure children, the self feels loved and loving, while others are conceived of as

available and reliable. In avoidant children, the self is thought of as unloved, and

others are rejecting and unavailable at times of need. Ambivalent children have an

internal representation of the self as unworthy and dependent, and of others as

unpredictable and unreliable. Disorganised children come to view the self as fearful

and isolated, and others as unavailable, unpredictable, unreliable and even hostile

(Howe, 2011).

Since the 1980s, there has been increasing interest in attachment among adults,

and its links to the formation of social relationships and romantic partnerships,

emotion regulation, and psychological functioning. Several measurement scales have

been developed to classify attachment style in adults. The adult attachment interview

(AAI; George, Kaplan, & Main, 1985) represents a move away from Ainsworth’s

behavioural paradigm to a focus on psychological orientation regarding attachment,

and how coherently the interviewee is able to talk about his attachment relationships.

Participants are then classified as tending towards one of four attachment styles:

secure-autonomous (or free to evaluate), dismissing, preoccupied-entangled, and

unresolved-disorganised, which correspond respectively to the secure, avoidant,

ambivalent, and disorganised patterns in infants.

Self-report measures, such as the Adult Attachment Questionnaire (AAQ)

(Simpson, Rholes, & Phillips, 1996), the Experiences in Close Relationships

questionnaire (ECR) (Brennan et al., 1998), and the Experiences in Close

Relationships – Revised (ECR-R) questionnaire (Fraley, Waller, & Brennan, 2000),

have also been used to evaluate adult attachment organisation. From the data gathered

by such self-report measures, two dimensions have emerged as underpinning adult

attachment style: Avoidance and anxiety. This way of classifying adult attachment has

become dominant within the field, so that adults are typically classified as either

secure (low on both attachment anxiety and avoidance), dismissive (low on anxiety

and high on avoidance), preoccupied (high on anxiety and low on avoidance), or

fearful (high on both anxiety and avoidance).

Secure attachment in adults is associated with higher functioning in a number

of areas. Securely attached adults are more likely to use resources in their social

environment to maintain their physical and psychological wellbeing, seeking health

advice sooner than insecure individuals, and showing more willingness to discuss

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problems with significant others (Howe, 2011). They are also more likely to feel

satisfied (Hazan & Shaver, 1987; Brennan & Shaver, 1995; Feeney, 1999), and less

anxious (Feeney, 1998), in their romantic relationships.

These relational benefits of secure attachment, such as higher satisfaction and

improved communication, are similar to the relational benefits of mindfulness

discussed in the previous section, and over the past decade researchers have noted

these links and begun to delineate the paths through which mindfulness and

attachment are linked. Saron and Shaver (2006) carried out correlations and a

regression analysis on the Five Factor Mindfulness Questionnaire (FFMQ; Baer,

Smith, Hopkins, Krietemeyer, & Toney, 2006) and a two-dimension (anxiety,

avoidance) measure of adult romantic attachment insecurity (Brennan, Clark, &

Shaver, 1998). Attachment anxiety and avoidant attachment were significantly

associated with and significantly predicted lower scores on three dimensions of

mindfulness: Nonreactivity to inner experience, acting with awareness, and

nonjudging of experience. Avoidant attachment was also significantly associated with

and significantly predicted lower scores on the two other dimensions of the scale:

observing/noticing/attending to perceptions/thoughts/feelings, and describing/labelling

with words. The two attachment dimensions accounted for 42% of the variance in

participants’ overall mindfulness scores.

Other studies have examined the links between attachment anxiety, attachment

avoidance, and mindfulness. Low attachment anxiety (although not avoidance) was

also found to predict mindfulness in a study by Walsh et al. (2009). Like Saron and

Shaver (2006), Goodall, Trejnowska, and Darling (2012) used the FFMQ, finding

significant negative correlations between avoidance and three of the factors

(describing/labelling, acting with awareness, and non-judging of experience), and

between anxiety and the same three factors as well as a fourth (non-reactivity).

There is promising evidence, then, that mindfulness and attachment are linked,

but it is also clear that the nature of this relationship is not a straightforward one: In

two studies, Pepping, Davis, and O’Donovan (2015) found no change in state

attachment security after manipulating state mindfulness, and vice versa. To shed

more light on the relationship between mindfulness and attachment, it is necessary to

examine some of the components that may be applicable to both; starting, in the

following section, with affect regulation.

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Affect regulation

An important area in which insecurely attached children and adults diverge from their

secure counterparts is affect regulation, by which is meant identification of the

emotional significance of a stimulus, production of an affective response, and

regulation of this affective state (including ‘switching off’ the response) (Phillips,

Drevets, Rauch, & Lane, 2003). Optimal development of brain areas such as the pre-

frontal cortex (responsible for executive function, including the moderation of social

behaviour), the insula and amygdala (linked to emotional response), and the

hypothalamic-pituitary-adrenal (HPA) axis (responsible for the release of the stress

hormone cortisol), depend on the quality of early caregiving (Fox & Hane, 2008).

Insecure attachment influences affect regulation in divergent ways depending

on the nature of the attachment style. People who score highly on attachment anxiety

tend to display hypervigilance – under-regulation of affect and heightened sensitivity

to attachment-related cues (Mikulincer and Shaver, 2003). This can lead to higher

levels of depression and anxiety in children (Brown & Whiteside, 2008), adolescents

(Lee & Hankin, 2009), and adults (Fraley, Niedenthal, Marks, Brumbaugh, & Vicary,

2006). Those who score highly on attachment avoidance incline towards over-

regulation of affect. Such a strategy is learned early in life when the child finds that

expressing feelings does not increase proximity with the caregiver, and inhibiting

them reduces parental rejection (Mikulincer & Shaver, 2007). Avoidant children and

adolescents will refrain from seeking help from others (Booth-LaForce, Rubin, Rose-

Krasnor, & Burgess, 2006; Scharf, Mayseless, & Kivenson-Baron, 2004), while

avoidant adults display poor insight into their own emotional processes (Howe, 2011).

There is also substantial evidence suggesting that trait mindfulness is

positively correlated with the capacity to successfully regulate one’s emotions.

Erisman, Salters-Pednault, and Roemer (cited in Chambers, Gullone, & Allen, 2009)

found a significant correlation between self-reported levels of mindfulness and scores

on the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004).

Mindfulness-based interventions may also positively influence affect regulation.

Campbell-Sills, Barlow, Brown, and Hoffman (2006) investigated the effects of

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acceptance versus suppression of emotions among patients with mood or anxiety

disorders. Participants were instructed to either accept or reject their emotions while

viewing an emotion-provoking film, and were measured on heart rate response and a

self-report measure of distress. The two groups reported a similar level of distress in

response to the film, but the acceptance group registered a lower heart rate and

reported lower levels of distress in the post-stimulus recovery period.

Working with a non-clinical sample, Arch and Craske (2006) used a 15-minute

breathing exercise to induce a state of mindfulness in one group of participants, with

other groups receiving 15-minute unfocused attention and worrying inductions.

Participants were then shown affectively valenced picture slides, and were measured

on emotional response (using a self-report scale), autonomic response (using a

measurement of heart rate), and avoidance behaviour (by measuring how long each

participant viewed aversive images). Those in the focused breathing group reported

lower emotional reactivity than the worry group, and significantly greater willingness

to view negative stimuli than the unfocused attention group.

More recent studies (Kumar, Feldman, & Hayes, 2008; Goldin & Gross, 2010)

have confirmed the potential for mindfulness interventions to positively influence

affect regulation. The role of attentional control appears to be key. Research has

suggested that the link between attachment style and emotion regulation is mediated

via attentional processes (Roemer et al., 2009; Walsh et al., 2009). Specifically, it is

the present-moment attention prescribed by mindfulness, characterised by an attitude

of openness and acceptance, that is found to reduce levels of anxiety and negative

affect (Hayes & Feldman, 2004). The next section will look at how attentional

processes are shaped by early attachment experiences, and will also discuss the

conceptual and empirical links with mindfulness.

The role of attention

According to Fonagy (2001), a person’s capacity for directing their attention towards

a particular (internal or external) object is shaped during early childhood, when the

primary caregiver engages with the child by diverting his attention from one thing to

another. Over time, the child internalises this process; in effect, the caregiver is

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modelling attentional control. Such an ability has implications for mental wellbeing (a

person who is aware of his attentional processes, and able to influence them, is less

likely to be overwhelmed by unwelcome thoughts or memories) and for social

functioning (someone who is attentive to the emotions and cognitions of others is

likely to enjoy more successful relationships). This is borne out by studies that have

found negative associations between trait anxiety and attentional control (Derryberry

& Reed, 2002; Eysenck, Derakshan, Santos, & Calvo, 2007).

The link between attention and attachment has been explored in empirical

studies. Walsh et al. (2009) found significant positive correlations between attentional

control and parental nurturance, on both the father’s and the mother’s side.

Attachment anxiety is associated with cognitive inflexibility and difficulties in

regulating and directing attention: Anxiously-attached individuals encounter

difficulties in directing attention away from attachment-related stimuli (Mikulincer,

Gillath, & Shaver, 2002), and find it difficult to disengage from emotionally

significant cognitions and memories (Mikulincer & Orbach, 1995). This can have

adverse consequences on emotional wellbeing – for instance, attachment insecurity

has been linked to excessive rumination (Mikulincer & Shaver, 2003; Pearson,

Watkins, Mullan, & Moberly, 2010).

Those with an avoidant attachment style, conversely, demonstrate good

cognitive flexibility. This may be due to the hypothesised ‘deactivation’ of the

attachment system that is characteristic of the avoidant style (Howe, 2011), and can be

reversed through an experimentally induced activation of the attachment system

(Gillath, Giesbrecht, & Shaver, 2009).

Research has indicated that attention is a core feature of mindfulness. Bishop

et al. (2004) identified mindfulness as a process of regulating attention to bring

awareness to current experience, while the MAAS (Brown & Ryan, 2003) has

attention/awareness as its underlying factor. Teasdale, Segal, and Williams (1995), in

an early attempt to combine cognitive therapy with mindfulness, used ‘attentional

control’ as a synonym for mindfulness.

The relationship between mindfulness and attention has two important

dimensions. Firstly, mindfulness is associated with sharpened attention and cognitive

flexibility (Slagter et al., 2007; Lutz, Slagter, Dunne, & Davidson, 2008; Woodruff et

al., 2013). Secondly, mindful practice encourages the individual to direct attention to

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uncomfortable or unpleasant stimuli, while withholding judgement on the valence of

these stimuli; this is what Epstein (1995) terms ‘bare attention’. In consequence,

mindfulness is associated with lower experiential avoidance (Kumar et al., 2008), and

an increased ability to sustain attention (Tang et al., 2007; Chambers, Lo, & Allen,

2008). It was previously thought that these improvements in attentional control only

occur in experienced meditators, but more recent studies have noted similar outcomes

even after short mindfulness interventions (Zeidan, Johnson, Diamond, David, &

Goolkasian, 2010; Teper & Inzlicht, 2013).

These studies, however, did not include long-term follow-up, and a recent,

longitudinal study provides a counterpoint to some of the studies listed above.

MacCoon, MacLean, Davidson, Saron, and Lutz (2014) compared participants in the

MBSR program with a control group in a health enhancement program, and found no

significant difference in sustained attentional ability. Further research is needed in

order to judge whether mindfulness can increase attentional control, but it is possible

that the salient factor is not the degree of attention, but the experiential quality of this

attention – it could be argued that bringing attention to present moment phenomena

does not constitute a mindful act if it is not carried out in a spirit of acceptance.

This section and the previous section have discussed two psychological

phenomena, affect regulation and attention, that are implicated in both attachment

processes and mindfulness. The following section offers some tentative observations

about the neural activity that might be involved in these phenomena, and about the

ways in which mindfulness might help an individual to regulate emotion and attention,

with reference to neurobiological studies.

Neural correlates of mindfulness and attachment

There is significant overlap between the processes of attention and affect regulation,

and it is likely that they are linked in a feedback loop: Greater capacity for directing

attention facilitates affect regulation, while those with low ability to regulate their

emotions find it harder to maintain control over attentional processes. Furthermore,

many of the same brain regions are implicated in both attention and emotion

regulation (Davidson and Irwin, 1999). Such areas are linked to both attachment

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processes and mindfulness – for example, parental communication in the early years

impacts the child’s pre-frontal cortex, an area that governs self-awareness, attention,

and emotional communication (Siegel & Hartzell, 2003).

Schore (2001a, 2001b) has investigated the neurobiological consequences of

secure and insecure attachment in childhood by contrasting the neurobiology of a

securely attached infant with that of an infant with a disorganised attachment style. A

particular area of interest is right brain development, for the reason that the right brain

(specifically the right amygdala and right insula) has been implicated in emotion and

stress regulatory systems, notably the HPA axis (Buck, 1994). The brain of an infant

who experiences significant attachment disruptions on a frequent basis, without

reparative action from a caregiver, is exposed to chronically elevated levels of

glucocorticoids such as cortisol. These can reach neurotoxic levels and damage cells

in those areas responsible for regulating affect, leading to long-term deficiency in

psychological functioning (Schore, 2001b).

By contrast, infants with a secure attachment demonstrate greater functioning

in areas such as the orbitofrontal cortex, where cognitions and emotions are integrated

and which allows the growing child to become attuned to her changing environment

and respond appropriately to external and internal stimuli (Schore, 2001a). Similarly,

higher levels of mindfulness have been linked to higher grey matter volume in the

right insula and right parahippocampal gyrus (Murakami, Nakao, Matsunaga, &

Ohira, 2009), reduced activity in the amygdala (Goldin & Gross, 2010) and insula

(Paul, Stanton, Greeson, Smoski, & Wang, 2013), and increased activity in brain areas

associated with attentional processes (Goldin & Gross, 2010). Lazar et al. (2005)

found that mindfulness meditation leads to increased cortical thickness in areas that

are responsible for empathy and self-observation, and a recent study by Lutz et al.

(2014) suggested that even a short mindfulness intervention can attenuate activation of

the amygdala and parahippocampal gyrus during exposure to negative stimuli.

For healthy development of those brain areas responsible for emotion

regulation, an enriching environment in early childhood is important. Right-brain

development in the cortex and sub-cortex is linked with early attachment experiences

(Ryan, Kuhl, & Deci, 1997), while epigenetic studies of rodents have shown the

importance of maternal licking and grooming, which can lower cortisol levels in

offspring (Weaver et al., 2004). Mindfulness has also been shown to attenuate levels

25

of cortisol – participation in the MBSR program has been found to lower cortisol

levels, during the program itself and at 6 and 12-month follow-up (Carlson, Speca,

Patel, & Goodey, 2004; Carlson, Speca, Faris, & Patel, 2007; Matousek, Dobkin, &

Pruessner, 2010).

Creswell, Way, Eisenberger, and Lieberman (2007) examined the neural

mechanisms associated with attention and affect regulation by measuring brain

activity in the amygdala (associated with emotional processing) and the prefrontal

cortex (responsible for executive function) of participants as they viewed emotionally

threatening images and carried out a stimulus labelling task. Those who scored higher

on the MAAS were less reactive to the threatening stimuli, as indicated by a lower

bilateral amygdala response and greater activity in the prefrontal cortex (specifically

the dorso-medial, left and right ventrolateral, medial, and right dorsolateral areas),

with a strong inverse association between activation of those areas and the right

amygdala. The authors of the study concluded that those with higher trait mindfulness

might be able to regulate emotions more effectively through greater inhibition of

amygdala responses by the prefrontal cortex. These findings have been supported by a

study of generalized anxiety disorder patients by Hölzel et al. (2013) who measured

activity in the prefrontal cortex and amygdala before and after mindfulness training.

A final consideration is that of neural plasticity. During early childhood there

is a critical phase in which the brain undergoes significant changes, including

neurogenesis, synaptic pruning, and synaptic growth at a greater rate than during later

life. For optimal brain development during this period, caregiver-child attachment is

vital (Joseph, 1999; Sable, 2007). Deprived of loving, attentive contact, the infant

brain is unlikely to develop to its potential (the case of the Romanian orphans (e.g.

Kaler & Freeman, 1994) is often cited as an example of this phenomenon). There is a

body of evidence to suggest that, among adults, mindfulness practice can promote

neuroplasticity (Davidson et al., 2003; Siegel, 2007). Pronounced changes have been

found in areas associated with attention and emotion regulation (Gray, Braver, &

Raichle, 2002; Lazar et al., 2005). Such findings point to the potential benefits of

mindfulness as an intervention for insecurely-attached individuals.

Having thus far focused largely on quantitative findings, this review will now

turn to the qualitative data that are available on the subject of mindfulness and its

proposed links with interpersonal phenomena.

26

Qualitative studies

In a qualitative study of an MBCT intervention, (Allen, Bromley, Kuyken, &

Sonnenberg, 2009), ‘relationships’ was one of four themes that emerged during

thematic analysis. Participants reported greater emotional closeness with their friends

and family, better communication, and increased empathy. Other themes were

‘acceptance’, which can be linked conceptually to affect regulation, ‘control’, which

relates to awareness and attention, and ‘struggle’, which refers to the process of

engaging with the program.

Improved interpersonal functioning was also reported by 16-24 year olds in a

study of a non-clinical sample by Monshat et al. (2012). Participants’ experience of a

six-week mindfulness training program was organised by the researchers into three

phases, beginning with their initial distressed emotional state, progressing through a

stage in which they began to gain stability, and finally reaching a third stage in which

they reported greater clarity of mind and greater understanding of self and others.

Participants in a study of the interpersonal effects of MBCT reported a

sharpened awareness of their tendency to react to internal and external triggers in

social interactions. This increased awareness allowed them to avoid responding in

habitual ways in favour of a more mindful response attuned to the specifics of the

situation, with a concomitant improvement in communication skills. Some

participants also reported that the program helped them to be more empathic;

specifically, they said that when helping others in distress, they were able to ‘be with’

them rather than to immediately look for solutions (Bihari & Mullan, 2014).

Daly and Mallinckrodt (2009) used a grounded theory approach to study how

experienced therapists engage with clients with attachment anxiety or avoidance. One

point of consensus between all 12 therapists was that clients with attachment-related

issues tend to require a greater number of sessions to achieve therapeutic change.

Some of the therapists suggested that some degree of self-disclosure (related to

feelings about the therapeutic process rather than autobiographical details) might be

appropriate for highly anxious clients, to avert clients’ fear that the therapist is

withholding and cannot be trusted. Consistency was also highly prized, as was the

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need to discuss termination of therapy from an early stage. Among the strategies

employed by therapists with insecure attachment patterns was to use language as a

way of modulating the client’s affect regulation mechanisms, either through

upregulation (for anxious clients) or downregulation (for avoidant clients).

The qualitative data, although scant, does appear to lend support to the

findings of quantitative studies in that attention, affect regulation, and interpersonal

functioning are all prominent themes. Across the studies, participants reported greater

self-understanding, which led to greater understanding of others and improved

interpersonal relationships. If mindfulness can be employed as a way of improving

interpersonal relationships, then it stands to reason that there may be potential benefits

for the therapeutic relationship; these will now be discussed.

Implications for therapeutic outcome

Research has increasingly suggested that the relationship between therapist and client

is the most influential factor in determining outcome of therapy (Cooper, 2008).

Furthermore, Clarkson (2003) describes the ‘developmentally needed’ or ‘reparative’

relationship between therapist and client, which is needed when a client has been

subject to childhood trauma, strain, or neglect, leading to breakdown in trust (or

failure of trust to develop) in others – or in other words, insecure attachment.

The therapeutic relationship has been figured in terms of an attachment

relationship (Bowlby, 1988; Mallinckrodt, 2010), in that the therapist attempts to

provide a secure base for the client’s self-exploration. The Client Attachment to

Therapist Scale (CATS; Mallinckrodt, Gantt, & Coble, 1995) was conceived as a way

of exploring this conceptual link, and consists of three subscales that map closely onto

existing classifications of adult attachment: Secure, avoidant-fearful, and preoccupied-

merger. Using this scale, the security of client attachment to therapist has been

positively linked with depth of exploration during therapy (Mallinckrodt, Porter, &

Kivlighan, 2005).

However, we might expect less securely attached individuals to find it more

difficult to enter into an alliance with the therapist, which might prove a barrier to

successful outcome of therapy (Horvath & Bedi, 2002). The literature tends to support

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this notion (Kivlighan, Patton, & Foote, 1998; Eames & Roth, 2000). Daniel (2006)

states that, for insecurely attached clients, a large proportion of the therapy must be

dedicated to modifying internal working models of interpersonal relating. Given the

pro-social benefits of mindfulness, one potential way of doing so may be to employ

mindfulness-based interventions aimed at encouraging trust in others. Additionally,

the therapist can model a trusting, nonjudgemental approach when thinking about

interpersonal relations – Bowlby (1988, p.140) compared the role of the therapist to

that of a mother providing a secure base for her child to explore the world.

In terms of therapeutic outcome, several studies have explored the potential

effects of client attachment style. Meyer, Pilkonis, Proietti, Heape, and Egan (2001)

conducted interviews at the start of treatment (psychotherapy, pharmacotherapy, or

both), with 149 patients who had been diagnosed with personality disorders, with

follow-up interviews 6 and 12 months later. Secure attachment predicted relatively

better improvement in functioning and symptomatology after 6 months. Mosheim et

al. (2000), in a study of short-term (7 weeks) therapy with inpatients diagnosed with

mood disorders, anxiety disorders, and eating disorders, found that participants rated

as securely attached showed a bigger improvement than non-secure participants. In

contrast, Fonagy et al. (1996) did not find a strong link between attachment style and

outcome of therapy. In a study of 82 individuals who had been diagnosed with

personality and mood disorders and underwent psychoanalytic treatment, results were

inconclusive, although the group classified as insecure-dismissive showed greatest

relative improvement in symptoms.

Another consideration is the attachment style of the therapist, which can

impact both positively and negatively on the therapeutic relationship. Rubino, Barker,

Roth, and Fearon (2000) measured therapist attachment style on the dimensions of

anxiety and avoidance, and found that those high in anxiety responded less

empathically to ruptures within the therapeutic alliance. The authors suggested that

this might be a result of such ruptures being interpreted by the anxious therapist as

indicators of the client’s wish to leave therapy. Other studies are inconclusive on the

relationship between therapist attachment style and efficacy of therapy (Dunkle &

Friedlander, 1996; Sauer, Lopez, & Gormley, 2003).

Two recent studies have directed attention to the interaction between therapist

and client attachment styles. Marmarosh et al. (2014) measured attachment style of

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therapist and client in 46 dyads, as well as their respective ratings of the therapeutic

alliance. No direct effects of attachment style were found, but the authors did note an

interaction on the dimension of anxiety, in that the highest ratings of alliance were

found among dyads whose levels of attachment anxiety contrasted. Such a finding

supports the notion that contrasting relational styles between therapist and client are

beneficial for the outcome of therapy (Bernier & Dozier, 2002), perhaps because it

lessens the likelihood of collusion (Eagle & Wolitzky, 2009) or because contrasting

styles complement each other by enabling an ‘optimum’ level of expressed emotion in

sessions. By contrast, Wiseman and Tishby (2014) found that similar attachment

styles promote positive therapeutic outcome, but only when both are low in avoidance

– suggesting that this is less an effect of matching than of low avoidance being

beneficial for the process of psychological exploration and relationship building.

With the growing popularity of mindfulness in the field, mindfulness-based

interventions have been proposed as a way for mental health professionals to increase

wellbeing and increase mindful awareness (Ruths et al., 2012), and reduce the risk of

burnout (Di Benedetto & Swadling, 2014). In a study of experienced emotions during

helping behaviour, present-moment attention and nonjudgemental acceptance

predicted, respectively, an increase in positive emotions and a decrease in negative

emotions (Cameron & Fredrickson, 2015). However, there are few studies on the

relevance of mindfulness to the therapeutic relationship, despite a book by Hick and

Bien (2008), and a more recent review by Brito (2014), urging more research in this

area.

Some of the most robust evidence of mindfulness as a clinical intervention

comes from meta-analyses of MBCT (e.g. Piet & Hougaard, 2011) and MBSR (e.g.

Klainin-Yobas, Cho, & Creedy, 2012) interventions. However, both programs contain

multiple components, such as group discussion, psychoeducation, cognitive-

behavioral formulation of distress, and various mindfulness exercises. The evidence is

still unclear as to the ‘active ingredient’ of such interventions (Fjorback et al., 2011;

Metcalf & Dimidjian, 2014). This has implications for the introduction of mindfulness

into an individual therapy context, as some of the observed benefits of the MBCT and

MBSR programs may be specific to the context of the program.

Research that unpacks these interventions, to find out which elements are

therapeutic, could also have an indirect benefit for therapists using mindfulness in

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individual therapy. The following, penultimate, section of this literature review draws

parallels between therapists and caregivers, in a discussion of how mindfulness (and,

potentially, greater attachment security) may be passed on from one human being to

another.

Transmission of mindfulness

Similarities between the roles of therapist and caregiver can be seen in Meins’ (1999)

concept of ‘mind-mindedness’. Parents who display a high level of mind-mindedness

are interested in their children’s emotional and cognitive world, and are able to discuss

thoughts and feelings with them. They also encourage their children to reflect on the

mental world of others, assisting them in this way with their burgeoning theory of

mind. Ultimately this helps children to regulate their own emotions, and understand

the emotions of others, and could explain how attachment style is passed on from

parent to child.

Fonagy (1996, 2000, 2001) discusses similar processes in his work on

mentalization. A recurrent theme in the literature on mindfulness is that self-

awareness, self-attunement, and empathy for the self foster awareness of, attunement

with, and empathy for others. This is the also the basis of mentalization, defined as

‘keeping one’s own state, desires, and goals in mind as one addresses one’s own

experience; and keeping another’s state, desires, and goals in mind as one interprets

his or her behaviour.’ (Coates, 2006, p.xv) A person who is adept at using these

intrapersonal and interpersonal skills is said to be high in ‘reflective functioning’.

There is a significant conceptual overlap between mentalization and

mindfulness, which are both concerned with purposive attending to mental states,

awareness, and emotion regulation. The difference, according to Allen (2006, p.15), is

that while mindfulness is rooted in present-moment awareness of ‘what is there’ for

the individual, mentalization can relate to past and future mental states, in the self or

in others. The distinction appears to be slight, and perhaps it lies in the focus of

change. Where mindfulness entails changing the meaning of experiential phenomena,

mentalization may involve explicit attempts to change the content of these

phenomena.

31

A securely attached parent will be high in reflective functioning, and through

the awareness and interest that she shows in her parenting, will act as a model for her

child, who is therefore more likely to develop good reflective functioning and secure

attachment. Successful caregivers interact with their children on an emotional level,

mirroring the emotion that the child is experiencing. This is key to the child’s nascent

understanding of her emotional life. There is also evidence that mothers interact with

their children in a similar way to how their own mothers interacted with them. In this

way, attachment style can be ‘inherited’ – a meta-analysis of 854 parent-child dyads

found a correlation of .47 between parent and child (Van Ijzendoorn & Bakermans-

Kranenburg, 1997).

When a parent fails to display this kind of empathic mirroring, the child risks

impairment in her emotional and social development. Fonagy, Gergely, Jurist, and

Target (2002) refer to this process as ‘affect mirroring’. We can also draw a link to

psychotherapy, in which empathy is a kind of affect mirroring. Gerhardt says of the

psychological interaction between parent and infant that, ‘my carer shows me my

feelings’ (Gerhardt, 2004, cited in Howe, 2011, p.28). Accurate reflection of feelings

and cognitions is a core therapeutic skill.

If the therapist succeeds in providing a secure base, through accurate

reflection, empathy, positive regard, and congruent interest in the client’s growth, then

this may also facilitate, on the part of the client, greater willingness to explore difficult

emotions, cognitions, and memories, which has been linked to higher levels of

mindfulness. For instance, Heeren, Van Broeck, and Philippot (2009) administered an

MBCT intervention and took ‘before’ and ‘after’ ratings on a number of cognitive

measures. It was found that mindfulness increased specificity of autobiographical

memory (replicating the findings of an earlier study by Williams, Teasdale, Segal and

Soulsby (2000) on a sample of depressed patients) and cognitive flexibility. This is

particularly instructive for psychologists working within a cognitive-behavioural

framework, which places an emphasis on cognitive distortions such as over-

generalisation, catastrophising, and all-or-nothing thinking (Wilding & Milne, 2010).

32

Summary and conclusions

What is clear from the literature is that insecurely attached people are more likely to

be diagnosed with mood disorders and personality disorders, and generally display a

lower level of psychological and social functioning than securely attached people. But

they also appear less likely to benefit from psychological therapy than are secure

individuals (although further studies are needed to confirm this). In a situation where

the people who are in most need of an intervention are the same people who are least

likely to respond well to that intervention, there is a problem. What, then, can be

done?

The good news is that, although attachment style is established early in

childhood, and tends to remain consistent throughout the lifespan (Howe, 2011), it

does not inevitably remain the same. For instance, a person who displayed secure

attachment behaviour in childhood can lose this attachment security following

experiences of loss or abandonment. Similarly, an insecurely attached child may

become a securely-attached adult, through the support of reliable, available, and

loving interpersonal relationships. Such individuals are referred to within the literature

as having ‘earned’ attachment security (Siegel & Hartzell, 2003)

We have seen that caregiver-child interactions help children to develop

awareness of their own and of others’ emotional states, psychological motivations,

and behaviour. The same process occurs in the relationship between therapist and

client; therefore teaching mindfulness skills to therapists could be a way of improving

therapeutic outcome (Wallin, 2007; Bruce, Manber, Shapiro, & Constantino, 2010;

Brito, 2014), even if these skills are not passed on explicitly in the course of the

therapy. Perhaps, given enough time, and through collaboration with a skilled

therapist, an insecurely attached client could earn attachment security.

An obstacle here is the element of time. Secure attachment does not develop

quickly: Hazan and Zeifman (1994) note that, among adult romantic couples, it can

take up to two years for partners to use each other as a secure base. And if the

individual is avoidant in his attachment, further complications will arise in that he will

feel less able to place the trust in the therapist necessary for positive psychological

change. Furthermore, it might be questioned whether there is any value in focusing on

trying to change attachment style. After all, attachment classifications are a construct,

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and their utility lies in their ability to describe patterns of behaviour, affect regulation,

and cognitive style. These are the elements that affect an individual’s wellbeing and

day to day functioning, not whether they ‘belong’ to a certain style of attachment per

se. Attempts to increase attachment security, then, have increasingly focused on the

underlying change mechanisms that have been discussed in this review, specifically

affect regulation (Wei, Vogel, Ku, & Zakalik, 2005), and attention and cognitive

control (Gillath et al., 2009). As discussed, these are also processes associated with

mindfulness, and it has been suggested that mindfulness and attachment phenomena

function in a feedback loop – interpersonal attunement may help an individual to

access her internal world more readily, which in turn will lead to improved

interpersonal relating (Siegel, 2007).

The relationship between mindfulness and attachment is a relatively new area

of study, and there are several limitations present in the existing data. Many studies

are correlational, and so it is difficult to ascertain direction of influence, or whether, as

suggested above, there is a bi-directional influence. It should also be noted that many

studies of mindfulness interventions reporting large effect sizes did not use active

control groups, with most using single-group pretest-posttest quasi-experimental

designs. When controls are introduced, reported outcomes are less pronounced. A

meta-analysis of RCTs by Goyal et al. (2014) found moderate effect sizes for

depression (Cohen’s d = 0.3) and anxiety (d = 0.38) after eight-week mindfulness

interventions (dropping to 0.23 and 0.22, respectively, at 3-6 months follow-up).

Nevertheless, the authors point out that these effect sizes are comparable with those

found by studies of anti-depressant treatment in primary care.

The majority of studies also rely on self-report measures, which may not be the

most effective measure of mindfulness and attachment. Studies that use more

‘objective’ outcome measures, meanwhile, are also problematic, in that methods of

measuring processes such as attentional control or emotion regulation often appear to

lack ecological validity. Additionally, most studies using a mindfulness intervention

do not include long-term follow-up and therefore cannot indicate whether lasting

changes have been achieved. This is a particular problem for the investigation of

mindfulness, as it is stated repeatedly within the literature that mindfulness is

cultivated over time, through commitment to living in a mindful way (Kabat-Zinn,

2016) – either by maintaining a formal meditation regimen or by focusing one’s

34

efforts to perform daily tasks mindfully. There is also a lack of qualitative data within

the literature. A study of the interpersonal outcomes for participants in mindfulness

training, combining quantitative and qualitative methods, could be instructive as to

how such an intervention could lead to greater attachment security.

It may also be asked whether certain studies that claim to measure mindfulness

(or related phenomena) are actually doing so, or whether something else is occurring.

Many studies are decontextualised, and are removed from contexts that might be

relevant to the clinical application of mindfulness. Mindfulness is a multi-dimensional

construct, and there is no consensus on how it should be defined. For example, the

MAAS has a single underlying dimension of ‘open/receptive awareness and attention’

(Brown & Ryan, 2003), while others have several sub-scales. Because of this lack of

consensus, two different studies making claims about ‘mindfulness’ may in fact be

engaging with two discrete components (e.g. acceptance and ability to focus

attention). Methods of eliciting mindful states in participants are also sometimes

questionable. Campbell-Sills et al.’s (2006) instruction to participants to ‘accept’ or

‘suppress’ their emotions, for example, is at odds with the non-striving attitude of

mindfulness.

Equally, there are issues with laboratory studies of attachment: Does being

presented with names of attachment figures (Mikulincer et al., 2002), or thinking

about past close relationships (Gillath et al., 2009) really recreate the complexities of

human interpersonal relationships? This leads us to a more general point about

attachment classification, whose neatly defined categories lend themselves to

quantitative inquiry. In asserting that individuals can be observed or interviewed, and

on the basis of the results be assigned to a category (their ‘attachment style’), suggests

a positivist epistemology that has implications for clinical practice, particularly for the

counselling psychologist who may be more influenced by the humanist (we are

interested in the whole person), existentialist (we are interested in meaning), and

phenomenological (we are interested in the experience of the individual) traditions.

Attachment theory has much to tell us about human development and interaction, and

attachment styles are helpful when deployed on a heuristic basis… but they can also

tempt a practitioner into failing to meet the ‘whole person’, as required by the

counselling psychology tradition.

35

An important consideration when evaluating the efficacy of mindfulness

interventions is that observed benefits of mindfulness appear to be linked to

expectancy factors. This is an issue for studies in which participants self-select to a

mindfulness condition; in such cases the findings can be generalised only to those who

are already interested in practising mindfulness and who presumably expect benefits

from doing so. Improved outcome is also associated with adherence to mindfulness

practice, with studies finding that time spent practising predicts positive outcome

(Speca, Carlson, Goodey, & Angen, 2000; Carlson, Ursuliak, Goodey, Angen, &

Speca, 2001). It may be that there is a direct link between positive expectations and

outcome, or that this is mediated by adherence to mindfulness practice; further

research is necessary to unpack the links between expectancy, adherence, and

outcome.

Further work, both quantitative and qualitative, is also needed to shed further

light on the mechanisms through which mindfulness interventions can improve

interpersonal relationships of all types. In terms of relevance to counselling

psychology, the most pertinent relationship might be that between therapist and client.

Increasing knowledge of how mindfulness can be applied within a therapeutic context,

in the service of increasing attachment security, improving interpersonal functioning,

or enhancing the work of therapy, could potentially be of great value to the field.

36

Acknowledgements

The author wishes to thank his supervisors, Riccardo Draghi-Lorenz and Linda Morison, for their support and input.

Conflict of Interest

The author declares that he has no conflict of interest.

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RESEARCH PROJECT 1

Therapist and client experiences of joint mindfulness

Abstract

There is evidence that mindfulness practice can have salutary effects on interpersonal

functioning, including increased empathy and satisfaction in relationships. These

findings have implications for the therapeutic relationship, and a growing body of

research suggests that therapist mindfulness can enhance clinical skills and forge a

stronger therapeutic alliance. This qualitative study explores the effects of therapists

and clients engaging together in joint mindfulness practice within the therapy room.

Four therapist-client dyads engaged in a joint eight-minute meditation at the start of

two therapy sessions, separated by a regular session without meditation. Semi-

structured interviews were used to elicit their experiences. Transcripts were then

analysed using interpretative phenomenological analysis (IPA) to develop themes and

superordinate themes. Prominent themes within the data included greater attunement

between therapist and client, sharper focus, a slower pace, and a shift from the ‘doing’

to the ‘being’ modes of existence, suggesting that joint mindfulness between therapist

and client may assist in the process of therapy.

Keywords: Mindfulness, meditation, therapeutic relationship, qualitative

Introduction

Mindfulness, defined by Jon Kabat-Zinn (2003, p.145) as ‘the awareness that emerges

through paying attention on purpose, in the present moment, and nonjudgmentally to

the unfolding of experience moment by moment,’ is an ancient concept said to have

roots in Buddhist philosophy (Kabat-Zinn, 2004). Mindfulness skills can be cultivated

by engaging in everyday tasks mindfully (i.e. through ‘observation of constantly

changing internal and external stimuli as they arise’; Baer, 2003, p.145), or through

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participating in mindfulness meditation exercises, which typically involve focusing

attention on the breath, and bringing attention back to the breath each time attention

starts to wander. Mindfulness has been shown to have a range of mental and physical

health benefits (Baer, 2003; Brown, Ryan, & Creswell, 2007; Keng, Smoski, &

Robins, 2011).

There is emerging recognition that mindfulness practice can have significant

interpersonal benefits. Reported outcomes in several qualitative studies of mindfulness

training (Allen, Bromley, Kuyken, & Sonnenberg 2009; Monshat et al., 2013; Bihari

& Mullan, 2014) have included increased empathy and improved communication,

while quantitative studies have correlated mindfulness with higher empathy

(Dekeyser, Raes, Leijssen, Leysen, & Dewulf, 2008) and greater satisfaction in

interpersonal relationships (Wachs & Cordova, 2007). Dan Siegel (2007, 2009) has

developed understanding of the neurobiological links between mindfulness skills and

the forging of affectional bonds with others, highlighting research findings suggesting

that mindfulness meditation can promote growth in areas of the prefrontal cortex

associated with empathy and emotion regulation.

In light of these findings, Ellwood (2013) examined the links between

mindfulness and attachment in a literature review. Key findings within the literature

were that insecure attachment is associated with difficulties in attentional control and

emotion regulation, and that mindfulness has been implicated in the development of

both. These links have been supported by neuroscientific studies (Goldin & Gross,

2010; Teper & Inzlicht, 2013), and there is a nascent body of work that suggests that

mindfulness training can positively impact both attention and emotion regulation (e.g.

Hölzel et al., 2013). Accordingly, recent years have seen the introduction of

mindfulness-based relationship enhancement for couples (Carson, Carson, Gil, &

Baucom, 2004, 2006) and mindfulness-based parenting programs (Duncan &

Bardacke, 2010; Bögels & Restifo, 2014).

One area that remains relatively unexplored is how mindfulness can be

implemented within the therapy room. Research suggests that the relationship between

therapist and client is a strong predictor of therapeutic outcome, regardless of

theoretical approach (Martin, Garske, & Davis, 2000; Cooper, 2008). Given its

potential to enhance interpersonal relationships, it might be expected that mindfulness

could have salutary effects in this regard. Further benefits might arise from enhanced

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attentional control and emotion regulation, allowing the client to identify areas of

desired change and to ‘stay with’ difficult emotions (Mallinckrodt, Porter, &

Kivlighan, 2005).

Existing research in this area has focused on therapist mindfulness. Several

studies (e.g. Grepmair et al., 2007; Ryan, Safran, Doran, & Muran, 2012) suggest that

enhanced therapist mindfulness might sharpen therapeutic skills such as empathy and

active listening. Others (Shapiro, Brown, & Biegel, 2007; Schure, Christopher, &

Christopher, 2008) have recommended mindfulness meditation as a form of self-care

for therapists. Wexler (2006) found significant positive correlations between therapist

mindfulness and the strength of the therapeutic alliance, as rated by therapist and

client. Razzaque, Okoro, and Wood (2013) found therapist mindfulness to explain

32.4% of the variance in therapeutic alliance, although this study only used therapist

ratings.

To date, however, there is very little research into how mindfulness meditation

might be used within the therapy room to improve the therapeutic relationship and

facilitate the process of therapy. Even a book specifically on the topic of mindfulness

and the therapeutic relationship (Hick & Bien, 2008) has little to say on this subject,

focusing instead on links between mindfulness and various theoretical approaches,

and mindfulness as a way of enhancing specific therapeutic skills. The current study

therefore aims to address this gap in the literature, by asking therapist and client dyads

to engage in joint mindfulness meditation at the start of therapy sessions. Because this

is an unexplored area, the study is exploratory and qualitative in nature, with the aim

of finding out how therapists and clients experience joint meditation. In light of

Counselling Psychology’s relational stance, and the wider recent trend in psychology

to view the relationship between therapist and client as a co-constructed,

intersubjective space (Mitchell, 2004), it was considered important to approach the

experience from both sides of the therapeutic relationship; hence the decision to

interview both therapists and clients.

The following main research question was generated: ‘How do therapists and

clients experience brief, in-session joint mindfulness practice, in terms of the

therapeutic relationship and the process of therapy?’ The following secondary

research questions were also generated: (a) Do therapists and clients perceive the

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experience of joint meditation differently? (b) Are therapy sessions that begin with a

joint mindfulness meditation qualitatively different from those that do not?

Method

Design

A qualitative approach was chosen for this study, as the aim was to find out what it is

like to meditate, jointly, at the start of therapy sessions, rather than to measure

quantifiable effects of said meditation. Specifically, there was a focus on the

individual experience of participants, and so interpretative phenomenological analysis

(IPA; Smith, Flowers, & Larkin, 2009) was considered to be an appropriate research

method. The epistemological approach of IPA is phenomenological and idiographic,

and is concerned with the uniqueness of individual experience (Smith et al., 2009).

This emphasis on the subjectivity of individual experience is appropriate for a

study of mindfulness meditation, which requires that the meditator adopt an

observing, non-judgemental stance towards mental and physical phenomena that arise.

In other words, there is no ‘right’ or ‘wrong’ way to meditate mindfully, and no goal

is pursued other than bringing attention to what is occurring in the present moment,

and so the experience of mindfulness meditation will be different for each person who

practises it. IPA also acknowledges the researcher’s role in the process of data

gathering, emphasising that the researcher is involved in a process of making sense of

the participant, who is making sense of their experience. The process therefore

involves a ‘double hermeneutic’ (Smith & Osborn, 2008).

Why qualitative?

The choice of a qualitative approach in this first research project reflects several

considerations. The most important relates to the research question and what the

current study hopes to discover, which is what it is like to meditate with another

human being within the context of a therapeutic dyad. There is a relative lack of

literature addressing what it is like to engage in mindfulness meditation. The vast

majority of research studies on mindfulness are quantitative, and therefore are

concerned with measurable outcomes: pain and pain acceptance (Morone, Greco, &

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Weiner, 2008), depressive symptoms (Sephton et al., 2007), delay in relapse of

depression (Teasdale et al., 2000), anxiety (Anderson, Lau, Segal, & Bishop, 2007),

rumination (Deyo, Wilson, Ong, & Koopman, 2009), and parent-child relationship

quality (Coatsworth, Duncan, Greenberg, & Nix, 2010). However, even the few

qualitative studies that do exist also focus mainly on outcomes: Bihari and Mullan

(2012) explored ‘changes in relationships’, while Morone, Lynch, Greco, Tindle, and

Weiner (2008) studied the effects of mindfulness meditation on chronic pain.

The existing body of literature, then, has little to say about the experience of

meditation during the process itself. The current study hopes to address this imbalance

by asking participants to report not just any changes that they noticed, but also what

they experienced during the actual joint meditation. Qualitative enquiry is therefore

appropriate for what the study hopes to achieve.

Moreover, previous qualitative studies have tended to focus on specific

interventions. Mason & Hargreaves (2001) used MBCT; Chadwick, Kaur, Swelam,

Ross, and Ellett (2011) adapted the MBCT program for their study; Mackenzie,

Carlson, Munoz, and Speca (2007) used MBSR. Participants in these studies reported

notable effects of engaging in these mindfulness-based interventions; however it may

be that the ‘active ingredient’ in such studies was located somewhere other than the

experience of meditation: MBCT (Segal, Williams, & Teasdale, 2002) involves an

explicit early focus on turning towards low mood and depression; MBSR (Kabat-Zinn,

1982) incorporates a whole-day retreat between weeks 6 and 7; both include group

discussion, performing everyday tasks mindfully, mindful movement, the setting of

homework, and didactic material – in the case of MBSR, this involves educating

participants on the links between stress and illness, while the MBCT course includes

the teaching of cognitive formulations of depression and anxiety.

The current study, in contrast to most other research involving mindfulness

meditation, narrows the focus to the experience of meditation itself, and does not

include those other elements that may also have a significant influence on participants.

Finally, a qualitative, interpretative approach is congruent with what I hope to

achieve with the research, which is to explore what may go on within and between

two people when they meditate in the therapy room, thus potentially enhancing the

understanding of therapists who use such a technique or are thinking of doing so.

Quantitative approaches, which are more likely to be separated from ‘real-life’

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contexts, are less suited for the pursuit of such knowledge (Sandelowski, 1996). The

emergence into popularity of qualitative research methods has perhaps contributed (as

has the development of counselling psychology as a discipline) to the reduction of

distance between academic psychology and therapeutic practice, which, it has been

argued, had been drifting apart from one another (Legg, 1998, p.7).

Why interpretative phenomenological analysis?

As stated above, there is a deficit of knowledge within academic literature concerning

the phenomenological aspects of meditation, and an even more pronounced lack of

understanding of what it is like to meditate jointly with someone else. It therefore

stands to reason that the method of inquiry should lend itself to an understanding of

phenomenology. Interpretative phenomenological analysis (IPA; Smith, Flowers, &

Larkin, 2009) offers an appropriate research method.

The locus of interest in the current is rather specific in comparison to much

qualitative research, and indeed most IPA studies, which often focus on individuals’

experience of processes that occur over extended time periods – the experience of

having a chronic illness, for example, or of attending a training programme. By

contrast, the focus of this study is on the experience of two short joint meditations and

the therapy sessions that followed.

Nevertheless, IPA is an appropriate method to use, as the aim of this study is

to understand individual experience. IPA, an idiographic approach, can aid this

process significantly. Meditation is a personal experience, and mindfulness meditation

particularly so, given its aim to foster awareness of ‘what is already there’. Yardley

(2000) proposes that qualitative research is well suited to understanding variation

between individuals. A method with an idiographic focus, such as IPA, is particularly

suited to this, as it does not seek to describe a universal experience, but to the contrary

embraces individual differences (Spinelli, 1989). In this sense it may resonate more

fully with the experiences of readers, even though specific details will likely be

different. Indeed, one critique of nomothetic research methods is that they describe an

‘average’, ‘ideal’, or ‘paradigmatic’ case that does not (and perhaps cannot) have a

counterpart in the actual world (Kastenbaum, cited in Datan, Rodeheaver, & Hughes,

p.156).

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IPA engages with the ‘hermeneutic circle’, in which understanding of a text

takes place at several levels, each dependent on the others. Thus the reader of a text

needs to be aware not only of the text itself, but also the wider context in which the

text was produced, and the context of the reader herself or himself. This idea has been

influential on the development of IPA, which does not seek to bracket assumptions but

rather attempts to use them in the process of interpretation (Willig, 2008, p.56).

Schleiermacher (cited in Smith, Flowers, & Larkin, 2009, p.22) even proposed that the

interpreter can achieve ‘an understanding of the utterer better than he understands

himself.’ Moving too far along the route of privileging the interpreter, however, can

risk the researcher imposing meaning on the text that is hard to justify.

Good practice in IPA, therefore, involves something of a balancing act

whereby the researcher attempts to hold in mind the hermeneutic circle and move

between different levels of understanding: How to make sense of a particular utterance

in light of the entire interview? Or in the context of all interview data collected, or

even of the wider discourse surrounding the subject matter? In turn, how does the

individual utterance influence our understanding of these wider contexts? And what

about the assumptions that the researcher brings?

Why not other research methods?

The two major qualitative methods that presented themselves as alternatives to IPA in

this study were grounded theory and discourse analysis. This section explicates why

these options were not used in the current study.

Approaches that place language at the centre of inquiry have found great

popularity within the last 25 years, reflecting a shift away from positivism and

objectivism, and towards a postmodernist approach that acknowledges the co-

existence of multiple perspectives on the same phenomenon (Shaw & Frost, 2015).

Discursive psychology (Edwards & Potter, 1992)) and Foucauldian discourse analysis

(Parker, 1992) reject the cognitivist notion that language is a direct representation of

reality. Instead, speech is viewed as social action, and is interpreted within the social

context and with an emphasis on what it achieves (or hopes to achieve) (Willig, 2008,

p.94). Such an approach also entails engaging with the likelihood that participants in a

research study tailor their responses (consciously or unconsciously) according to what

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they believe the researcher wants. For example, in both of my research studies, some

participants may have oriented towards expressing a positive view of mindfulness,

because they might have assumed that I believe mindfulness to be effective.

While the approach of the current study accepts that language is not a direct

window onto an unchanging reality, discourse analysis was not chosen as a research

method, largely because its main interest is in discourse as produced in a public

context. Its epistemological thrust is towards understanding how versions of reality are

produced and constituted in language (Willig, 2008, p.107), and is not concerned with

ideas of subjectivity and intentionality. The current study, by contrast, hopes to

understand the essence of the experience of joint meditation, with the caveat that this

‘essence’ is necessarily elusive and accessed after the fact only through language, in a

joint venture by researcher and participant.

The parameters of the current research study, moreover, perhaps do not lend

themselves to a discourse analysis approach. Ideally, discourse analysis should

analyse naturally occurring text and talk (Hepburn & Wiggins, 2005). There are

doubts as to the extent this is possible, in terms of ethics and logistics. One way would

be to record a group discussion of mindfulness within the context of an MBCT or

MBSR course (entailing the willing and informed consent of all group members,

which itself would present an obstacle). Another interesting approach to how the

concept of mindfulness is represented within the field would be to apply DA to

existing literature on mindfulness – this literature is hugely influential in how

mindfulness is understood by people, either through their direct reading or second-

hand through mindfulness teachers. Some responses in my own research reflected

‘standard’ definitions that I have read within the literature (this is further discussed in

the equivalent section of the discussion of the second research project).

However, both a recording of a group discussion and an analysis of the corpus

of literature are removed from the context in which I would like to explore

mindfulness, i.e. the dyadic relationship between therapist and client. It would be

hypothetically possible to arrange a discussion group, but undesirable to do so as –

even setting aside the logistics of gathering all participants in the same room – it

would entail breaching confidentiality of the research participants, half of whom were

clients in therapy and thus represented a participant group for whom matters of

confidentiality and anonymity were especially important.

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Grounded theory, on the other hand, could have been used to investigate the

experience of joint meditation between therapist and client. Glaser (1978), one of the

founders of the grounded theory approach, proposed that the first question asked by

the grounded theorist should be ‘What’s happening here?’ Although the ‘basic’

quality of this question is appealing in the context of the current study, which explores

a scenario not previously investigated within the literature, it also implies a positivist

approach in its implication that there is a ‘something’ that is objectively occurring,

and that this ‘something’ can be accessed through the accounts of those participating

in the process.

This would be at odds with the author’s own stance that within such a study

there are multiple realities at play (those of the participants, the researcher, and the

wider cultural context), informing and influencing each other, and that these realities

are fluid rather than fixed: two joint meditations that are superficially the same can be

experienced radically differently according to what else is going on for the

participants at that time. It would also be inconsistent with this study’s particular

emphasis on individual subjectivity in the process of meditation. The aim is not to

extrapolate from the experiences of participants and make universal claims, but solely

to understand what it might have been like for these particular people to engage in the

process of joint meditation at this particular time, with the suggestion (but not the

expectation) that these experiences might resonate with the experiences of others who

have engaged in a similar process.

The focus of this first research project, furthermore, would be somewhat

narrow for a grounded theory approach. It would be inappropriate to attempt to

develop a theory of such a specific situation; this study is interested in how the world

is experienced within a particular context at a particular time (Willig, 2008, p.52),

without necessarily extrapolating to a wider context.

Participants

Participants in the study were four therapist-client dyads, comprising eight

participants in total. This size was considered appropriate as it would allow for a range

of experiences (and insure, to a degree, against participant attrition) while avoiding a

prohibitively long process of gathering, transcribing, and analysing data (Smith,

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Flowers, & Larkin 2009). It was not required that therapists were working from a

particular theoretical approach, but it was stipulated that the therapy itself should not

be specifically mindfulness-based, as it was desired that meditating together would be

a ‘fresh’ experience for therapist and client.

Participants did, however, report that they were familiar to some degree with

the concept and practice of mindfulness meditation. When asked how they understood

the term ‘mindfulness’, all mentioned present-moment awareness, and all except two

referred to acceptance or non-judgement. None of the participants had previously

engaged in joint meditation in a therapeutic setting.

Ages of participants ranged from 31 to 62, and dyads had been engaged in

therapy for periods ranging from 18 months to 10 years. Participant information is

presented below, with therapists and clients paired (all names have been changed):

Table 1. Participant information

Dyad/Names Age Sex Type of therapy Length of therapy

1. Claire (therapist) 58 F Psychodynamic 18 months Maria (client) 31 F

2. John (therapist) 44 M CBT 10 years Alice (client) 31 F

3. Jane (therapist) 52 F CBT 18 months Ryan (client) 44 M

4. Richard (therapist) 62 M Psychodynamic 2 years Clarissa (client) 43 F

Procedure

The recruitment process was as follows. Therapists in private, non-NHS settings were

contacted via email and personal contacts, and provided with an outline of the study.

They were asked to approach any clients whom they thought might be interested in

taking part. Therapists and clients who expressed an interest were then provided with

a more detailed summary of the study, its rationale and procedure, and, if they still

desired to take part, were asked to sign a consent form (appendix 1).

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Participants were provided with an information sheet (appendix 2) and an

audio file of an eight-minute guided mindfulness meditation (mindfulness of the

breath and body; Williams & Penman, 2011), to be played on a digital device. They

were asked to participate in the meditation together at the start of two therapy

sessions, which were separated by a session without the meditation. The number of

meditation sessions was set at two, with the intention that this would allow

participants to observe qualitative differences between the sessions with meditation

and those without, and between the two meditation sessions themselves. It was also

hoped that by limiting meditation sessions to two, there would be minimal disruption

to the normal course of therapy, and less risk that sessions would be missed.

Following completion of the second session with the meditation, therapist and

client were contacted to arrange a suitable time and place so that they could be

interviewed, separately, about their experience of engaging in joint mindfulness. All

interviews took place within five days of the second session with meditation, with the

exception of one interview, which was delayed by a week due to illness. Interviews

were semi-structured, to provide some degree of consistency across interviews while

allowing flexibility. This approach offers a balance between controlling the direction

of the interview and allowing the interviewee to contemplate and redefine their

thoughts during the interview (Willig, 2008). Mean interview length was 25 minutes.

Questions covered participants’ knowledge, understanding, and previous

experience of mindfulness and meditation, their experience of joint meditation with

their therapist/client, their experience of the sessions in which the meditation took

place, and their thoughts about what place mindfulness or meditation might hold for

them in future (see appendix 3). Interviews were recorded on a digital recorder.

Analysis

Following completion of the interviews, recordings were transcribed and the resulting

transcripts were analysed using interpretative phenomenological analysis (IPA).

Analysis was carried out according to recommendations by Smith, Flowers, and

Larkin (2009). Initial exploratory notes were made on a first reading of each

transcript, which were then translated into tentative themes after a second reading.

These themes were then grouped into provisional superordinate theme clusters, before

moving on to the next transcript. As analysis of each transcript commenced, the

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researcher attempted as far as possible to approach the new text with a ‘fresh’ eye, and

to forget the themes that had arisen during analysis of previous texts.

When this stage of analysis was complete, themes and clusters across all

transcripts were compared, with particular attention paid to points of convergence and

divergence between the two members of each therapist-client dyad. A final table of

themes and clusters was then compiled (see appendix 5), with regular reference back

to the transcripts in order to preserve the meaning of participants’ statements – IPA,

which has roots in the phenomenology of Husserl and Merleau-Ponty (Smith,

Flowers, & Larkin, 2009), emphasises an idiographic approach to knowledge; it

focuses on the particular. With this in mind, care was taken not to lose sight of

participants’ original utterances.

Credibility

During all stages of the research process, Yardley’s (2000) guidelines on credibility

were considered. Sensitivity to context was important in terms of acknowledging the

‘double hermeneutic’ of IPA and the researcher’s role in co-constructing meaning, and

by grounding analysis in participants’ statements. The study strived to demonstrate

commitment and rigour by following guidelines by Smith et al. (2009) in how to

conduct IPA. Transparency and coherence were displayed through clear descriptions

of methodology and procedure, and by researching an under-examined area, and

conducting a unique study, it is hoped that the current study will have impact and

importance to readers.

All materials, notes, interview transcripts and drafts were retained and ordered

in such a way that an independent observer could trace the process of research,

analysis, and writing (the ‘virtual audit’; Yin, 1989).

Ethical considerations

Conducting psychological research requires consideration of ethics at every stage of

research, from the research design stage through data collection, analysis, write up,

and publication. The BPS (2009, 2010) has published guidelines for practitioners and

researchers, which emphasise that they are to be used as guidance rather than step-by-

step instructions. Reflexivity is paramount, or in other words, ‘thinking is not

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optional’ (BPS, 2009, p.5). That there is no single method of ensuring that a piece of

research adheres to good ethical practice is borne out by the existence of various

approaches within the field of ethics (Hammersley & Traianou, 2012): deontology

(which focuses on the action itself), consequentialism (which focuses on outcomes),

situationism (which takes an idiographic approach), virtue ethics (which places

emphasis on the character of the actor), and relational ethics (which considers ethics in

terms of relationship).

Brinkmann and Kvale (2008) also discuss the distinction between micro ethics

and macro ethics. The former relate to the researcher’s interaction with participants,

including questions of safety, anonymity, confidentiality, and informed consent. The

latter are concerned with the research’s situation within the wider world, and involve

asking how the findings will be disseminated and applied, and the potential benefits or

harm that could ensue. The ethical considerations taken on by ethics committees are

likely to be questions of micro ethics; therefore there is more onus on researchers to

be mindful of macro ethics (Steffen, 2016).

Engaging with existing ethical frameworks such as those published by the

BPS, and securing approval from a university ethics committee, are just two aspects of

attending to ethics during a research project. Gaining ethical approval does not mean

that the research no longer needs to think about ethics; in fact, it is after this stage that

ethical mindfulness (Bond, 2000) is particularly important as there may be fewer

checks on the progress of the research. This is why it is crucial for researchers to

consider their own moral code and decision making process when carrying out

research, as there might not be hard and fast rules to follow at every stage of the

process. Steffen (2016, p.33) notes that this is particularly so during qualitative

research projects, in which researchers might be more likely to be faced with the

unexpected.

For the qualitative researcher, the importance of reflexivity is even more

pronounced, due to the particularly involved nature of the researcher’s role in shaping

data collection, analysis and presentation. When carrying out interviews as a method

of data gathering, psychologists can employ skills gained from therapeutic practice,

such as empathic reflection. This can serve to build rapport and help interviewees to

feel that they are safe and that they are being heard. There is also the potential for

harm here, though, if the researcher falls prey to the temptation to offer a ‘semi-

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therapeutic relationship’ (Brinkmann & Kvale, 2008, p.267): Creating a sense of

intimacy between researcher and participant may lead to more personal disclosures

from participants, but may tacitly invite the participant into a relationship that will not

endure after the interview is over. If pre-meditated by the interviewer, this may

amount to an abuse of power; ethical researchers need to remain aware of such

possibilities in order to avoid such a situation arising.

Reflexivity is also of the utmost importance during the process of analysis,

where the power differential between researcher and participant may be even more

pronounced, due to the participant no longer being able to speak for herself or himself.

Due to the ‘invisible’ nature of the process of interpretation, the researcher is in an

especially privileged position at this stage (Doucet & Mauthner, 2012, p.127). A

qualitative researcher will never be able to fully and precisely capture the experience

of another; the process of analysis and interpretation will always result in some

meaning being lost or altered. IPA acknowledges this in its engagement with the

hermeneutic tradition. What is important is transparency about these stages of

research, to minimise the risk of imposing meaning on participants who are not

involved in this stage of research, which, if done recklessly or deliberately, may

amount to what Willig (2012, p.45) terms ‘interpretative violence’.

Ethical approval was sought and granted by the Faculty of Arts & Human

Sciences Ethics Committee at the University of Surrey (see appendix 4). Informed

consent was obtained from participants, who were informed that they retained the

right to withdraw from the research process at any time, without giving a reason. To

preserve the confidentiality of therapy, participants were not asked about the specific

content of therapy sessions (although clients were free to discuss content if they

desired), and therapists were not given access to responses given by their clients, and

vice versa. Recordings and transcripts were coded and stored separately to ensure

anonymity.

Efforts were also made to adhere to the four principles of ethical research as

laid out by the British Psychological Society (BPS, 2010). Respect for the autonomy

and dignity of persons was addressed by gaining informed consent and ensuring that

participants remained anonymous and their confidentiality preserved. The researcher

aimed to maximise the scientific value of the project by following good practice

guidelines (see ‘Credibility’). It is hoped that the study will fulfil the criterion of

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social responsibility in that the findings can potentially be instructive to therapists

who use mindfulness, or are considering doing so, in their work. Maximising benefit

and minimising harm is the final principle named by the BPS. The researcher aimed to

minimise harm by conducting interviews in a sensitive manner, and informing

participants that they could withdraw from the process at any time. It is also hoped

that the process benefited participants by engaging them in a practice that is designed

to enhance psychological wellbeing. It is worth unpacking these principles further, to

consider how they might apply specifically to the participant groups in this study.

Respect for the autonomy and dignity of persons

This principle is associated with the value statement contained within the BPS Code of

Ethics and Conduct (2009, p.10): ‘Psychologists value the dignity and worth of all

persons, with sensitivity to the dynamics of perceived authority or influence over

clients, and with particular regard to people’s rights including those of privacy and

self-determination.’

An important issue regarding this principle involved recruitment of

participants, which involved first recruiting therapists and then clients through

therapists. This raised questions about power and influence that were considered

during the process of risk assessment (see appendix 6, ‘Risk assessment summary’).

All therapist-client relationships involve a power dynamic, in that the therapist claims

knowledge and experience relative to the client, who is typically seeking help from the

therapist to help with emotional, cognitive, or behavioural problems in his or her life

(Bond, 2000). This dynamic inheres even when the therapist is consciously attempting

to minimise the power differential (Shillito-Clarke, 2010, p.514).

There was a risk, then, that clients might feel pressured by their therapists to

participate in research, or that therapists might worry about being accused of doing so.

These issues were considered during risk assessment, and several measures were put

in place to attempt to minimise these risks. One safeguard was that no payment was

offered to participants, as it might act as an incentive for therapists to encourage client

participation. However, even if there were no direct incentive for therapists, there was

a risk that a therapist might actively encourage a client to take part if they believed it

to be in the client’s best interests. Although such an action might be well-intentioned,

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this would impinge on the client’s autonomy and represent what Bond (2000) terms

‘parentalism’.

Therefore, when contacting therapists, guidelines were offered as to who might

be willing and suitable to take part. It was recommended that potential participants

should not be in crisis or in acute psychological distress; a recommendation based on

the principle of ‘fair subject selection’, which includes avoiding the recruitment of

more vulnerable members of the population (Emanuel, Wendler, & Grady, 2000,

p.2704). It was also recommended that clients should have been in therapy for a

period of over six months. This last recommendation was based on the rationale that

clients in longer-term therapy would be more likely to have established a robust

therapeutic alliance with their therapist; therefore, they were considered less likely to

feel pressured into participating, and the alliance would be less likely to be affected by

the introduction of an ‘outside element’.

Guidelines were also offered to therapists as to how to speak to them about the

study. Therapists were requested not to ask clients to participate in the study, but

simply to make them aware of it as something they might be interested in, perhaps by

giving them a copy of the study outline. It was emphasised that therapists should make

clear to clients that there was no pressure or expectation to participate.

Another aspect of ethical research practice that is covered by respect for the

autonomy and dignity of persons is informed consent. To obtain informed consent,

participants must be ‘given ample opportunity to understand the nature, purpose and

anticipated consequences of any professional services or research participation’ (BPS,

2009, p.12). Participants were provided with information about mindfulness, the study

and how data would be handled, and assured of their confidentiality and the right to

withdraw from the process at any time. They were invited to ask questions about any

aspect of the research that was unclear or for which they wanted further information.

Informed consent might also involve offering to provide participants with a copy of

the finished research report (Olsen, 2010, p.95). This raised a dilemma in the current

research: doing so would actively expose the responses of therapists and clients to

each other. Although the research would eventually be accessible online, and so this

eventuality could not be guarded against completely, the decision was made not to

offer copies of the research report to participants. A further safeguard against the risk

of participants being identified by someone attending to this research was the removal

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of the annotated transcript (previously included as an appendix) before publication of

the e-thesis.

Scientific value and social responsibility

According to the BPS (2010, p.9), poorly designed research risks, at the very least,

wasting resources. At worst, it can result in misleading results being published and

cause harm. It also impacts negatively on participants, in that research involving

human participants is only justified (in terms of risk) if it will result in society gaining

knowledge (Emanuel et al., 2000). To carry this point further, even well designed

research can be considered of little or no scientific value if it fails to contribute to

existing knowledge, and is considered a waste of the resources of the researcher, the

provider of funding, and anyone who reads it (Vanderpool, 1995). If a study repeats or

overlaps substantially with previous work and yields results that have already been

accepted within a scientific community, it adds nothing new to the field, and therefore

has not satisfied either of the criteria under consideration here. Scientific value and

social responsibility, then, are intimately linked.

In this study, as stated, the researcher attempted to achieve scientific value by

following an established research protocol, interpretative phenomenological analysis

(IPA; Smith, Flowers, & Larkin, 2009). This provided structure for carrying out

research that was led not by the whims of the researcher, his supervisor, or

participants, but by methodological proposals laid out by highly experienced scholars

in the field of qualitative research.

Also contributing to the scientific value and social responsibility of the

research was that it involved inquiry into a topic that has gained little attention within

the existing literature. There have been many quantitative studies of mindfulness, as

well as some qualitative research. However, it has tended to focus on mindfulness as

practised alone, and often in the context of formalised mindfulness interventions such

as the MBSR and MBCT courses. This study involved a novel focus on joint

mindfulness meditation as practised within therapy sessions, and as such did not

repeat proven results.

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Maximising benefit and minimising harm

The principles of beneficence and non-maleficence, drawn from moral philosophy,

have long been used to assess the ethicality of research involving human participants

(Bond, 2000). It is accepted that most research involving humans will involve a

degree of risk. There is no universal benchmark for an acceptable level of risk; rather,

this is judged in proportion to the anticipated benefit accruing from the research. This

is known as the risk-benefit ratio (Emanuel et al., 2000), and is covered by articles 18,

20, and 21 of the Declaration of Helsinki (World Medical Association, 1964).

Some of the risks of harm to participants are listed above, under Respect for

the autonomy and dignity of persons, along with strategies aimed at mitigating these

risks. Other potential harm was considered, with relation to the interview process. One

consideration related to the time and location of interviews. Initially it was planned

that interviews would take place after the second therapy session with joint

meditation. Conducting interviews at this time, when memory of the experience was

fresh in participants’ minds, would have contributed to maximising the benefit of the

research in terms of the knowledge being produced. However, conducting interviews

soon after a therapy session might have carried the risk of harm to participants, by

asking them to participate in the research process at a time when they might be in

distress or feeling vulnerable after therapy. The decision was made in this instance to

prioritise the minimisation of harm, and interviews were instead scheduled to take

place within a few days of the final therapy session, rather than immediately

afterwards.

With regard to the interview process itself, it was decided beforehand and

stated explicitly to participants that the researcher would not ask therapists to divulge

details about their clients, and would not ask clients or therapists to reveal explicit

content of therapy sessions. The aim of this was to assure both parties that the

confidentiality of therapy would be protected, and to foster an atmosphere of trust and

safety. I employed ‘ethical mindfulness’ (Bond, 2000) during interviews, by keeping

these issues in mind when asking questions. Whenever possible, I allowed participants

to lead the discussion, and attempted to limit the number of questions I asked. During

interviews I engaged in active listening and used empathy in my responses; it was

hoped that this would encourage participants to expand and reflect on their responses,

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while providing a safe space and allowing them to remain in control of what they

disclosed (Braun & Clarke, 2013).

A further consideration was the potential for the mindfulness exercise to stir up

emotions in participants. Mindfulness promotes the direction of attention towards

whatever one is feeling in the moment, whether it is positively or negatively valenced,

or neutral. This can sometimes lead to a temporary exacerbation of emotional distress

(Cioffi, 1993). This was taken into account during the risk assessment, and it was

concluded that, as the meditation would take place in the safe space of the therapy

room, with the chance for clients to discuss any distress with their therapist. There was

also potential, of course, for therapists to feel distress after meditating; however, there

was not thought to be a greater risk of this happening than during the course of a

normal therapy session, when what is being discussed can sometimes raise issues that

are sensitive for the therapist. Therapists would also have support systems in place,

including supervision and self-care regimens.

Insufficient consideration was perhaps given to the potential for somatic

activation, however. The guided meditation used in the study was a breathing exercise

titled ‘mindfulness of the breath and body’; what was not apparent to the researcher

was that this exercise could increase anxiety in a person with anxiety relating to the

body, which occurred with one participant during the first meditation. This could be

considered a failing on the part of the researcher. The ethical principle of

responsibility (BPS, 2009, p.19) requires that researchers ‘Consider all research from

the standpoint of research participants, for the purpose of eliminating potential risks to

psychological well-being, physical health, personal values, or dignity.’ Although I had

attempted to uphold this principle during the design of the study and the process of

risk assessment, my failure to address, specifically, the potential for somatic

activation, might have exposed the participant to distress that could have been

mitigated if greater attention had been paid to this possibility.

What I can take from this is that, when conducting research in future, it would

be beneficial to elicit input from a wider range of sources regarding potential for

harm. The risk assessment for this study was carried out in collaboration with my

research supervisor; ideas and information could also have been stimulated from

discussion with peers. Closer consultation with participants with regard to potential

harm would also help to minimise the risk of this harm, or exclude the participant

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from the research process if this risk was considered greater than the potential for

benefit. Of course, such a discussion would have to be handled sensitively, in order to

preserve respect for the autonomy, privacy, and dignity of participants.

Results

The results of the semi-structured interviews are presented in this section, which

begins with a summary of participants’ understanding and previous experience of

mindfulness. The section continues with a presentation of themes and theme clusters

that were gleaned from the data, before concluding with participants’ remarks about

their overall experience and their expectations for future mindfulness practice.

Experience of joint mindfulness: Themes and clusters

Three superordinate themes were developed from the data: Experience of meditation

within the session, Effects on the therapeutic relationship, and Effects on the process

of therapy. See appendix 5 for a table of the themes.

Experience of meditation within the session

This theme cluster gathers together four themes that related to how participants

experienced the two joint meditations: Heightened awareness, Sensing the other’s

presence, Difference between the two meditations, and Divergent experiences.

Heightened awareness

In keeping with the professed aims and observed effects of mindfulness, participants

reported heightened awareness during the meditation exercise. Much of this awareness

was of bodily sensations, which is perhaps to be expected, given the focus of the

guided meditation on breath and body. Two participants reported that their attention

was directed towards the heart:

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Claire (therapist): There’s something about the meditation which drop’s one’s consciousness down into… the heart area, or the gut.

Clarissa (client): [I noticed a] slow heart rate. I felt calm.

While, for Clarissa, this bodily awareness was associated with calm, another

participant reported the opposite effect, and that she had actively disregarded the

instructions on the recording in order to lower her anxiety:

Alice (client): I had to change the instructions in my head to be more focused on external things such as if I could hear birds outside… because I don’t like focusing on bodily sensations at all.

Researcher: You’re not so keen on focusing on the body aspect?Alice: Yeah, I find it quite distressing, and I think [so would] anyone with a somatoform related disorder […] I spend half of my life trying to avoid bodily sensations, so I wouldn’t want to sit somewhere and then try and focus on them.

Another participant noted that she was more aware of her surroundings during the

meditation:

Jane (therapist): I was very conscious of all the creaks and groans of the building. [There was] an ice cream van, I could hear the music playing, I’d never noticed it around here before. So we became really conscious of the building, the area slightly around us.

There are potentially contradictory messages in Jane’s response. Viewed from one

perspective, it might seem that this awareness might be better termed ‘distraction’.

‘Creaks’ and ‘groans’ are sounds that one might associate with a haunted house rather

than a modern therapy practice (where the therapy in question took place). Moreover,

ice cream vans, heard through an open window while engaged in a ‘work’ task, are

emblematic of childhood desires to be elsewhere. From an alternative perspective, it is

interesting to note that Jane referred to ‘we’ and ‘us’, suggesting a greater awareness

of the client’s experience (although she did not specify whether this was her felt sense,

or knowledge that she had gained from comparing experiences with the client at the

end of meditation). Awareness of the other during meditation is described in the next

theme.

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Sensing the other’s presence

Participants also reported that they were aware of the presence of their meditation

partner. Notably, three of the four clients reported lower awareness of the other during

the second meditation, due to familiarity with the process:

Clarissa (client): The knowledge that he was there kept popping back into my mind. But… much less so the second time.

Therapists also described being aware of their client. John, whose client Alice had

experienced the first meditation exercise as distressing (see ‘Divergent experiences’,

below), described increased concern for her welfare during the second exercise:

John (therapist): In the second meditation, I was very aware of the client. I think that was because I was aware of how they had experienced the first meditation, as quite anxiety provoking.

Because he had been unaware of the client’s distress during the first meditation, John

perhaps felt he had to compensate for this by remaining vigilant to her experience

during the second meditation.

Difference between the two meditations

Because mindfulness meditation is an exercise in non-striving, recognition, and

acceptance of what is already there, it is to be expected that each meditation session

will have its unique flavour. Nevertheless it was striking that interviewees reported

finding it easier to engage with the process during the second meditation:

Jane (therapist): I think I did it better the second time.

Researcher: What do you mean by ‘better’? Jane: I think I really did try to focus on my breathing, focus on my body, being part of the environment. Whereas the first time it was harder.

Jane’s statements imply that she perceived a standard against which she measured her

participation in the exercise, placing value judgements on how well she had

‘performed’. One can perhaps also detect some reticence about the first meditation

practice, in that she seems to suggest that she had not ‘tried’ to focus on her breath and

body during the first meditation.

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Two clients, Alice and Clarissa, described feeling less self-conscious during

the second meditation exercise, and attributed this to being more familiar with the

process. Another result of this familiarity was that, for several participants, the second

meditation exercise seemed shorter, with two participants reporting feeling surprised

when the meditation ended:

Alice (client): The second one didn’t seem to be that long, and I was surprised when it had finished.

Ryan (client): The second time… I remember feeling quite surprised when the bell rang, and thinking, ‘God that went really quickly.’

One way of interpreting this is that, during the first session, participants might have

had concerns that the meditation would intrude into their therapy and reduce the

available time for talking (see the theme ‘Sense of intrusion’). Perhaps, having been

through the experience once and realising that it did not prevent the session from

being used well, participants were less concerned about losing time from the session

and therefore experienced the meditation as shorter.

Divergent experiences

One dyad, John and Alice, experienced the first meditation very differently from each

other. As noted previously, Alice found the mindfulness exercise distressing. This is

how the two participants described the experience:

Dyad 2John (therapist): I was feeling quite relaxed, and quite chilled out, because I’d enjoyed the mindfulness experience. My client was feeling, I think, significantly less relaxed and chilled out, having got a bit activated. Alice (client): In the first session I felt like he really got something out of it and was in a different zone to me, whereas I found it really distressing, so I found that although we’d just gone through the same shared experience, we were worlds apart in a sense. Whereas in the second one it felt like we were kind of more on the same page.

It may be that Alice’s sense of the distance between her experience, and that of her

therapist, added to her anxiety. Certainly, the metaphors she uses demonstrate just

how acutely she felt this distance: She sensed her therapist being in a ‘different zone’,

which is then reconfigured in even bigger terms when she states that they were

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‘worlds apart’. When recalling her experience of the second meditation, she hints at a

sense of intimacy in using the metaphor of being ‘on the same page’.

Two participants in another dyad, Jane and Ryan, diverged in how they

remembered the experience of meditation. Specifically, both recalled that the first

meditation session had been interrupted, but differed in their accounts of the nature of

this interruption:

Dyad 3Jane (therapist): During the first meditation we had to pause it, because the receptionist was yelling up to check that I’d got my key on me. So yeah… sorry can you repeat the question, I’ve lost my train of thought.

Ryan (client): I think we were 30 seconds in and the phone rang.

Based on their own accounts, Jane and Ryan were the dyad who engaged least with

the meditations, and also who reported least positive outcomes and the most negative

responses to the experience. There is also perhaps a parallel process occurring in

Jane’s description, in that, as she describes the process of meditation being

interrupted, her attention wanders. Although one cannot infer causation, it is

interesting to note, of all four dyads, Jane and Ryan’s descriptions of their respective

experiences seemed to correlate the least with each other (see also Effect on emotional

processes).

Effects on the therapeutic relationship

This superordinate theme encompasses three themes that described relationship

processes during the sessions that began with joint meditation, and how these might

have been influenced by the experience of meditation: Shared experience, Equality,

and Attunement.

Shared experience

The sense of a shared experience was a frequent theme found within participants’

accounts. This was valued by both therapists and clients, who seemed to welcome the

chance to engage in something together:

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Dyad 2John (therapist): When I’ve done mindfulness practices before there’s always been a sense of there being an agenda, like it’s being pushed on me. With this it was actually nice to be doing something together, it didn’t feel forced.

Alice (client): In the groups I’ve been to before which were therapist-led, they don’t really engage in the process with the rest of the group, so I guess there’s a sense of joint experience, or almost intimacy with the therapist, which made it seem like we were kind of reading from the same page.

Dyad 4Richard (therapist): There’s a richness about the experience of meditating with somebody else… just the presence of somebody else when you’re both doing the same thing… it’s a bit like playing music together or, more extreme, making love. Clarissa (client): There was just a sense of having had a shared experience, and having that now as part of our history, if you like. Part of the history of our relationship.

Aside from any other outcomes, the mere act of doing something in which both

therapist and client assume the same role seems to have been experienced positively

by the majority of participants. Alice’s description of the ‘intimacy’ of meditating

with her therapist is echoed by Richard’s analogies of playing music or making love.

For some dyads, this shared experience was described in terms of ‘teamwork’.

This goes further than simply stating that therapist and client were engaging in a

process together, by conceptualising that process as a task involving mutual support

and shared goals. This sentiment was most clearly expressed by Claire and Maria,

who described it in a noticeably similar way:

Dyad 1Claire (therapist): Doing the meditation together created a sense that we’re a team, we’re in this together.

Maria (client): [I felt] a sense of connection, a sense of ‘she’s there, she’s working with me’

Phrases such as ‘we’re in this together’ suggest, not just a shared experience, but also

a shared challenge. This could be interpreted as a way of responding to the novelty of

the situation, but there is also a parallel with therapeutic work in a wider sense, in that

an meaningful piece of therapy will almost inevitably be experienced, at least some of

the time, as challenging for therapist and client.

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Equality

Going further still, an idea that was expressed by several participants was that

engaging in meditation together fostered a sense of equality between therapist and

client:

Dyad 2John (therapist): In therapy in general… there’s always one of you who is the client and one who is the therapist, and there’s a different dynamic, you’re in different roles. With this it was nice to be doing the same thing together. So in that sense, I think it brought us closer together.

Alice (client): Sometimes with the groups it feels like there’s some kind of power dynamic or something, where you’ve got the group leaders who are the psychologists, and they are leading you into an experience which it feels like they are in charge of, whereas this felt a lot more natural and shared, which… I think it did change the therapist-client dynamic slightly.

Clarissa (client): I think there was something bonding about the experience. I think it’s a nice ‘equal’ thing to do… There’s an equalising element to it.

Researcher: And do you think, in general, that’s not the case in therapy? Clarissa: Yeah I do think it’s not the case in therapy. I think that there is a power dynamic… one [person] offering healing and the other seeking it. And there’s a difference there. And there’s something about this that sort of made us the same.

Participants used the phrase ‘power dynamic’ to describe the respective roles of

therapist and client, which implies the ‘difference’ mentioned by Clarissa. For this

client, engaging in joint mindfulness practice dissolved the boundary between her

therapist and herself to some extent, and made them more ‘the same’. For Alice,

listening to a recording with her therapist felt more natural than being guided by a

mental health professional.

Attunement

‘Attunement’ was a theme that emerged in several participants’ accounts, and was

described in various ways. Some participants described it in terms of rhythm or pace:

Dyad 4Richard (therapist): I think we kind of tuned into each other, so we both got into the same level of being […]

Researcher: When you say you tuned into the same thing, what level does that work on? Would it be a conscious tuning in, or unconscious?

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Richard: I think both… I imagine it probably goes through the breathing quite a lot… Not consciously, necessarily, but as you both calm down and both slow down, I think you feed back from one another about the deeper relaxation that you’re getting into… there was a calmness in the session after the meditation, so there was a sense of things having continued to slow down, and also thoughts being more clear.

Clarissa (client): I was calmer and so, I suppose, a little more slow. A little slower paced in my thinking and speaking.

Richard interpreted this in terms of unconscious processes, with therapist and client

feeding information back to each other unconsciously. He seems to suggest that this

attunement may have remained below consciousness during the session, and was only

apparent on later reflection.

For Claire and Maria, attunement represented heightened empathy and

understanding:

Dyad 1Claire (therapist): I have a sense that when two people sit together in a guided meditation, there is a kind of attunement that happens, quite naturally. Which is really important in working psychotherapeutically, to be able to get on a wavelength with a client… You ‘get it’ more readily.

Maria (client): We are on the same wavelength. We are on the same topic, she is not guessing how I feel, what’s going on. She… was there with me… she was really understanding me.

It is interesting to note that both therapist and client here use the word ‘wavelength’ to

describe their sense of attunement. As with Richard and Clarissa, there appears to be

an unconscious process at work. The therapist perceives that she understands the

client more readily, and the client perceives that she is understood, and this

phenomenon is experienced by therapist and client, without either necessarily

remarking on it.

Effects on the process of therapy

This cluster comprises six themes that related to the process of therapy, and how this

might have been affected by the experience of joint meditation: Being vs doing,

Focus, Going deeper, Effect on cognitive processes, Effect on emotional processes,

and Sense of intrusion.

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Being vs doing

Mindfulness privileges the ‘being mode’ over the ‘doing mode’ (Kabat-Zinn, 2004).

This distinction between these two modes of existence is demonstrated by one of the

dyads, John and Alice. CBT practitioner John expressed ambivalence about the

benefits of meditating within a therapy session. He valued the novelty of this shift

from doing to being:

John (therapist): It was an interesting way to start the session, from the perspective I guess of not launching in directly to grilling someone about what’s going on, how have they been...

…but shared his doubts about whether mindfulness practice engages enough with the

doing mode:

John (therapist): You need to be actually doing something with it there in the session, creating something new, sticking your hand down the toilet. Whereas a lot of the literature, I feel, seems to be saying it’s enough to just be aware, to be in the present moment in a spirit of non-judgement. But it’s not enough.

John’s ‘toilet’ metaphor implies that a mindfulness-based approach to therapy is not

active enough, and perhaps a little on the ‘safe’ side. John’s client, Alice, meanwhile,

found it difficult during the first meditation to enter the being mode:

Alice (client): The first [mindfulness exercise] seemed a bit more like a trial to endure, rather than the second one [which] seemed like a more relaxing space.

Her word choice suggests the distinction between doing (‘trial to endure’) and being

(‘relaxing space’). Although the client depicted this shift from doing to being in

positive terms, her therapist did not seem to experience it in the same way. In fact, the

metaphors he uses, of the toilet and of ‘grilling’ the client, suggest a directive

approach to therapy perhaps at odds with the ‘being’ mode promoted by mindfulness.

Focus

For several participants in the current study, engaging in joint mindfulness seems to

have had a significant effect on the focus of therapy sessions. This manifested for

some as a heightened sense of focus, and led in some cases to a shift of focus. For

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Claire and Maria, there was more focus in the sessions with meditation than in the

middle session without the exercise:

Dyad 1Claire (therapist): The two sessions where we did the mindfulness practice actually led into quite focused pieces of work, whereas the middle session was a bit more scattered, it was a bit more of a catalogue of things… our felt sense was that space opened up.Maria (client): I was more relaxed, I was able to focus and talk about something, or talk about one thing, not necessarily a hundred things – because that’s what happened in the second session when we didn’t do the exercises.

Maria also reported that the second joint mindfulness exercise seemed to change her

intentions as regards topic matter for the session:

Maria (client): We did the meditation, and… there you go, something has shifted again… I actually noticed that I don’t want to talk about the interviews, I want to talk about something else that happened that week, which was about relationships.

Perhaps significantly, following a joint meditation with her therapist, the new focus of

the session was on relationships.

Another participant, Ryan, reported that relationship issues came to the fore

after engaging in meditation. In this instance, his relationship with his therapist Jane

became a topic of the first session that began with mindfulness practice:

Ryan (client): It was the first time I’d felt strong feelings of irritation with her in the room, of her almost being the bad object. And that irritation became part of the session, quite an important part… you could say perhaps it played a part, perhaps the openness to be there, the space of giving 10 minutes allowed this to come up.

Both Maria and Ryan seem to be talking about prioritising what they wanted to speak

about during the therapy sessions. Their wording is interesting, as the shift in focus is

depicted not as a conscious decision on their part, but almost as an organic

‘emergence’ of the critical issue: ‘something has shifted’ (Maria); ‘allowed this to

come up’ (Ryan). In this sense, Ryan’s use of the word ‘space’ is noteworthy, and

echoes Claire’s statement that ‘space opened up’, and also Alice’s description of a

‘relaxing space’ (see Being vs Doing). It could be that this substitution of the being

mode for the doing mode provides space within the session for important issues to

emerge.

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Going deeper

For one of the dyads, Claire and Maria, this ‘space’ that opened up in the session

allowed therapist and client to explore issues in more depth:

Dyad 1Claire (therapist): It felt as if the work dropped more quickly… into something about core beliefs, core scripts. Something a bit more under the radar came to the fore in that session. Maria (client): It seemed like my therapist was able to think as well with me, and ask me the right questions for us to explore things, and get deeper.

Both therapist and client acknowledge the greater depth, but attribute it to different

causes. Maria attributed the depth to the attunement described in theme cluster 2, and

her therapist’s increased ability to ‘ask the right questions’. For Claire, this depth

came about because meditation facilitated access to unconscious processes:

Claire (therapist): Meditation opens that gateway into that realm where one can access some of the wisdom that is locked away most of the time in the unconscious.

As a psychodynamic psychotherapist, Claire is accustomed to thinking about the

unconscious, and aspects of the client’s internal world that may be hidden from the

client herself (‘under the radar’). It appears that her interpretation of mindfulness is

influenced by the theoretical framework she employs in therapy sessions.

Effect on cognitive processes

The influence of theoretical approach was also apparent among those dyads (John and

Alice, Jane and Ryan) working within the CBT model. The following exchange with

Alice, who has been in long-term CBT, is instructive:

Alice (client): I think in the second session that we did it I became more mindful than the first session.

Researcher: Okay, so ‘more mindful’ means, to you…?Alice: Just more in the present moment I suppose in the sense my thoughts did really slow down. I felt more detached from value judgements. In the first session that we had I suppose a lot of the thoughts that were going through my mind were concerned

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with what my therapist thought of me, or what he was thinking at the time, doing this exercise. Whereas the second time I don’t remember having those thoughts.

It appears that, because cognition is the salient aspect of Alice’s work with her

therapist, it is the prism through which she views the effects of mindfulness

meditation. This was also noticeable in Jane and Ryan’s interpretation of mindfulness:

Dyad 3Jane (therapist): I look at it as trying to ground yourself… trying to slow down our thought processes when they run away from us.

Ryan (client): I think I kind of use it as a technique to access thoughts.

Although they both focus on cognitive elements, there is a subtle difference in how

they understand the relationship between mindfulness and thoughts. Jane focused on

regaining control over thought processes, while Ryan spoke of the greater awareness

of cognitions made possible by mindfulness.

Effect on emotional processes

As previously discussed, Ryan described heightened emotion during the session, in

the form of irritation with his therapist, and speculated that this may have arisen as a

result of the meditation. For other participants, meditating within the session seems to

have had the opposite effect. Maria attributed the clearer focus of her session to a

calming of emotions:

Maria (client): Somehow I think mindfulness must have helped me to… calm down my anxiety levels or my emotions… and then [I was] able to think and feel what is most important.

Richard and Clarissa also described lower levels of emotion during the sessions that

began with joint meditation:

Dyad 4Richard (therapist): [In the first session] we ended up talking a little bit abstractedly, a little bit theoretically, in a way that I wouldn’t normally talk in a session with that client. And then, weirdly and interestingly, there was another change after the second meditation, which was that we ended up talking about quite a lot of practicalities.

Clarissa (client): I actually noticed that they were a bit less, perhaps less emotional than normal… It was as if emotional stuff didn’t come up in those sessions, and

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whether that’s because of what’s happening in my life at the moment, or whether it’s because of the meditation, I couldn’t say.

While Clarissa was reluctant to attribute this to the meditation, Richard was more

explicit about what he saw as the mechanisms at work:

Richard (therapist): I think that, when you’re meditating, and you have those thoughts that come in and you just gently push them away, and you focus back on, in this case your breathing… that, on the one hand, calms you down, but on the other hand I think can have the effect of distancing you from the emotional content of the thoughts and the images. And in a normal therapy session, it would be those images, thoughts, reverie, which would be the doorway into the emotional connectedness with the client.

Like Claire, Richard works within the psychodynamic approach, but whereas Claire

saw meditation as opening the ‘gateway’ into the unconscious and therefore a deeper

understanding of the client, Richard, using the similar metaphor of a ‘doorway’,

suggested that meditation might close down certain avenues of exploration because of

lowered emotion.

Sense of intrusion

A final theme that was found within the responses of three of the dyads was that

engaging in the current study was felt, to varying degrees, as an intrusion into the

process of therapy. Jane and Ryan described a sense that the joint mindfulness

exercises were not aimed at enhancing their experience in the therapy room, but rather

were for research purposes. In their description of the experience of meditation, it is

notable that the members of this dyad seemed to see the meditations as separate from

the therapy sessions, and not part of them.

Dyad 3Jane (therapist): It felt as if it had got in the way of our session instead of it being part of the session.

Ryan (client): It felt like it was almost getting in the way of what we were there for.

Both participants here express the idea of the meditation obstructing (‘got/getting in

the way’) what were presumably considered to be more important activities.

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Another way in which joint meditation was portrayed as obstructing the

process of therapy is that, for some dyads, the meditation itself became the topic of the

session for a period after the exercises, and some participants were concerned about

the time meditation took up within the sessions. Claire did, however, offer a

counterpoint:

Claire (therapist): Eight minutes is quite a big chunk of a 50-minute session. But I will remember that felt sense of the session being quite spacious after starting it in that way.

For Claire, there is a trade-off, in that the time ‘lost’ to the mindfulness exercise was

recouped in the sense that it allowed space for important thoughts, feelings, and issues

to arise.

Participants’ concluding remarks

At the end of interviews, participants were asked if they had any future plans to

practise mindfulness, and were given the chance to add any further thoughts. In

general, interviewees offered positive remarks about their experience of joint

meditation, tempered with reservations regarding the practicality of introducing it into

therapy sessions on a regular basis. Of the therapists, only Jane said that the

experience of meditating with her client had had no positive effect. John

acknowledged the potential benefits for his practice of engaging in personal

mindfulness practice, but expressed doubt that he would have time to do so:

John (therapist): In terms of the therapy, I would like to be able to have that time to clear my thoughts, or at least slow them down a bit and be able to assess where I am. But… if you have a full day of clients, where do you fit it in?

Richard shared his thoughts about who might benefit from joint meditation with a

therapist, and who would not:

Richard (therapist): I think the sorts of techniques that my client and I were doing would be very useful with an anxious patient who was being flooded, and rather counterproductive to somebody who was already a bit closed off, a bit schizoid and a bit detached.

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Claire, who prior to taking part in the study, had occasionally used spontaneous

breathing exercises with clients, suggested that she might introduce planned

meditation to her work:

Claire (therapist): I’m quite grateful to you for actually putting this discipline on my client and me to try this out… The thing that I think might be different for me now is I might be more experimental about consciously planning, with the client, to structure in some meditation… Just take some time, and actually to be quite generous with the time.

Of the clients, Alice in particular said that she had appreciated the process of

meditating with her therapist, and pointed out that such an exercise could assist in

starting off sessions as a joint venture:

Alice (client): The therapist has been in their room the whole day, just talking to various clients or doing their work or whatever. The client has just come in off the street having had travelling or something so… quite a different experience. So to share something could really facilitate a session I think, potentially.

She also suggested a shorter meditation of three or four minutes, to lessen the impact

on the session in terms of time taken. Clarissa and Maria described the ‘benefits’ of

mindfulness practice, but again noted that time taken for joint meditation was felt as

taking time from the therapeutic work, which they suggested could benefit from

clients meditating individually outside of sessions. Ryan emphasised that for joint

mindfulness practice to be beneficial to therapeutic work, it must be a joint decision

on the part of therapist and client:

Ryan (client): I think it’s a very interesting premise, to do this. I think it has to be something that therapists and clients agree together would be helpful.

Discussion

Most previous studies on the effects of mindfulness have focused on longer-term

interventions such as MBCT or MBSR. Given that this research only involved two

eight-minute meditations, it was not expected that participants would report

significant changes to their own interpersonal functioning. Instead, the focus was on

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how meditating together might effect changes to the relationship between therapist

and client and the process of therapy.

The research questions presented at the end of the introduction will now be

considered in turn.

How do therapists and clients experience brief, in-session joint mindfulness

practice, in terms of the therapeutic relationship and the process of therapy?

This study, which took a phenomenological approach, sought to capture each

participant’s experience of engaging in joint mindfulness practice, and therefore

answers to this question are necessarily diverse. Nevertheless, certain themes emerged

repeatedly in several interviews.

Therapists were unsurprisingly vigilant to the wellbeing of their clients, and

were perhaps therefore less able to engage fully in the meditations. As an illustration,

two clients said that they were only initially aware of their therapist’s presence during

the meditations, with a third commenting that their awareness of the therapist was

significantly lower in the second meditation. Therapists seemed more aware of their

client’s presence in both meditations, and all the way through.

In terms of the effect on clients, it was postulated in the introduction that the

higher attentional control and emotion regulation associated with mindfulness (Arch

& Craske, 2006; Hölzel et al., 2013) might help clients to identify issues to work on,

and to tolerate difficult emotions aroused during a session. Two clients (Maria and

Clarissa) reported that the mindfulness exercise led to feelings of calm within the

session. In Maria’s case, this sense of relaxation allowed her to identify the issue she

wanted to bring to the therapy session, leading to a shift of focus. The Results section

of this paper separated cognitive and emotional elements into two themes; however,

perhaps this is unrepresentative of what occurs in psychological therapy. Mindfulness

involves an integration of cognitive and emotional processes, in that practising

mindfulness involves consciously attending to emotions while maintaining an

observational stance that, it is claimed, allows for greater tolerance of negative

emotional states. This is also the logic of therapeutic approaches that focus on

emotional processing (Greenberg, 2002).

Siegel (2007) hypothesises that achieving an optimum balance between

cognition and affect involves neural integration between right-brain and left-brain

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functions, which he suggests, based on neuroscientific research (e.g. Halpern,

Güntürkün, Hopkins, & Rogers, 2005), are broadly responsible for processing that is

holistic, somatic, and proximal to stimuli (right brain), and linguistic, logical, and

distal in relation to stimuli (left brain). He further argues that mindfulness meditation

aids neural integration because it involves shifting between the two modes of

perception (i.e. when the meditator notices the mind wandering to thoughts and value

judgements (left brain), s/he redirects attention towards the body (right brain)).

In contrast to Maria and Clarissa, Alice and Ryan reported higher emotions

during and after the first joint meditation. Guided meditation that focuses on the body

may be contraindicated for clients such as Alice, with a somatoform anxiety disorder,

although she did report greater feelings of calm and ‘slower thoughts’ following the

second meditation when she focused her attention outwards. Ryan described a sense

of irritation emerging during the meditation, and suggested that the exercise allowed

the space for these feelings to be noticed. The experiences of Maria and Ryan, who

reported a shift in, respectively, focus and emotional content, perhaps echo Larry

Rosenberg’s (1998, p.15) analogy of mindfulness being a ‘mirror’ that reflects what is

already there.

In terms of relationship factors, all of the dyads except Jane and Ryan said that

they valued the shared experience of meditating together, which seemed to reduce the

perceived distance between the roles of therapist and client. This led to a sense of

being in a team, of equality between therapist and client, and of attunement. This latter

concept appears to be key for the establishment of an effective therapeutic

relationship, and Bruce, Manber, Shapiro, and Constantino (2010, p.83) propose it as a

central mutative element of therapy that can ‘promote greater well-being, and increase

the patient’s ability to form and maintain interpersonal relationships.’ The sense of

equality fostered by the exercise is also relevant to the therapeutic relationship,

particularly the ‘person-to-person’ aspect of the therapeutic relationship described by

Clarkson (2003). This is not to suggest that meditating together is the best (or only)

way to reduce the perceived power distance between therapist and client, but it does

suggest that, if therapists are able to establish a sense of joint endeavour, benefits may

accrue to the therapeutic relationship.

Other effects on the process of therapy included a slower pace, and a perceived

shift from the doing mode to the being mode, both of which have been reported effects

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of mindfulness training of therapists in qualitative studies by Schure, Christopher, and

Christopher (2008) and McCollum and Gehart (2010). Participants in a study by

Bihari and Mullan (2014) of the interpersonal effects of MBCT reported that they

were less likely to try to ‘fix’ the problems of others and more able to ‘be with’ those

in distress. This combination of an observer’s stance with empathic understanding

addresses two important components of the therapist’s role.

Do therapists and clients perceive the experience of joint meditation differently?

One striking feature of the interview transcripts was how frequently therapists and

clients used the same terminology to describe their experiences. Claire and Maria

described being on the same ‘wavelength’; John and Alice, the same ‘page’. Aside

from this common phrasing (which may have been the result of therapist and client

discussing their experiences after the exercises), it was notable that therapists and

clients were very close in their descriptions of what happened during these sessions.

The exception is Jane and Ryan, who, of the four dyads, reported the least

positive effects of meditating together, and were also the most divergent in their

descriptions. For instance, Ryan spoke extensively of feelings of irritation that arose

within the first session that began with mindfulness, and suggested that the meditation

had provided the space for these feelings to emerge. Jane, in her account, described no

changes in the relationship or the process of therapy. Similarly, the experience of

interruption to the meditation was remembered differently (see Divergent

experiences).

A possible interpretation of this relates to the attunement described previously.

Those participants who seemed to engage most fully with the mindfulness exercise

were more attuned to their own experience, and to that of their partner, so that even

when these experiences differed greatly, as with John and Alice’s first meditation, this

was acknowledged and processed within the session, which itself may have been a

bonding experience. In Alice’s words, ‘it was a shared experience – we obviously

both had different experiences from it, but there was an overarching sharing.’

The concept of attunement is discussed frequently in literature on attachment,

and appears to be crucial for the development of a secure attachment bond between

parent and infant, as well as for the establishment of a strong therapeutic relationship

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(one in which client and therapist feel able to sit with and explore painful emotions, in

which the client feels their needs are being met, and which misunderstandings or

mistakes by the therapist do not lead to rupture of the therapeutic alliance). This is

what Gergely and Watson (1996) describe as ‘affect mirroring’, and Fonagy and

Target (1997) as ‘reflective function’. What seems important is that the caregiver (or

in the context of therapy, the practitioner) does not mirror affect too closely, but

maintains a ‘just right’ level of involvement with the other’s emotions, such that the

emotion is regulated. If an emotion such as anxiety is reflected too closely, this

confirms and accentuates the perception of threat to the infant (or client). If it is

reflected to an insufficient degree, this communicates that the caregiver is unavailable

and emotionally uninvolved. These two situations can be mapped conceptually onto

the preoccupied and dismissing attachment styles.

The notion that a moderate level of affect mirroring is optimal is supported by

research linking moderate levels of attunement between parent and child to secure

attachment at one year (Beebe, Lachmann, & Jaffe, 1997). We can draw a conceptual

link here to Rogers’ (1957, p.98) definition of empathy: ‘To sense the client’s private

world as if it were your own, but without ever losing the “as if” quality’. To provide

support to the client, the therapist must not become caught up in the client’s affect,

while also taking care to avoid giving the impression of being emotionally detached.

A potential avenue for future research might be aimed at exploring the links between

therapist mindfulness, therapist-client attunement, and in-session phenomena such as

depth of exploration.

Are therapy sessions that begin with a joint mindfulness meditation qualitatively

different from those that do not?

Differences perceived as positive by participants included sharper focus, a greater

sense of attunement or connection between therapist and client, changes in topic or

depth of exploration, slower pace, and changes in emotion. Less desirable outcomes

included higher distress and a sense of intrusion into therapy.

It is impossible to say for sure that these differences arose as the result of

mindfulness. The very act of introducing a new element into therapy might have been

the catalyst for changes, particularly as all dyads had been together for at least 18

months, and would therefore presumably have an established way of working.

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Participants may also have been more sensitive to any differences, in the knowledge

that they were taking part in research. The responses of participants within this study

nevertheless suggest that therapy sessions that begin with a joint meditation are

experienced differently to those that do not.

Critical engagement with analysis

As stated above, an important point that limits the claims that can be made in this

discussion is that it is difficult to state definitively that any of the observed phenomena

were the direct result of joint meditation between therapist and client. Indeed, it is

frequently claimed that cultivating mindfulness requires regular, long-term practice

(Kabat-Zinn, 2016), and some of the most pronounced results, in terms of self-

reported mindfulness, performance on attentional response tasks, and neuroscientific

studies, are found among long-term, experienced meditators (Lutz et al., 2004;

Treadway & Lazar, 2009). Nonetheless, there is some evidence that brief mindfulness

exercises can have salutary effects even when practised in isolation (Alberts &

Thewissen, 2011) or on a short-term basis (Zeidan, Gordon, Merchant, & Goolkasian,

2009).

A limitation of the current research base on mindfulness is that many studies

are decontextualised; either because they introduce components of mindfulness (such

as attention and acceptance) in isolation, or because they are removed from settings

where mindfulness interventions would normally take place. This study attempts to

recontextualise mindfulness by situating the intervention in the therapy session.

However, other factors position the exercise outside of the normal parameters of

therapy: participants were aware that they were taking part in research, and so the

meditation was somewhat denatured. Furthermore, mindfulness interventions in a

normal therapeutic context are likely to be guided by therapists; it is unlikely that

many therapeutic dyads engage in joint meditation that is guided by a third party (in

this study, the meditation recording).

This limitation of the study has implications for how we can interpret the

findings and apply the knowledge gained. IPA incorporates a critical realist

epistemology, and as such its aim is not to produce universal laws (Alvesson &

Sköldberg, 2010, p.40). Rather, it is concerned with the production of contextualised

89

knowledge (Madill, Jordan, & Shirley, 2000; Larkin, Watts, & Clifton, 2006). As a

counterpoint, Smith (2004) cites Warnock (1987) in arguing that an intense focus on

the particular can lead to insights about the universal. So, while a valid criticism of the

methodology applied in the current research is that the context is narrow, this does not

mean that the results gained from this study cannot be applied to a wider context. This

study, then, can tell us something about what happens when a new element (in this

case, joint meditation) is introduced to an established therapeutic context, as well as

providing knowledge about how inducing mindful states in therapists and clients

might influence how the session subsequently unfolds.

A criticism that has been levelled at IPA is that, because it does not prescribe

fixed methods, replication of IPA studies is impossible (Giorgi, 2011). It is true that

IPA does not offer a step-by-step procedure for data analysis; some prominent IPA

proponents have even suggested that it is more useful to view IPA as not so much a

‘method’ but rather a ‘stance’ (Larkin, Watts, & Clifton, 2006, p.104). However, IPA

places emphasis on the constructed nature of knowledge and the unique contribution

made, not just by the participant, but also the researcher and the interaction between

each participant with the researcher. When considering this, aspiring to create

replicable results is incongruent with taking an interpretivist approach such as IPA.

Limitations

Limitations of the current study include the fact that none of the participants was new

to the practice of meditation, and so each would have brought to the study their own

presuppositions: Those already favourably disposed to mindfulness might have

experienced the meditations most positively. Equally, those for whom mindfulness

had slightly negative connotations (some participants described it as ‘trendy’, and one

questioned the evidence behind some of the claims made for mindfulness) might have

had less positive experiences. Measuring participants’ opinion of mindfulness might

have been instructive when viewed in the context of their experience of joint

mindfulness.

It should also be noted that cultivating a mindful attitude takes time, and there

is evidence to suggest that mindful qualities such as non-reactivity are more present

among experienced meditators as compared to novice meditators (Taylor et al., 2011).

90

The current study focused on the experience of participating in joint mindfulness

meditations, then, rather than the effects of heightened mindfulness per se.

Furthermore, by introducing guided meditation practice into therapy sessions, these

sessions would necessarily have had a different ‘feel’ for therapist and client. Caution

should be taken when interpreting observed changes in the session, as to whether they

were the result of meditating together, or simply an effect of a change in routine for

the therapeutic dyad.

Another limitation is that it was difficult for some participants to remember the

experience of therapy sessions. As Heidegger (1927/1978) notes, reflection on a

particular experience requires some degree of detachment from that experience;

obviously this is not desirable within a therapy session, for therapist or client. Two

participants made notes on their experiences in this study; perhaps future studies

might suggest this to all participants in order to secure a more ‘experience near’

(Kohut, 1978) account of the effects of joint meditation.

Conclusion

The novel experience of meditating together within the therapy room elicited a range

of responses from participants. A reported positive outcome was that joint

mindfulness practice seemed to reduce the ‘distance’ between therapist and client,

leading in some cases to feelings of attunement, equality, and a greater sense of being

understood. This has potential implications for clients who are experiencing trust

issues, such as those with an insecure attachment style. Several participants also

reported that meditation helped them to focus their attention and to ‘slow down’,

which for some allowed important issues to emerge within the therapy room. Perhaps

such an exercise could assist with Bion’s (1967) advice to begin each session ‘without

memory, desire, or understanding.’

It is clear, however, that joint mindfulness is not a panacea to be introduced

into any therapeutic situation. These results suggest that therapist and client must be

open and willing to engage in the process of meditating together. If the client feels that

the meditation has been imposed upon them, this could actually be counter-productive

to the therapeutic relationship. Additionally, caution should be taken with individuals

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who, like Alice, might experience an inappropriately focused mindfulness exercise as

distressing. Some participants also expressed resistance to the idea of their therapy

time being taken up by an apparently passive activity. Interestingly, despite the

theoretical overlap between mindfulness and CBT that has led to mindfulness-based

approaches such as MBCT and ACT being considered part of the ‘third wave’ of CBT

approaches, it was the CBT therapists in this study who were most sceptical of the

idea of introducing formal joint meditation into sessions. For these participants,

mindfulness meditation, at least in the form it took in this study, was considered not

‘active’ enough.

Despite these caveats, this study has demonstrated that introducing joint

mindfulness meditation into therapy sessions, where appropriate, could have

beneficial effects for therapeutic relationship and the process of therapy. Future

studies might take a quantitative approach and employ measures of therapeutic

relationship (e.g. Mallinckrodt, Gannt, & Coble, 1995; Kim, Boren, & Boren, 2001)

and depth of exploration (e.g. Stiles et al., 1994) to examine the impact of joint

mindfulness.

Acknowledgements

The author would like to thank his supervisor, Linda Morison, for her kind support

and enthusiasm.

Ethical standards

This study has been approved by the Faculty of Arts & Human Sciences Ethics

Committee at the University of Surrey, and was therefore performed in accordance

with the ethical standards established by the 1964 Declaration of Helsinki and its later

amendments. All persons gave their informed consent prior to taking part.

Conflict of interest

The author declares that he has no conflict of interest relating to the present study.

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APPENDIX 1

Consent form

Ethics Committee

Hello, and thank you for taking part in this study. Before continuing, please read the following, and sign below. Thank you!

I the undersigned voluntarily agree to take part in the study on therapist and client experiences of joint mindfulness practice.

I have read and understood the Information Sheet provided. I have been given a full explanation by the investigators of the nature, purpose, location and likely duration of the study, and of what I will be expected to do. I have been advised about any discomfort and possible ill-effects on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.

I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998). I agree that I will not seek to restrict the use of the results of the study on the understanding that my anonymity is preserved.

I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice.

I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.

Name of volunteer (BLOCK CAPITALS) ........................................................

Signed ........................................................

Date ......................................

Name of researcher/person taking consent (BLOCK CAPITALS) ........................................................

Signed ........................................................

99

Date ......................................

APPENDIX 2

Information sheet

Information Sheet for Participants

Dear participant,

You are being asked to take part in a research study on mindfulness, conducted by Jacob Ellwood, as part of the requirement for his Doctorate in Psychotherapeutic and Counselling Psychology at the University of Surrey. The study is being supervised by an academic researcher, Linda Morison, and it has been approved by the Psychology Research Ethics Committee.

Your participation could further understanding of mindfulness and its relevance to therapy, and might benefit you personally in that mindfulness has been found to have multiple benefits for those who practise it.

Mindfulness, a concept that dates back thousands of years, refers to ‘the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment’ (Kabat-Zinn, 2003). In order to foster the ability to engage in such present-moment awareness, there exist a variety of mindfulness practices such as mindful breathing meditation and mindful movement. Beneficial outcomes of mindfulness practice include increased emotion regulation, heightened attentional skills, and increased interpersonal skills. The current study examines the effects of joint mindfulness practice (between therapist and client) on psychological therapy.

In agreeing to take part in this study, you will be asked to take part in two brief (eight-minute) mindfulness meditation exercises with your client[/therapist], in two separate sessions (separated by a session without the joint practice). Following completion of the second session, you will be interviewed about your experience of engaging in joint mindfulness practice.

All information will be kept confidential, and your identity will be kept anonymous in interview recordings/transcripts. Your responses will not be made available to your client[/therapist]. You retain the right to withdraw from the study at any time, without giving a reason and without prior notice.

Any complaint or concerns about any aspects of the way you have been dealt with during the course of the study will be addressed; please contact Linda Morison on 01483 686875 or l.morison@surrey.ac.uk.

Kind regards,

100

Jake EllwoodPrincipal Investigator

APPENDIX 3

Interview schedule outline

Demographic informationParticipants will be asked for the following information: - Age - Sex- Type/length of therapy

General questions about mindfulness and meditation- What do you understand by the term ‘mindfulness’?- Have you ever meditated before taking part in this study? If so, have you ever engaged in joint or group meditation?

Questions about the process of joint mindfulness practiceMain question - Please tell me about the experience of engaging in joint mindfulness practice with your therapist/client.

Possible prompts- What was the first mindfulness session like? - How was the second mindfulness session?- Were the instructions on the recording clear? Were you able to follow them?- Were you aware of your therapist’s/client’s presence during the mindfulness exercise?- How did the experience compare to your previous experience[s] of meditation practice? [If applicable]- How did you experience time during the mindfulness practice? Did the exercise feel short? Long?

Questions about the therapeutic relationship and process of therapyMain question- What did you notice about the therapy sessions that began with mindfulness practice? Did they feel different from sessions without the exercise?

Possible prompts- Did you notice anything about the content of the sessions with mindfulness practice (e.g. topics of discussion, depth of exploration)? If so, do you relate this to the mindfulness exercise? [Participants will be told that they are not expected to divulge sensitive information]- What did you notice about your relationship with your therapist/client in the sessions that began with mindfulness practice?

Final questions

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- Do you want/expect to practice mindfulness in future, either jointly or on your own?- Is there anything else you would like to add?

APPENDIX 4

Ethical approval

102

APPENDIX 5

Table of themes

103

APPENDIX 6

Risk assessment summary

1. Potential risks to principal investigator

The main risk that the principal investigator will face is that he will be alone with

interviewees. To minimise the risk of harm, or the risk of allegations of improper

behaviour, he will inform his supervisor in advance of interviews to let her know

when they will take place, and arrange to send a text message to her before and after

interviews, to inform her of what is happening.

2. Potential risks to participants

(a) Therapists

There is a potential for increased stress among therapists who take part in the research,

in that they are being asked to alter their usual method of clinical practice. No pressure

will be placed on therapists to take part, and the principal investigator will inform

them that participation is entirely at their discretion. To reduce stress in the session, a

pre-recorded mindfulness exercise will be used, so that the therapist does not feel

under pressure to conduct the practice in a certain way.

There is a risk that therapists might be accused by their client of exerting

pressure on them to participate in the research. To minimise this risk, therapists will

be encouraged to approach potential participants by emphasising that there is no

pressure or expectation on the client to participate, and that by choosing not to

participate this will in no way affect the therapist-client relationship or the future

process of therapy.

(b) Clients

There is a risk that clients might feel pressurised to take part in the research, when

they are asked to do so by their therapist. As stated above, therapists will emphasise

that there is no obligation to participate, and that non-participation will not damage

their relationship with the therapist.

104

As interviews will take place after a therapy session, there is a risk that clients

might be in a state of distress, particularly if difficult or emotive issues have been

discussed during the session. To minimise the risk of the interview provoking further

distress, the principal investigator will ask clients if they would like some time

between the session and the interview to collect their thoughts or for levels of distress

to decrease.

There is also the risk that the interview process might stir up distressing

thoughts or emotions for the clients. It will be made clear to interviewees that they are

under no obligation to share the details of therapy sessions, or personal details, and

that the focus is on the experience of mindfulness practice and the therapeutic

relationship. Clients will also be informed that they are free to withdraw from the

process at any point without explanation or prior notice.

If it is apparent that a client is becoming distressed during the interview

process, the investigator will check whether they are okay to continue, and give them

the option to take a break or to terminate the interview process. If the investigator

senses that the client is at risk, he will ask them about this, and suggest that they

contact their therapist or ask their permission to contact their therapist.

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RESEARCH PROJECT 2

Bringing mindfulness to the therapeutic relationship: Towards a grounded theory

Abstract

Psychologists are directing increasing amounts of theoretical and empirical attention

to the relational aspects of mindfulness. Potential benefits accruing from mindfulness

include increased relationship satisfaction, empathy, and communication skills.

Emerging research findings suggest that a mindful approach to therapy could have

significant benefits for the therapeutic relationship, but as yet, few studies have

explored this topic. This qualitative study uses a grounded theory approach to explore

therapist perceptions of how they bring mindfulness to the therapeutic relationship,

and the effects of doing so. The perceptions of eight therapists who practise

mindfulness in their personal and professional lives were elicited using semi-

structured interviews. Analysis involved the constant comparison approach advocated

by grounded theory, and theoretical sampling was used to shape participant selection

and areas of inquiry. Initial codes were consolidated into larger categories, and

connections were drawn between these categories. Four main categories were

constructed: ‘cultivating mindfulness’, ‘bringing mindfulness to the relationship’,

‘transforming the client’s experience’, and ‘providing a secure base’. These were

conceptualised as forming the basis of a process in which therapists use mindfulness

to establish a strong therapeutic relationship that provides the conditions for reparative

processes and deeper exploration within the therapy. A results model is presented and

discussed in relation to existing literature. Recommendations are made for future areas

of research.

Keywords: Mindfulness, therapeutic relationship, attunement, grounded theory

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Introduction

Mindfulness, defined by Kabat-Zinn (2003, p.145) as ‘the awareness that emerges

through paying attention on purpose, in the present moment, and nonjudgmentally to

the unfolding of experience moment by moment’, is an ancient Buddhist practice that,

in the past two decades, has entered mainstream psychological discourse. Mindfulness

can be cultivated through formal exercises such as body scans, sitting meditations, or

mindful movement, or informally through performing everyday tasks with a mindful

attitude. It has been used as an intervention to alleviate both psychological distress

(Keng, Smoski, & Robins, 2011) and physical pain (Chiesa & Serretti, 2011), and to

reduce stress in settings such as the workplace (Irving, Dobkin, & Park, 2009).

In recent years, researchers have begun to direct their attention to the relational

aspects of mindfulness, which has been applied in formal interventions aimed at

enhancing romantic relationships (Carson, Carson, Gil, & Baucom, 2004) and

parenting skills (Duncan, Coatsworth, & Greenberg, 2009). Some of the reported

benefits for interpersonal functioning include improved communication skills

(Burgoon, Berger, & Waldron, 2000), increased empathy (Wang, 2007), and higher

relationship satisfaction (Barnes, Brown, Krusemark, Campbell, & Rogge, 2007). A

caveat must be added that many of these studies use self-report measures and positive

outcomes may be attributable to participants’ belief that mindfulness is beneficial,

particularly when they are experienced meditators who have ‘bought in’ to the concept

of mindfulness. Nevertheless, there is an ever-increasing corpus of literature on

relational mindfulness, and Ellwood (2013) explored this knowledge base in a

literature review of mindfulness and attachment.

These findings have significant implications for counselling psychology,

which places particular emphasis on relational processes, and on the relationship

between therapist and client as the key dimension of effective therapy (Woolfe,

Strawbridge, Douglas, & Dryden, 2010). This relational stance is supported by

substantial evidence suggesting that the most important factor in successful therapy is

the therapeutic relationship, regardless of theoretical approach (Cooper, 2008). In light

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of the importance of the therapeutic relationship, and of the links between mindfulness

and interpersonal relating indicated by theory and research, it is perhaps surprising

that relatively little attention has been given to the relevance of mindfulness to this

relationship.

Hick and Bien (2008) addressed this gap in the literature in their book

Mindfulness and the therapeutic relationship, which described the conceptual links

between mindfulness and the therapist-client relationship (including empathy and

therapeutic presence) as well as specific applications of mindfulness (including the

acceptance and commitment therapy and insight dialogue approaches). Largely

missing from the book, and in the wider literature, was an exploration of how

mindfulness might be used formally within therapy sessions to aid the therapeutic

relationship and the process of therapy.

To shed light on this topic, Ellwood (2014) conducted a qualitative study of

therapist and client experiences of joint mindfulness meditation at the start of two

therapy sessions, using interpretative phenomenological analysis (IPA; Smith,

Flowers, & Larkin, 2009). Results were mixed: Participants described greater focus

and depth in the work, and reported effects on the therapeutic relationship included a

sense of teamwork and equality of roles, and greater attunement between therapist and

client. These positive effects were tempered by some participants feeling that

‘importing’ a formal mindfulness exercise had intruded upon the therapeutic space.

Nevertheless, it was noteworthy that a short, eight-minute joint meditation had seemed

to transform the shared experiential quality of subsequent sessions, and that

participants and clients had expressed support for the idea of therapists (and/or clients)

meditating before sessions began (to bring themselves more fully into the work).

The study therefore raised questions about the effect of working more fully

from a stance of mindfulness, on the process of therapy, and particularly on the

therapeutic relationship. It was decided, then, to take a step back from the research to

ask about the processes involved when mindfulness is applied to the therapeutic

relationship, either explicitly through the teaching of mindfulness in sessions, or

implicitly through the therapist cultivating mindfulness via personal practice and then

bringing mindful qualities to their relationships with clients.

Falb and Pargament (2012, p.352) define ‘relational mindfulness’ as ‘the

process of practising mindfulness while interacting with others, integrating words with

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silence and learning to listen and speak mindfully,’ and note that there is ‘a dearth of

empirical research’ (p.353) on this subject. Some qualitative studies have explored

therapists’ understanding of the effects of mindfulness. Aiken (2006) found that

therapists believed that mindfulness helped them to develop empathy towards clients,

while ‘connectedness’ was an important theme developed from interviews of

therapists carried out by Rothaupt and Morgan (2007). An IPA study by Cigolla and

Brown (2011), of therapists who maintained a personal mindfulness practice, yielded

notable findings, with participants reporting enhanced compassion for self and others,

and that mindfulness helped them to work with more relational depth.

To date, however, no qualitative study has attempted to develop a theory of

how mindfulness impacts the therapeutic relationship. Therefore, the initial research

question for the current study was deliberately open-ended: ‘How do therapists bring

mindfulness into their work, and what are the effects (if any) on the therapeutic

relationship?’ It was felt that this satisfied Willig’s (2008, p.38) recommendation that

the research question should serve to identify, but not make assumptions about, the

area of interest.

A grounded theory methodology was deemed appropriate as a way of

addressing this research question, in part because the research area remains

underdeveloped, and a grounded theory approach would allow for the development of

new understanding, grounded in the data. Moreover, the proposed study was interested

in the processes involved in bringing mindfulness to the therapeutic relationship, and

grounded theory, which derived, in part, from the pragmatist tradition (Tweed &

Charmaz, 2012), has an interest in actions and processes.

Method

Design

This qualitative study used a grounded theory methodology, specifically the

constructivist approach expounded by Charmaz (2014), which appealed to the

researcher’s own epistemological beliefs. In this understanding of knowledge

acquisition, knowledge is constructed by humans in interaction with the world and

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with each other. It is therefore dependent on social interactional processes embedded

in human culture, rather than consisting of objective ‘truths’ or ‘facts’ waiting to be

discovered. An analogy can be found in human vision. Rather than windows onto an

objective external world, the eyes are part of a complex system that collects and

constructs information in such a way to allow humans to make sense of their

surroundings. Similarly, whereas the positivist grounded theory approach of Glaser

and Strauss (1967) describes theoretical categories ‘emerging’ from the data,

constructivist grounded theorists deny that such categories exist independently of the

researcher, and explicitly acknowledge their own role in co-constructing meaning with

participants.

Constructivist grounded theory shares many elements with the original Glaser

and Strauss approach, including an iterative procedure in data gathering and analysis,

theoretical sampling, and an interest in meaning and action (Charmaz, 2014, pp.12-

13). With its greater focus on the researcher’s role in the construction of meaning, the

constructivist methodology promotes reflexivity at all stages of research, which is also

compatible with counselling psychology’s emphasis on reflexive practice in research

and therapeutic work (see below, ‘Incorporating reflexivity’). It also emphasises the

flexibility of grounded theory (for example, forgoing an insistence that there must be a

‘core category’), which was important for me as I believe that adhering too closely to

a manualised approach can foreclose avenues of exploration and analysis, and limit

the usefulness of a study.

Why qualitative?

Qualitative approaches have, in the past, been valued chiefly as initial explorations

into a certain topic, laying the groundwork for quantitative surveys of the same

territory (Leininger, 1992). Qualitative methods have been placed far down the

‘hierarchy of evidence’, with systematic reviews of randomised controlled trials

(RCTs) and RCTs at the top (Corrie, 2010). Ponterotto (2005, p.126) asserts that

psychology has been dominated by positivist epistemologies and their associated

quantitative methods. More recently, however, qualitative enquiry has come to be

valued in its own right, with the understanding that the two paradigms produce

different kinds of knowledge – but that it is unnecessary to value one over the other;

instead they are complementary and each can inform the other. The rise to prominence

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within counselling psychology of interpretivist methodologies has a historical

antecedent in the writings of Wilhelm Dilthey, who argued that ‘rationalistic’

approaches could not adequately describe human phenomena (Hughes & Sharrock,

1997). The goal of natural science is scientific explanation, while the goal of human

science is understanding the ‘meaning’ or multiple ‘meanings’ of social phenomena

(Ponterotto, 2005, p.129).

When choosing a research method for this second study, it first had to be

decided what the study hoped to achieve. Following the conclusion of the first

research report, several possible directions presented themselves. Participants’

responses in the IPA study suggested that joint mindfulness practice between therapist

and client could be linked to greater focus and depth, and a reduction of the perceived

distance between the two participants. A limitation of the study was that meditation

only took place on two occasions, separated by a session without meditation. A follow

up quantitative study might have examined the effects of more sustained joint

meditation, i.e. over more sessions, with a control group asked to perform (for

example) an unfocused attention exercise for the same period of time. Therapists and

clients could be asked, periodically, to fill in self-report forms relating to state

mindfulness (e.g. Brown & Ryan, 2003; Lau et al., 2006; Tanay & Bernstein, 2013),

therapist-client attachment (e.g. Mallinckrodt, Gantt, & Coble, 1995), and other facets

of the relationship between therapist and client (e.g. Agnew-Davies, Stiles, Hardy,

Barkham, & Shapiro, 1998; Stiles, Gordon, & Lani, 2002; Shelef & Diamond, 2008).

However, such an in-depth study would represent a significantly greater

commitment to the process than that of participants in the first study, which would

likely have presented obstacles in terms of recruitment and ethical considerations

(some participants in the first study experienced the meditation as an intrusion; risking

a greater sense of intrusion would be undesirable). Taking an in-depth approach to the

study of just one dyad (e.g. Vinca, 2009) is one way of limiting potential negative

impact, and would face fewer logistic difficulties, but would still face the same ethical

considerations. However, the utility of taking a quantitative approach would be

negated by the researcher’s inability to generalise from the results of just one

therapist-client pair.

Another option was to ask therapists to meditate on their own before sessions,

and to fill in self-report measures of state mindfulness, state attachment (e.g. Gillath,

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Hart, Noftle, & Stockdale, 2009), and relational/in-session processes. This would have

the benefit of not intruding on the session itself, or on clients. In a discussion with my

supervisor where such an approach was mooted, she pointed out that an unwanted

aspect of asking therapists to fill in self-report measures of attachment might be

participants’ familiarity with the concept itself. Responses might therefore be filtered

through the participants’ prior knowledge and subject to (conscious or unconscious)

response bias. For example, therapists who are likely to volunteer for such a study

might be predisposed towards mindfulness, and respond in a way that reflects

favourably on the practice; alternatively, those who are not predisposed towards

mindfulness might be keen to show that meditating had no effect on attachment.

Questions have also been raised over the validity of measures of mindfulness,

even by the co-author of a prominent mindfulness scale, the Freiburg Mindfulness

Inventory (FMI; Buchheld, Grossman, & Walach, 2001). Grossman (2008, 2011)

addresses a number of problems with existing measures, including a lack of external

referents for measuring validity, a concern that self-reported behaviour does not

necessarily correspond to actual behaviour, a lack of convergence between different

measures, and response bias related to level of experience with mindfulness. The

result is that such measures are divorced from both original Buddhist definitions of

mindfulness, and from definitions proposed by the authors of mindfulness-based

interventions (e.g. Kabat-Zinn), and that they lack a sound empirical basis.

I was also drawn once again to a qualitative approach by the questions that the

first research report raised. Among these was the notion that the joint mindfulness

meditation introduced into these therapeutic dyads was somehow ‘artificial’, in that it

did not reflect the usual working practices of the therapists who took part. Those

therapists in the first study who did use mindfulness explicitly in their work said that

this involved the therapist guiding the client, in roles that were more differentiated

than those established by the guided meditation of the first study. They also suggested

that elements of their personal mindfulness practice, although superficially a solitary

pursuit, were interpersonal in nature. Falb and Pargament (2012) propose that the label

‘relational mindfulness’ can be applied to a range of phenomena, each of which

involves relating and communicating in a deliberately attentive way. These might be

formal or informal mindfulness practices, or even verbal communication that

emphasizes moment-by-moment awareness and acceptance of self and others. An in-

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depth qualitative study of therapists’ understanding and application of relational

mindfulness could shed light on such areas that have remained largely ignored by the

current literature on mindfulness.

There also remains a gap in the literature relating to how mindfulness promotes

change, as opposed to whether change has occurred. Because of this gap – and also

perhaps because of my identity as a counselling psychologist (Lane & Corrie, 2007,

p.122) – the former appeals to me as a more interesting question. Neuroscientists (e.g.

Siegel, 2007; Hölzel et al., 2011) have addressed the mechanisms of mindfulness

within the brain; few have attempted to explore the mechanisms of mindfulness within

the therapy room.

Why grounded theory?

Some follow-up studies ‘zoom in’ on a detail from the findings of the previous study.

For this research study, I wanted to ‘zoom out’. The IPA study had provided answers

as to what it was like for the members of several dyads to meditate together at the start

of therapy sessions. This remains a highly specific scenario, however, and as

mentioned in the previous section, one that is somewhat denatured from the process of

therapy. In this second study I wanted to widen the scope by inquiring about how

mindfulness might relate to all aspects of the therapeutic relationship. Questions that

were present in my mind at the start of the process were what is happening here? and

what even is meant by mindfulness, as participants perceive it? The bottom-up, ‘back

to basics’ approach afforded by grounded theory would allow me to address these

questions. Grounded theory, as an inductive process, is suited to inquiry into a topic

for which there exists no explanatory model. Findings are not tested against existing

theory, but instead involves comparing data with the developing theory, and vice

versa. Initial data gathering generates early hypotheses, which are then used to shape

subsequent data collection with the aim of assessing the ‘fit’ of these hypotheses, and

eventually to develop them into a coherent account (Willig, 2012, p.3).

Specifically, I chose to use the constructivist form of grounded theory. This

approach suits my own beliefs about the nature of the world and how we can gain

knowledge of it. In any form of inquiry, but especially qualitative inquiry, the

researcher’s background and beliefs will inform the findings. I disagree with Husserl’s

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assertion that the researcher can ‘bracket’ his or her assumptions when interpreting

data (Husserl, cited in Smith, Flowers, & Larkin, 2009, p.13). Heidegger (cited in

Smith, Flowers, & Larkin, 2009, pp.24-5) argued that ‘An interpretation is never

presuppositionless apprehending of something presented to us,’ while Gadamer (cited

in Smith, Flowers, & Larkin, 2009, p.26) went further in suggesting that ‘A person

who is trying to understand a text is always projecting.’ These two quotations might

instil despondency in the qualitative researcher who is hoping to arrive at (some

version of) the ‘truth’. Nonetheless I believe that, once the researcher has

acknowledged this state of affairs, it increases the potential of opening oneself up to

possibilities that may previously have been unavailable, in terms of the interpretative

work. In a similar way, the therapist works on his or her own issues in therapy so that

they do not form an insurmountable barrier to understanding the inner life of their

clients. By maintaining an awareness of our own prior beliefs and bias, we can strive

to minimise them.

Why not other research methods?

Discourse analysis goes even further than constructivist grounded theory in its view of

knowledge as socially constructed. Its locus of interest is language, and how we

construct meaning through the words we use. Language is an interesting and relevant

concern to this research topic. For example, when asking people for their definition of

mindfulness during the research process for the first study, participants tended to give

‘stock’ responses, that matched closely to ‘standard’ definitions of the concept (there

is no universally accepted definition of mindfulness; Davis and Hayes (2011) review

various interpretations that have been used). This may have been due to their

familiarity with existing mindfulness literature, or perhaps participants were

influenced by the participant information sheet I supplied, which included Kabat-

Zinn’s (2003, p.145) working definition of mindfulness as ‘the awareness that

emerges through paying attention on purpose, in the present moment, and

nonjudgmentally to the unfolding of experience moment by moment’. A similar trend

was noted during the early stages of this second study, at which point I delayed asking

participants for their understanding of mindfulness until several minutes into the

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interview. Responses were subsequently more diverse, and more personal in nature as

participants spoke about the aspects of mindfulness that were important to them.

A discourse analysis of how the concept of ‘mindfulness’ has been constructed

within the literature could elucidate the evolving understanding of this concept, in

light of its spread from spiritual texts, through psychology and into mainstream

discourse. However, as with the first study, this is removed from the context in which

I wanted to understand mindfulness, which is mindfulness as it applies to the

relationship between therapist and client. Even a discourse analysis of how therapists

construct understanding of relational mindfulness would have placed an emphasis on

language, which was not the chief concern of this project. A phenomenological

approach (which was anyway unavailable for this second study, having been used in

the first study) would have perhaps shifted the focus to individual experience. What

this piece of research wanted to achieve was an exploration of the processes that may

be occurring in the therapeutic relationship when therapists are informed by a mindful

approach, and grounded theory has a particular interest in actions and processes

(Tweed & Charmaz, 2012).

Most significantly, grounded theory is appropriate for an open, flexible

approach to a large subject. Other methods would not allow me to bring together

aspects of understanding into some kind of digestible whole. Whether this would

represent a ‘theory’ remained to be seen, but it was my belief that grounded theory

represented the best chance to develop an analysis and findings that could be taken as

a whole in order to, potentially, inform practice.

Incorporating reflexivity

I am a final-year student in a doctoral program in counselling psychology. I maintain a

personal mindfulness practice, and have used mindfulness both explicitly and

implicitly in my therapeutic work. Grounded theory is a reflexive approach that

encourages researchers to identify, acknowledge and question their own assumptions

and possible bias (Strauss & Corbin, 1990). My own major assumptions about the

research topic were that mindfulness has significant relevance to interpersonal

phenomena, and that it can be beneficial to both therapist and client in a therapy

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setting. I attempted to ‘bracket’ these assumptions and, as far as possible, approach the

topic with the ‘beginner’s mind’ promoted by mindfulness (Kabat-Zinn, 2004).

Participants

Participants comprised eight practising therapists who identified their therapeutic

approach as being informed by mindfulness. Two were trainee counselling

psychologists working in psychodynamic placements; the others had experience

ranging from 4 years to 30 years (mean = 13.17 years), and identified their theoretical

approaches as follows: integrative (N = 3), psychosynthesis (N = 2), and core process

psychotherapy (N = 1). All participants said that they maintained a regular personal

mindfulness practice, and all reported working with an emphasis on the relational.

Table 1 provides participant information (all names have been changed).

Table 1. Participant information

Name Years since qualifying Therapeutic approach

1. David Trainee Psychodynamic (currently)2. Steven 8 Integrative3. Sarah 15 Integrative4. Cassie Trainee Psychodynamic (currently)5. Pamela 30 Integrative6. Arlene 10 Core process7. Fiona 12 Psychosynthesis8. Mark 4 Psychosynthesis

Procedure

Recruiting participants

Theoretical sampling (see ‘Data collection and analysis’, below) was used to shape the

process of recruitment. Participants were recruited via personal contacts with the

researcher or research supervisor (N = 3), word of mouth referral from previous

participants (N = 2), and emailing therapists who expressed an interest in mindfulness

on their websites (N = 3). They were provided with an information sheet (appendix 1)

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and consent form (appendix 2) including the researcher and research supervisor’s

details, and asked to contact the researcher if they were interested in taking part.

Data collection and analysis

These two processes are described in one section due to the particular attitude to data

collection and analysis specified by grounded theory approaches. Where other forms

of qualitative inquiry might proceed in a linear fashion, beginning with gathering data

and proceeding to analysis of this data, the grounded theorist starts the process of

analysis from a very early stage of data collection; this in turn informs subsequent data

collection strategies, in terms of where and how new data is sought. This is the

process of theoretical sampling, defined by Charmaz (2014, p.192) as ‘seeking and

collecting pertinent data to elaborate and refine categories.’

In the current study, the logic of theoretical sampling informed both the

evolution of the interview schedule, and how participants were selected. For example,

analysis of early interviews revealed certain concepts rarely discussed within

mainstream psychological discourse, such as transpersonal notions of shared energy.

This prompted the researcher to contact therapists working outside of mainstream

theoretical approaches such as psychosynthesis and core process psychotherapy,

which are informed by both mindfulness and transpersonal understandings of the

therapeutic relationship.

In terms of the interview schedule, Charmaz (2014, p.64) notes that conducting

interviews without using an interview schedule would be the ideal way to avoid

imposing the researcher’s agenda on interviewees, but also cautions that lacking such

a schedule can also result in missed leads and the imposition of preconceptions. The

researcher decided to develop a basic initial interview schedule (appendix 3)

consisting of questions about demographic data, a question about how they understood

the concept of mindfulness, and a general, open-ended research question (‘The topic

of my research is “Bringing mindfulness to the therapeutic relationship”. What do you

make of this?’) that was designed to avoid, as far as possible, ‘leading’ the participant.

Potential follow-up questions were also included in this initial schedule.

Of course, by openly framing the research in terms of the therapeutic

relationship, it is likely that this approach was already influencing the responses of

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participants. An alternative would have been to ask more general questions about

mindfulness and therapy, and wait to see if data arose regarding the therapeutic

relationship. The disadvantage of such an approach would be much longer interviews,

with much data that was not immediately relevant to the phenomenon that the

researcher wished to investigate. Moreover, informing participants in advance about

the topic of the research allows them to think about the topic before the interview,

which might lead to more in-depth insights. It should also be added that a

constructivist position does not pretend that it is possible to remove the researcher’s

influence.

As data gathering and analysis proceeded, the content of the interview

schedule was modified in order to yield richer data about some of the categories

developed during analysis of early transcripts. These included questions about forms

of unconscious communication between therapist and client, and about the relevance

of mindfulness to attachment processes in therapy. Although the interview schedule

evolved during the process of research, it remained sparse, to allow the process to be

largely participant-led, which would create space for the discussion to proceed in

ways I had not anticipated. The schedule used for the final interview is included in

appendix 5. Interviews took place in confidential settings at a time and location of

participants’ choosing, and were recorded on a digital recorder. Mean interview length

was 47 minutes.

Transcripts were initially subjected to line-by-line coding (see appendix 4 for

an extract of a coded transcript), where possible using gerunds to emphasise actions

and ensure a focus on processes rather than topics – which can help to avoid forcing

participants’ statements to conform with the researcher’s preconceptions (Glaser,

1978). The next stage was focused coding, in which frequently occurring codes, or

codes that were deemed to be of particular significance, were consolidated into larger

categories. Following this, theoretical coding grouped these categories into higher-

order categories, which were compared to the initial raw data as a way of assessing

their ‘fit’ with what participants had initially said, and to assess variation within

categories. At all stages of data collection and analysis, memo writing was employed

in order to develop ideas about the data and assist in the development of categories.

Because of time limitations, theoretical sampling could not be pursued until

saturation. Although, by the end of analysis, no new categories were being developed

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from the data, this is not sufficient to claim saturation (Charmaz, 2014, p.213). An

example of how the research process could have proceeded relates to the choice of

participants. In the current study, all participants said either that mindfulness was

integral to their way of working, or that they had used explicit mindfulness techniques

with clients in the past. A fuller understanding of the subject matter might have been

achieved by interviewing therapists who do not self-identify as using mindfulness in

their work, but who nonetheless retain a strong personal involvement in mindfulness.

Credibility

Yardley (2000) proposes four areas in which qualitative researchers can take measures

to enhance the credibility of their work: sensitivity to context, commitment and rigour,

transparency and coherence, and impact and importance.

The current study attended to sensitivity to context by acknowledging the

researcher’s role in meaning making, and grounding theoretical claims in participants’

own accounts. Member-checking (Charmaz, 2014, p.210) was carried out, by

contacting participants at the end of the data gathering process and asking them for

their thoughts on the theoretical diagram (see fig.1). A follow-up interview was also

carried out with one participant (David, the first interviewee) at this stage, for an in-

depth discussion of the finalised theory.

Commitment and rigour was demonstrated by adhering to the key processes

involved in grounded theory, as described by Charmaz and other authors. Data

analysis underwent several stages, in the interests of extracting meaning as fully as

possible. Transparency and coherence were displayed via thorough description of the

research process (including a diagram to clearly present the categories and links

between them), and the retention of materials in such a way as to constitute a ‘virtual

audit’ (Yin, 1989). Finally, in terms of impact and importance, this study aimed to

address an under-explored area, and one which has relevance to therapeutic practice,

and as such could be of interest to a substantial number of people within the field.

Ethical considerations

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The study was considered to be low-risk, as it involved interviewing therapists, who

were not considered to be vulnerable. There were not thought to be any health and

safety risks for the researcher or participants, and interviews were not expected to

address material that could cause distress for participants. Fast-track ethical approval

was therefore sought and granted by the Faculty of Arts & Human Sciences at the

University of Surrey (appendix 6). Informed consent was obtained from participants,

who were informed that they could withdraw from the process at any time, without

giving a reason. To ensure anonymity, recordings and transcripts were coded and

stored separately, and pseudonyms were used in the report.

Research guidelines by the British Psychological Society (BPS, 2010) name

four principles of ethical research: Respect for the autonomy and dignity of persons,

scientific value, social responsibility, and maximising benefit and minimising harm.

The current study attended to these principles in the following ways.

The autonomy and dignity of research participants was respected by ensuring

valid consent, confidentiality and anonymity. Priority was given to the views of

participants, and the developing analysis and theory-building process was rooted in

their statements, rather than attempting to make participants’ views conform to the

preconceptions of the researcher, which can occur when researchers direct

participants’ responses (through leading questions or verbal/nonverbal signals given

off during the interview process) or misrepresent what participants have told them.

In terms of scientific value, the BPS points out that poorly designed or

executed research is a waste of resources and can result in the spread of inaccurate or

otherwise misleading information within the field. Efforts were made at all stages of

the current study to adhere to good practice (see ‘Credibility’, above) and to ensure

transparency of the research process and what it hopes to achieve.

Social responsibility refers, in a general sense, to engagement with the wider

world. This includes considerations such as the contribution of research to the wider

benefit of human society. The current research topic was chosen as it was felt that

furthering understanding of the relational aspects of mindfulness could contribute to

the wellbeing of others. It is also important to acknowledge the limitations of the

research study in question, and how research findings are interpreted in general. A

conscious effort was made during the design, execution, and writing stages to be self-

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reflective, and to acknowledge the substantial influence of the researcher on the

outcome of research.

Lastly, the BPS urges researchers to maximise benefit and minimise harm. It

was considered unlikely that harm could ensue to participants in the current study, but

measures were in place to reduce the impact of harm if it did occur, such as reassuring

participants that they could decline to answer any questions they chose, and withdraw

at any time.

Although this study involved research with a non-vulnerable population, and

did not require participants to discuss sensitive issues, it was still important to keep in

mind ethical considerations, particularly during the process of data gathering and

analysis. I approached each interview in a spirit of respect for the values and beliefs of

therapists, in the service of preserving the autonomy and dignity of participants.

However, for the study to have scientific value, it was also important for the

researcher to be able to probe the responses of interviewees – not to challenge them,

as such, but to understand more fully their beliefs and values, what lay behind them,

and what the implications were for practice. A balance had to be achieved, then,

between expressing empathy and interest in response to participant statements (Braun

& Clarke, 2013).

Also considered during the process of gathering research were potential power

dynamics between the researcher and the study participants. In my position as a

trainee psychologist, I anticipated that there would not be a problem of the researcher

holding more power than the interviewees, who were all qualified psychologists or

psychologists in training. Furthermore, as all participants used mindfulness in their

therapeutic work, I was not approaching the process from a position of relative

expertise. Sometimes, when the interviewer is less experienced than the interviewee,

the power differential can lead the participant to dominate the interview, and

researchers to unquestioningly accept the ideas they propound (Odendahl & Shaw,

2002). In the current research, half of the participants had 10 or more years of

experience as therapists, and so I was careful keep this in mind as I approached each

interview.

A final point, regarding the principle of maximising benefit and minimising

harm, is that therapists who participated in this study might have benefited on an

individual level from doing so. Several participants mentioned that taking part in the

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interview had prompted them to think more deeply about why they choose to use

mindfulness in their personal and professional lives, and as a result had gained greater

understanding. In turn, this may have informed their practice and indirectly benefited

their clients. It is hoped that publication of this research will achieve a similar

outcome for those who read it.

Results

Results summary and model

Several categories were developed from the data, and through a process of constant

comparison, links between the categories were established and developed into a

model, which is presented in figure 1. The four main categories were ‘cultivating

mindfulness’, ‘bringing mindfulness to the relationship’, ‘transforming the client’s

experience’, and ‘providing a secure base’. These categories are linked in such a way

as to represent a process that occurs within the relationship between therapist and

client, rather than constituting separate aspects of the relationship.

The data suggest that the first stage of bringing mindfulness to the therapeutic

relationship entails cultivating mindfulness. This is achieved outside of the therapeutic

setting through personal mindfulness practice (both formal and informal), and within

the therapeutic setting through adopting a mindful attitude (characterised by attending

to phenomena on a moment-by-moment basis, in a spirit of open-minded enquiry and

non-judgement).

Participants reported that by cultivating mindfulness in this way, they achieve

enhanced presence, acceptance (of self, and of the client), and attunement (with the

client, and to their own processes). These qualities are communicated to the client

through both conscious and unconscious processes, and have a transformative effect

on the client, who, in the perception of participants, feels more held/contained,

accepted, and understood. Therapists in the current study believe that these sensations

can, in turn, lead to the client experiencing the therapeutic relationship as a secure

base, which can act as a reparative relationship when a client has experienced wounds

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in intrapersonal and interpersonal relating, and facilitate deeper exploration within

sessions.

Unless stated otherwise, quotations from participants in the results section

refer to bringing mindful qualities to the therapeutic encounter, rather than explicitly

engaging in mindfulness exercises such as joint meditation.

Fig. 1 Results model

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1. Cultivating mindfulness

All participants described using formal mindfulness meditation to cultivate mindful

qualities, as well as attempting to be mindful in daily activities. All were keen to stress

that mindfulness is not simply a resource that they call upon when needed, or a tool

that they use; rather, it was described as a ‘way of being’ (Cassie, 414-5), ‘part and

parcel of who I am’ (Fiona, 463-4), and something that is ‘very “soaked into” my life’

(Sarah, 483). The aspect of mindfulness most commonly mentioned as particularly

important for participants was present-moment awareness. Participants also described

acceptance and willingness to ‘turn towards experience’ (Fiona, 138-9) as integral

factors.

Some participants (Cassie, Arlene, Mark) described formally meditating before

sessions in the aim of enhancing their therapeutic work, and all said that they had used

formal mindfulness techniques with at least some of their clients. Motivations for

doing so included to ‘deepen the bond’ (David, 237-8), to ‘ground’ both therapist and

client (Cassie, 296-7), and to introduce focus at the start of a session and select a topic

of discussion for the session (Pamela, 84-5). For participants, guiding a client through

a mindfulness exercise entailed entering a meditative state themselves: ‘I’m guiding it,

but I’m meditating myself as well’ (Steven, 234). These formal meditations within

sessions were not seen as solely for the clients’ benefit, but as a way of establishing a

connection between therapist and client: ‘It’s a different way of contacting clients.’

(Mark, 137-8)

Participants also described the benefits that mindfulness had provided their

own intrapersonal and interpersonal relating: ‘It enables me to take more

responsibility in my relationships, in my personal relationships. It challenges me to be

authentic, congruent, to the best of my ability’ (Arlene, 554-7). Space and choice were

recurrent themes in interviewee responses: ‘It gives me more of a choice about how I

react to daily events. It cultivates some space.’ (David, 19-20) Interviewees also

described mindfulness as promoting a shift from an individual perspective to one that

is more open to the experience of the other: ‘Mindfulness can help keep the well of

empathy topped up.’ (Mark, 329-30)

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2. Bringing mindfulness to the relationship

Participants believed that cultivating mindfulness in their personal and professional

life, and consciously adopting a mindful attitude in therapy sessions, can enhance the

therapeutic relationship in several ways. The three core categories constructed to

describe these phenomena were attuning to relational processes, promoting

acceptance of self, and enhancing therapeutic presence. There are conceptual links

between these categories, and they should not be viewed as discrete units of

experience, but rather as interrelating and informing each other.

(a) Enhancing presence

For the purposes of the current study, ‘presence’ is defined as being alert, situated in

the moment, and attending to processes as they unfold, so that the client experiences

the therapist as being fully ‘with’ him or her. It is a more focused concept than Geller

and Greenberg’s (2012, p.181) conception of ‘therapeutic presence’, which is a multi-

faceted construct that maps closely onto other theorists’ definitions of ‘mindfulness’

(which in their understanding is limited to ‘a practice or a set of skills’). The definition

used here is closer to Welwood’s (2000, p.100) notion of ‘unconditional presence’,

which is ‘the capacity to meet experience fully and directly, without filtering it

through any conceptual or strategic agenda.’

Not knowing

Central to the process of enhancing one’s presence in the therapy room is the

cultivation of a ‘beginner’s mind’ (Sarah, 258), or a stance of ‘not knowing’ (Fiona,

186). David, when describing the process of teaching a mindful way of being to his

clients, said: ‘So we discuss thoughts and how they would go through their mind. And

once we recognise that…’ (46-7). In his description of this process, he positions

himself as a joint learner along with the client (‘once we recognise that’), as if they are

discovering mindfulness together. This makes sense in the context of viewing

mindfulness as an ongoing process rather than as a skill to be mastered – none of the

participants professed to be an ‘expert’ in mindfulness; on the contrary, they were

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keen to provide examples from their own lives of being unmindful. I pointed out this

use of ‘we’ to David, and his response underlines that engaging in joint mindfulness in

sessions is at least as much about connecting with the client as it is about teaching a

skill:

When I use the word ‘we’, I also mean that when we engage in the mindfulness practice in therapy, I’m not merely demonstrating a skill, it’s about connecting with the client in those five minutes of meditating together.’ (David, 67-71)

For therapists in this study, bringing the beginner’s mind to the therapeutic

relationship also means moving away from an interpretative therapeutic style, or the

desire to solve problems or ‘fix’ the client. Participants valued non-interpretation as

beneficial to the process of therapy:

The mindfulness in the moment is inquiring into what’s going on, what’s really, what’s happening right now, rather than jumping to an interpretation, but to stay with it as an embodied enquiry. (Arlene, 108-11)

This is particularly relevant when therapists find themselves caught up in theoretical

frameworks within the session:

Cassie: If clients feel that I’m as present and as available to them as I can be, it enhances the work that we do together.

Researcher: In what way? Cassie: Sometimes I can get quite caught up in thinking about things from different theoretical models… and think about what we should be doing, but I suppose mindfulness enables me to bracket those things, just to be with the client. (Cassie, 89-102)

As Cassie understands it, letting go of a need to adhere to a particular approach allows

her to be in the therapist-client relationship more fully.

Embodied sense

As suggested by Arlene’s phrase ‘embodied enquiry’, participants use bodily

awareness as a way of enhancing their presence. In a distal sense this is achieved

through long-term mindfulness practice; in sessions it can involve bringing attention

back to the breath: ‘If I find myself going off, overthinking what’s going on with the

client, I might just come back to my breathing for a moment.’ (Cassie, 223-5). Several

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participants constructed an opposition between cognitive and embodied ways of

being, suggesting that mindfulness can enable a shift from the former to the latter, and

a concomitant deepening of the therapeutic exploration:

Your energy drops from being in a very busy place into a more felt sense… I’m aware just of the balance of the body, and of the breathing rhythm. I think mindfulness definitely, it’s so key, being more aware of your body. And how the more stressed and frantic you become, the more in your head you are. (Sarah, 337-44)

Cassie implicitly associated the cognitive mode with being disconnected: ‘Not so

cognitive and disconnected from other ways of being or seeing things.’ (363-4)

Focusing one’s attention inwards towards cognitions implies a disconnection from the

external world, and a move towards a more individualistic interpretative stance. A

similarly introspective act, however, that of bringing attention to the body, is

constructed as an opening up to experience and to connection with others, and

enhancing the therapeutic relationship.

It may be that this is because embodied awareness is associated with

unconscious communication between therapist and client, as in Steven’s description of

using the body to become aware of transferential processes. Alternatively, it may be

that cognitions are conceptually linked with value judgements. The mindfulness-

informed therapists in this study spoke of the value of enquiry into bodily sensations

and emotions, without labelling them, as a way of effecting psychological change.

(b) Promoting acceptance

Shapiro, Carlson, Astin, and Freedman (2006) summarised the core elements of

mindfulness as intention, attention, and attitude. If category 1, ‘Cultivating

mindfulness’ represents the ‘intention’ aspect, and the previous sub-category,

‘Enhancing presence’ relates to ‘attention’, then acceptance constitutes the attitude

adopted in the therapeutic encounter. It is both an intrapersonal and an interpersonal

stance, as described below.

Acceptance of self

For therapists in this study, attuning to their sensations and emotions was associated

with developing acceptance of them. While participants described awareness of

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transference as beneficial to the work, there was also a sense that therapists’ personal

issues can also sometimes obstruct the work and prove a barrier to establishing a

therapeutic relationship.

If I’m not in contact with something within me, like anxiety or pain, and I’m numbing that out, then that’s going to get in the way, whereas if I can be present to what’s going on, and give it space and allow it to be there, then it’s not going to come between us… it’s not necessarily getting rid of it, but it’s learning to recognise that it’s around, and it’s an influencing factor. (Fiona, 159-71)

Significantly, participants did not say that mindfulness reduced levels of (for example)

anxiety, but that the awareness fostered by mindfulness allowed them to ‘bracket’

(Cassie, 94) difficult sensations, freeing them to focus on the work. As David noted,

‘If you’re overwhelmed by your own emotional reaction to a client, then it’s very hard

to empathise with them because what’s going on is you’re analysing yourself.’ (418-

20) He also described feelings of rejection being stirred by a client:

I was feeling rejected, I was feeling not good enough, deskilled. I think my mindfulness practice really helped to cultivate some space between some very strong feelings that I would have, which would have been of rejection, and of course what would normally come after that would have been defensiveness, or reassurance, or desperately trying to placate the client. But I was able to take a step back and say ‘What’s going on here? What is actually going on?’ (David, 365-72)

Bringing awareness to what was happening in the present moment allowed David to

distance himself from his urge to react emotionally, to bring acceptance to it, and to

remain receptive to in-session processes. This also, presumably, reduces the risk of

rupture to the therapeutic alliance, as can happen if the therapist reacts automatically

to what has been stirred up in relationship with the client.

Acceptance of the other

Increased self-knowledge, which participants felt mindfulness provides, contributes to

a sense of shared humanity with others, including clients. This can assist in accepting

the client unconditionally:

Mindfulness has really helped [me] look at the client and not judge them… You feel a lot of, I’m not sure about empathy, but a lot of compassion for their suffering… And it helps you not to judge. When you see that your own, how mad your own thought

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and emotion processes are, you can sort of, you can be more compassionate towards them. (David, 454-65)

Other participants said that mindfulness does not necessarily lead to greater

acceptance of the client, but can allow for clearer insight into situations where non-

acceptance occurs:

I’m still pretty judgemental. But maybe I’m less judgemental than I would have been otherwise. I can be quite judgemental of people in general and clients. So yeah, I don’t know. Does it make you less judgemental, or does it just make you realise that you’re being judgemental? (Steven, 368-72)

By remaining alert to the possible existence of non-acceptance, the therapist can bring

a greater awareness of the current level of relating between therapist and client.

c) Attuning to the relationship

The previous two sub-categories related to presence, which is an attentional process

(broadly speaking – although ‘not knowing’ can be regarded as an attitude), and

acceptance, which is an attitude. In this regard, these two processes are perhaps to be

expected when a therapist brings mindfulness to the therapeutic setting. ‘Attunement’

can be regarded as the ‘something extra’, the somewhat intangible quality of being in

sync with the client.

Coming into the same space

It was noted by participants that the experiences of therapist and client immediately

before starting a session are likely to have been very different. Cassie described her

experience of joint meditation at the start of her personal therapy sessions:

Rather than coming in from wherever I’ve been, and going straight into talking, you know my experience is very coloured by where I’ve just come from… I can just, you know sitting there for five minutes, coming back into myself and actually having time to feel what’s going on in me, and notice where my thoughts and feelings are, I think it really enhances the therapy. (Cassie, 271-8)

It was suggested by participants that ‘checking in’ at the start of the session can help

identify what the client wants to talk about:

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It feels like it brings us into the room. It kind of grounds us both. People will have been racing to get here… it definitely changes the energy because people focus on, ‘This is why I’m here, let me really connect with this.’ (Sarah, 269-76)

Another outcome of meditating together described by interviewees was that of

reducing the space between therapist and client. This was conceptualised as providing

a more ‘intimate’ (David, Steven, Sarah) bond between therapist and client, and

reducing the gap between their roles (David, Steven, Mark). Participants used the

metaphor of travel: ‘In our vibration, in our mood, in our sense of experiencing this

moment, we are on the same path.’ (Pamela, 124-5).

Participants also described an attunement that occurs on a bodily level between

therapist and client. Pamela claimed that she could ‘model’ a calmer way of being to

the client, and transmit this on an unconscious level:

It affects my energy level and my vibration, and that vibration then affects my client’s vibration. So if I go into a deeper, more settled, calmer vibration, that’s what the client tends to pick up. (Pamela, 20-3)

Information is also transmitted from client to therapist:

I think it’s really important to be attuned to what’s happening in my own body, ‘cause I can often pick up – and this is very much part of the work – I can, you know, when I’m attuned, well attuned, I know what’s going on for the client. And so, if I feel that my heart is starting to speed up or I’m bringing in a mindful awareness of that, I would slow things down. (Arlene, 251-7)

When asked about the mechanisms of such communication, participants were

uncertain, but believed that it is a transformative process (‘almost alchemic’; Fiona,

252) for the therapeutic relationship and therapeutic work.

Increasing awareness of process

Mindfulness was also seen as a way of attuning to the ‘process’ of therapy. David

described ‘taking a step back’ (371), while Mark spoke of the ‘distance’ it provides,

allowing for meta-awareness of what is going on:

If I have a particular client who has something that will press buttons, I’m just aware of that, and the mindfulness, I think, just creates a little bit of distance. (Mark, 401-4)

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The concepts of ‘taking a step back’ and ‘creating distance’ fit with the notion that

mindfulness provides people with space between a stimulus and their response to that

stimulus, and thus facilitates choice. David was asked to elaborate on how he

understood this process, and he answered in terms of transferential processes:

I think mindfulness as a therapist is very beneficial in that sense, because it allows you to see what’s going on. You know, rather than getting drawn in to the countertransference… and to respond to it straight away, you’re able to take a metacognitive view. (David, 400-5)

Other interviewees, too, claimed that adopting a mindful stance helped them attune to

the transference. Cassie noted that, ‘Mindfulness is another way of saying awareness.

You know, being aware of your transference and countertransference.’ (398-400)

Steven was more explicit about this process, which for him involved turning mindful

attention towards his bodily sensations:

I use it to guide me in terms of understanding or noticing the countertransference. So it’s from that perspective, using my embodied feeling to know what’s going on for me and have a sense of what’s going on for me and what might be coming from them, and what might be mine. Just having a sense of things at this body level, rather than just thinking. (Steven, 115-21)

This heightened attention to process can guide the therapist’s choice of intervention

(or non-intervention), as with the greater acceptance described in the previous sub-

category, can guard against rupture of the therapeutic relationship, in this case by

remaining sensitive to what is required in the moment.

3. Transforming the client’s experience

Participants said that these qualities, of being attuned to and accepting of the client,

and therapeutically present, are communicated to the client. This occurs on a

conscious level:

I might for example say, ‘Oh gosh I’m noticing as soon as you said that, I’ve got this real, you know, pain, real tightness in my gut as you’re saying that. And I’m wondering what’s going on for you, ‘cause I’m wondering if I’m having a reaction to you in some way.’ (Fiona, 174-8)

And also unconsciously:

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It feeds into how I am with the client. Um… but I mean, they would notice probably subconsciously, not necessarily a conscious thing. (Cassie, 115-7)

What, then, is the effect on the client? Understandably, therapists were more tentative

in describing how they believed clients experience the therapeutic relationship.

However, their responses did suggest that they believe clients feel more

held/contained, accepted, and understood, all of which contribute to the establishment

and maintenance of a strong therapeutic relationship.

(a) Feeling held/contained

Therapists described their belief that mindfulness helped them to ‘be with’

challenging situations in the therapy room, and that this was picked up on by their

clients:

I am more able to sit with difficult feelings and contain the client, when things kind of get difficult or emotional. (Steven, 492-4)

According to Fiona, whether the therapist is able to bring mindful awareness to the

therapeutic relationship can be the deciding factor in providing a sense of safety for

the client:

I think it can make the difference between a client feeling safe and held [or not]. (Fiona, 222-3)

For Arlene, what allows the mindful therapist to fulfil this role is the self-awareness

that mindful enquiry brings:

Someone once said to me [that the] therapist is like a vase, made out of clay. If there’s any cracks in that vase, the client is the water, and will find it. If I haven’t fully explored my own difficulties, my own relationship angle… then I’m not going to be available to my clients. (Arlene, 148-53)

(b) Feeling accepted

According to participants, mindfulness also contributes to clients’ sense of being

accepted unconditionally by the therapist. Sarah described a recent exchange between

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herself and a client who had previously had negative experiences in other therapeutic

dyads:

I said to her, ‘What was this experience like?’ and she said, ‘Oh, this experience was different, it was like a ray of sunshine.’ And so I said, ‘Why, what made it different?’ And she said, ‘I didn’t feel judged, I didn’t feel, you know, it felt like you were very firm and clear about the boundaries and what you could offer, but you were also very connected, very real, very non-judging. (Sarah, 228-35)

This therapist believed that mindfulness gave her the qualities – connectedness,

congruence, non-judgement – that allowed her to establish a strong therapeutic

relationship with a client who had previously felt unmet in these aspects.

(c) Feeling understood

Pamela believed that engaging in joint meditation can forge an unconscious bond

between therapist and client that allows clients to feel understood. Again, the

communication from client to therapist is through embodied sensations:

I would feel it very much, you know, I would actually even share with them afterwards, you know, I noticed that your heart was beating rather fast, or your stomach seemed to be a bit tight, did you feel any of this? And then they say ‘How did you know?’ And I say, well I just sensed it. (Pamela, 264-8)

The ability to remain present with the client was also thought to be key to imparting a

sense of understanding. Fiona invoked the concept of not knowing:

Fiona: We’ve both hit the same note, in a way. That we both, we’re like tuning the radio in, that the client feels ‘got’. You know, I might have said something and it’s ‘Yes! That’s it!’ It’s that ‘spark’ sort of moment, I think.

Researcher: And can mindfulness help with that? Fiona: I think so; I think I need to be as present as I can possibly be, if those opportunities are going to come up. Researcher: And being present helps you to understand what’s going on?

Fiona: I think it does, yeah. I think it does. It’s a willingness to be in a place of not knowing, but essentially being open too. I think as soon as I start to grasp at something, then I – ‘Oh I know all this person’s issues…’ – then I’ve lost it, I’ve gone really, I’m not going to be of any use to them. (Fiona, 289-301)

The importance for Fiona of this stance of not knowing is suggested by her statement

that she would not be helpful to clients if she did not retain it.

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4. Providing a secure base

By providing a space in which the client feels understood, accepted, and held,

participants in this study perceived that they could establish a ‘secure base’ for clients

in the therapy room. This concept is taken from attachment theory, and refers to the

idea that a secure attachment with a primary caregiver can allow a child to explore his

or her surroundings in the knowledge that s/he can return to the caregiver as a safe

haven if necessary (Bowlby, 1988).

Participants described the importance of therapists developing a secure base

within the self, and how mindfulness can assist in this:

There’s a sort of solidness that you develop within yourself, a robustness, that you know you can come home to… I think that developing a secure base within yourself, mindfulness plays a huge part of that. (Sarah, 444-50)

Siegel (2007, 2009) has explored the links between mindfulness and neural pathways

linked to attachment processes. Some participants in the current study also invoked

neurological processes as a way of explaining how practising mindful therapy can

assist the client in feeling safe:

When a client goes with me on this journey into, you know, calmness and ‘nowness’, I literally feel how their sympathetic nervous system slowly settles down… and then their parasympathetic nervous system, their system of safety, you know where endorphins and oxytocin and all these wonderful chemicals are released, comes to the forefront and you literally see the facial muscles relaxing, sometimes even a smile appearing. (Pamela, 50-9)

If therapist and client are able to establish a secure base within the therapeutic

relationship, two effects described within interviews were constructing a reparative

relationship and going deeper in the work. In turn, both the establishment of a

reparative relationship and deeper exploration can reinforce the sense that the

therapeutic relationship has provided a secure base.

(a) Constructing a reparative relationship

The reparative (or ‘developmentally needed’) relationship is described by Clarkson

(2003, p.13) as ‘the intentional provision… of a corrective, reparative, or replenishing

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relationship or action where the original parenting (or previous experience) was

deficient’.

The theoretical approach taken by two participants in the current study,

psychosynthesis, proposes that the therapist can act as an ‘external unifying centre’

(Assagioli, 1965), a concept similar to Vygotsky’s ‘zone of proximal development’

(Hedegaard, 1996) in that both theories propose that, in the presence of a nurturing

other, personal growth can occur that might otherwise be out of reach of the

individual:

The idea is that you act as the good parent, so that the ‘child’ part of the client can re-experience attachment safely, without the harm that was done when they first experienced attachment. (Mark, 436-9)

Both psychosynthesis practitioners believed that mindfulness is ‘hugely important’

(Fiona, 409) in developing this external unifying centre.

Therapists working from other theoretical approaches expressed a similar

belief that the mindfulness can help to establish a reparative relationship:

Arlene: Securely attached people generally don’t seek out therapy.

Researcher: That’s really interesting. Can mindfulness – working mindfully, or cultivating mindfulness – help someone to develop more secure attachment patterns?

Arlene: In therapy – yes. It has to be in the relational… if there’s a wound that’s happened in the relation you cannot heal that wound, as far as I’m concerned, out of a relationship… it’s my belief that you have to do it in relationship if you really want to see long-lasting change, real change. (Arlene, 428-48)

Mindfulness alone, then, cannot overcome insecure attachment patterns – it is the

belief of Arlene that this work has to be carried out in the relationship.

(b) Going deeper in the work

The ‘safe exploration’ described by Bowlby is facilitated within a mindfulness-

informed therapeutic relationship, according to participants, through the mindful

processes of anchoring oneself in the body or breath, and turning towards experience

to be with ‘what is’:

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You always come up against the real difficulties, and as human beings we tend to turn away from those, whereas mindfulness is really encouraging you to go towards them and be curious and work with them. (Sarah, 472-5)

Again, participants stressed the importance of moving beyond purely cognitive

insights to address what is happening in the body:

If I only meet my client in a ‘mind’ way, then they’re stuck working in a cognitive way. Most clients come with very old cognitive strategies for distancing themselves from their emotional experience. And for distancing themselves from others, you know, not being in relationship by using their mind. So by coming into that felt experience, it allows me to not get caught in that distancing strategy they’ve learnt. And to bring myself back into my felt experience and then form a different level of relationship with the client. (Mark, 165-74)

There is a sense in these statements of ‘opening up’ the work to a more rounded and

fuller way of working. If therapist and client have successfully constructed a safe

space, then it is more likely that the client will be able to explore painful subject

matter in a way that is tolerable for both therapist and client:

It’s very important that they have the ability to ‘pendulate’… to move from the place that’s feeling overwhelming, to a place that feels safe… but again it’s still trying to be mindful of what’s resourceful, what’s resourcing, and what’s overwhelming. So, you know, in that sense mindfulness is always there. (Arlene, 237-46)

This can be the difference between a therapeutic relationship that merely provides

temporary relief, and one that is truly transformative for the client. As one participant

put it:

In this relationship with me, they might dare to go somewhere where they haven’t dared to go before. And maybe if we do it a few times, you know, being relaxed and not worrying about everything, maybe they can then sometimes apply that when they’re not with me. (Pamela, 153-8)

The deeper exploration afforded by the secure base, then, can reinforce the therapeutic

relationship (and the client’s relationship to his or her own psychological processes),

as the client discovers new possibilities in intrapersonal and interpersonal relating.

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Closing remarks

It is worthwhile mentioning that several participants commented on the commonalities

between mindful qualities and those qualities that are widely assumed to contribute to

effective therapy: ‘So many of the core aspects of mindfulness are core to therapy’

(Sarah, 386-7). It is also important to note that participants described a process, rather

than a set of tools that they draw upon. Neither is mindfulness something that is

achieved once and for all time, and can then be drawn upon in future therapeutic

work. Rather, cultivating mindfulness is an iterative process involving a constant

return to processes unfolding from moment to moment. It is also something that

functions as a base from which to work relationally, rather than being limited to

specific applications within therapy. This idea was captured in a metaphor used by one

participant who compared mindfulness to the drone of bagpipes, which provides a

backdrop for the piper’s melodies: ‘It’s kind of the underpinning drone… it becomes

the sort of underpinning aspect of all the work, really.’ (Mark, 448-52)

Discussion

Based on the results drawn from the interview process, which included returning to

participants with the developing model, a tentative theory was developed. This is that

mindfulness-informed therapists experience mindfulness as a way of being, rather

than as something that they ‘do’. They cultivate mindful awareness via formal and

informal practice outside of sessions, and by bringing themselves to a state of mindful

awareness on a moment-by-moment basis. This results in an improved ability to be

present with the client, attending to phenomena as they arise in the moment, which is

signified by a move away from an interpretative, cognitive stance, and towards an

experiential, embodied mode of being. The state of being present is accompanied by

an attitude of acceptance, of the client and of the therapist’s own experience, and

together they contribute substantially to attunement between therapist and client,

which in turn allows for clearer perception of the relational processes unfolding in the

session.

Evidence for the next stage of this process is inevitably less comprehensive, as

the study drew from therapist perceptions and not client reports, but the data suggest

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that the client’s experience is transformed by the therapist’s mindful stance, resulting

in feelings of containment and acceptance, and the sense that they are understood by

the therapist, which together contribute to the client experiencing the therapeutic

relationship as a secure base, which can be reparative for those clients with unresolved

developmental needs, and provides the necessary safe space for exploration of

challenging issues and the experiencing of a new way of relating. In turn, these

experiences feed back in to the client’s sense of the relationship providing a secure

base.

The four main categories will now be examined in more detail, with reference

to existing literature within the field.

Cultivating mindfulness

In a sense, maintaining a mindfulness practice dissolved some of the boundaries

between participants’ personal and professional lives. They reported benefits for their

own personal relationships, which were described in terms of having more space

between stimulus and response, and consequently more choice in how to respond. At

the time of the study, not all participants were explicitly using mindfulness in their

work with clients, and those who were, said that they did not do so with all clients.

However, when mindfulness techniques were brought into the work, they were

characterised by a commitment to the process, involving moving into a meditative

state along with the client.

Therapists did not claim to be more mindful, or to work more effectively, than

other therapists who did not use mindfulness. However, they were clear that their

personal practices meant that they were more mindful than they otherwise would be.

Bringing mindfulness to the relationship

This category had three dimensions: presence, acceptance, and attunement.

Enhancing presence

Present-moment awareness is a fundamental – perhaps the fundamental – aspect of a

mindful way of being. If one is not alert to the unfolding of experience from moment

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to moment, then it is not possible to bring the healing attitude of acceptance to this

experience.

For participants in the current study, awareness of one’s embodied experience

was vital to the process of being present, which contrasts somewhat with some of the

participant views in the IPA study by Ellwood (2014). Participants in that study were

not regular meditators and did not profess to bring mindfulness to their work, and

some of them conceptualised mindfulness as a way of ‘accessing thoughts’. In the

current study of therapists experienced in mindfulness, a dichotomy was established

between embodied and cognitive modes of being, and it was felt that the former was

more conducive to working closely in relationship with a client. The significance of

the therapist’s body in relationship with the client was outlined by Boadella (1997),

who drew attention to process such as breathing patterns, posture, movement, and eye

contact, and their significance both to infant development and to growth within the

therapeutic relationship. Shaw (2004) elicited the views of 90 practitioners from

different theoretical approaches, in a series of discussion groups, on the use of the

body in therapy, and then interviewed 14 of them. Findings from a grounded theory

analysis were then presented to two groups of psychotherapists, in Vienna and

Stockholm. As with the current research, this large-scale study highlighted the

contribution that embodied awareness can make to the therapeutic encounter, for

therapists from a wide range of theoretical disciplines.

Closely related to embodiment is a move away from interpretation and towards

simply ‘being with’ the client, characterised by an open curiosity and the position of

not knowing, which can be described as the ‘beginner’s mind’. Mindfulness teaches a

nonstriving way of being, and participants in the current study applied this to their

work. Many therapists have recognised the value of non-interpretation (Stern et al.,

1998). Rogers, in a 1987 interview (Baldwin, 1987, p.45), claimed, ‘when I am

intensely focused on a client, just my presence seems to be healing’. Even Freud

(1912, pp.111-112) described a process of maintaining ‘evenly suspended attention’ in

order to ensure that the analyst fully attends to what the patient is saying: ‘He should

simply listen, and not bother about whether he is keeping anything in mind.’ For the

therapists interviewed in this study, cognitive processes, such as impulses towards

interpretation, detract from their ability to just be with the client. This aspiration to be

with, rather than do to, the client, is one of the aims of the counselling psychologist

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(Strawbridge & Woolfe, 2010, pp.10-11). Mindfulness seems to be conducive to this,

and has been formally implemented in a training program to enhance therapeutic

presence, with participants reporting greater awareness of their own – and their

clients’ – processes, a greater sense of calm during sessions, and more compassion

and acceptance during therapist-client interactions. They also perceived positive

effects for clients, resulting from these changes (McCollum & Gehart, 2010).

Promoting acceptance

This sub-category overlaps significantly with ‘being present’. Where that category

maps onto the ‘attention’ aspect of mindfulness, acceptance relates to the ‘attitude’

brought to awareness. The two are, however, in a sense inextricable: If a therapist is

not able to bring acceptance to the therapeutic relationship, then he or she will be

unable to be fully present in that relationship. In a mindfulness-informed framework

of understanding, all forms of psychological distress can be understood as ‘non-

acceptance’ – a commonly invoked metaphor in the literature is of the ‘two arrows’

sutta derived from Buddhist teachings, which likens the experience of a painful event

to being shot with an arrow, and unmindful reactions to the event (e.g. self-reproach,

rumination) to a second, more painful arrow.

It follows that if a therapist has not attended to personal wellbeing, it is less

likely that he or she will be able to help the client: Rubino, Barker, Roth, and Fearon

(2000) reported that anxiously attached therapists respond to therapist-client ruptures

less empathically than do their securely attached peers, and concluded that such

ruptures might be interpreted by the anxiously-attached therapist as indicators that

patients intend to leave therapy. More recent research (Todd, Forstmann, Burgmer,

Brooks, & Galinsky, 2015) suggests that the experience of anxiety attenuates

perspective taking and encourages ‘egocentric’ interpretations. Such findings resonate

with David’s description of feeling ‘rejected’ in the session, and how mindfulness

helped him bring acceptance to this experience and avoid reacting in such a way that

might have damaged his relationship with his client.

Mindfulness has therefore been used as a form of self-care for people working

within the caring professions. Mindfulness-based stress reduction training has been

found to enhance self-compassion in health care workers (Shapiro, Astin, Bishop, &

Cordova, 2005) and trainee therapists (Shapiro, Brown, & Biegel, 2007). Kingsbury

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(2009) found strong correlations between two aspects of mindfulness (non-judgement

and non-reactivity) and self-compassion, as well as two components of empathy

(perspective taking and experiencing discomfort as a response to others’ emotional

states). Intriguingly, self-compassion was a full mediator of the relationship between

mindfulness and perspective taking, which has relevance to Mark’s conceptualisation

of empathy, in the current study, as a resource that needs to be maintained: personal

mindfulness practice helps him to ‘keep the well of empathy topped up’. Compassion

for self as a precondition of compassion for the other is also a central theme of

compassion-focused therapy (Gilbert, 2009, 2010).

Attuning to the relationship

From the descriptions provided by interviewees in the current study, it appears that,

when a therapist brings mindfulness to the therapeutic relationship, either by

remaining present in a spirit of open-minded acceptance, or by engaging in a joint

mindfulness practice, there is an attunement that occurs between therapist and client.

Whereas some theorists (e.g. McCluskey, Roger, & Nash, 1997) treat attunement

between therapist and client synonymously with ‘affect attunement’, the descriptions

of participants in the current study suggest that attunement is broader than this.

One aspect of this attunement involves a reduction of the conceptual distance

between therapist and client. Therapists and clients in the previous study by Ellwood

(2014) reported that engaging in joint mindfulness fostered a sense of equality, as did

therapists interviewed for the current study. Similarly, participants in both studies

noted that therapists and clients are likely to have had disparate experiences

immediately prior to the session, and that focusing on the breath or body for a short

period at the start of sessions can bring them into the same experiential space.

Some participants also described unconscious attunement signalled by

unconscious bodily processes of the therapist and client coming into sync. This finds

parallels in the literature, in which a here-and-now focus has been indicated as a way

of noticing transference when it occurs (Feinstein, 1990; Kradin, 2007). Safran and

Reading (2008) describe a process of ‘affective communication’ that is present at both

conscious and unconscious levels within a therapeutic relationship, and note that

therapists can bring attention to such processes as a way of guiding themselves within

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the session. In such a way, Steven, in the current study, described using attunement to

his embodied state of being as an indicator of transferential processes.

The idea of using the body as a way of connecting to the experience of others

is not a new one – Merleau-Ponty (1962, p.186) wrote that, ‘It is through my body that

I understand other people.’ This embodied understanding of human beings’

relationship to the world and other people is in line with the field’s non-dualist stance,

which emphasises a holistic understanding of human experience. Different

interpretations have been applied to what happens in the therapist’s body during a

therapeutic encounter. Gestalt therapy focuses on embodied emotion as a way of

establishing ‘here and now’ contact between therapist and client (Kepner, 1988),

while from a psychodynamic perspective, this process has been termed ‘embodied

countertransference’ (Samuels, 1985; Field, 1989) or, particularly within the dance

movement psychotherapy tradition, ‘somatic countertransference’ (Pallaro, 2007;

Vulcan, 2009). Others, working within different traditions, might simply think of it as

bodily communication. However this embodied communication is conceptualised, it is

clear that it has transtheoretical relevance, and the therapists surveyed in the current

research believe cultivating mindfulness to be facilitative of working in this way.

Transforming the client’s experience

The claims made in this category are necessarily speculative as, regardless of the level

of attunement and understanding achieved within the therapeutic relationship, the

therapist is not the client and cannot speak for them. As Walsh (2008, p.75) cautions,

‘one’s sense of the client’s experience is always a projection based at least in part on

one’s own experience.’ Nevertheless, potentially promising avenues of exploration

were opened up by participants’ perceptions of client experiences. They believed that

clients feel more held/contained, accepted, and understood, which can be traced,

respectively, to the presence, acceptance, and attunement described in the previous

category (although these are not discrete processes; rather, they interact and feed off

each other).

Participants were unsure of the mechanisms involved in communicating

mindful qualities to the client, and of the resultant changes within the client. One

promising field that might shed light on this is the growing body of research

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surrounding mirror neurons and their role in promoting a sense of connectedness with

others. Siegel (1999, 2007, 2009) terms this field ‘interpersonal neurobiology’, and

proposes that cultivating mindfulness can increase attunement to the self, which in

turn helps one to attune to others. It has also been theorised that these are the neural

processes involved in primary attachment processes (Fonagy, Gergely, Jurist, &

Target, 2002) and the cultivation of empathy (Fishbane, 2007; Gallese, Eagle, &

Migone, 2007). Such interpersonal neural processes may be behind participants’ sense

of embodied, unconscious communication, for example Pamela’s description of ‘just

sensing’ the client’s emotional processes within her body.

The findings of the present research lend support to the hypothesis advanced

by Bruce, Manber, Shapiro, and Constantino (2010), which proposes that mindfulness

influences the client in therapy through promoting attunement in three relationships:

the therapist’s relationship with himself or herself, the therapist’s relationship with the

client, and the client’s relationship with himself or herself. The notion that the

therapist’s self-relationship influences his or her relationship with others is supported

by empirical evidence from extensive structural analysis of therapist-client

interactions (Constantino, 2000). The mechanisms through which this process might

occur are still unclear, but future research on the proposed existence of mirror neurons

in humans could help increase our understanding of the relationship between

intrapersonal and interpersonal attunement (Cozolino, 2014).

Establishing a secure base

It follows that, if the client’s activated, anxious emotions can be transmitted to the

therapist, then this communication can go in the other direction, with the therapist

holding feelings of safety that are then transmitted to the client, as in an attachment

relationship. Indeed, the therapeutic relationship has been described in terms of an

attachment relationship, with some overlaps and divergences from the findings of the

present study. Bowlby (1988, p.150) saw the role of the therapist as to be a

‘companion’, sitting beside the patient during exploration, rather than an expert

offering interpretations, which is consistent with the non-interpretative stance

described by participants in this study. He also, however, conceived of attachment as a

bond with someone who is perceived as ‘wiser and/or stronger’ (Bowlby, 1973).

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Several studies (e.g. Farber, Lippert, & Nevas, 1995; Mallinckrodt, 2010) have

proposed this element as essential to the formation of an attachment bond between

client and therapist. By contrast, participants in the current study conceived of

mindfulness as reducing the distance between therapist and client in terms of

dissolving the ‘knowledge gap’, and removing notions of the therapist’s ‘expert status’

(which of course is not to say that their clients do not experience them as

‘wiser/stronger’, just that they themselves do not experience this).

The stated outcomes of using mindfulness to establish a safe, holding

therapeutic relationship – providing a reparative relationship and going deeper in the

work – are linked in that previously unexplored aspects of the client’s self are likely to

have remained unexplored because of his or her attachment history, and the particular

form it took. For example, there is some evidence that attachment style is passed on

from caregiver to child (van Ijzendoorn & Bakermans-Kranenburg, 1997), and so a

child of an insecurely attached parent might learn that negative emotions are

dangerous and that one should distance oneself from anything that might cause them

to arise. By contrast, a mindfully integrated therapist will encourage a ‘turning

towards’ negative stimuli in a spirit of curiosity and acceptance.

This idea is supported by research evidence that has linked secure client

attachment to the therapist with greater session depth (Mallinckrodt, Porter, and

Kivlighan Jr., 2005). There is also evidence to suggest that the therapist’s attachment

style can moderate this relationship between therapist-client attachment and depth of

in-session exploration (Romano, Fitzpatrick, & Janzen, 2008). This supports the idea

that when the therapist is able to establish a secure base within herself or himself –

which can be achieved through mindfulness practice (Snyder, Shapiro, & Treleaven,

2012) – this is beneficial for the therapeutic relationship and consequently on session

exploration.

A final note of caution should be sounded, making clear that positioning the

therapist as a secure base for the client does not tell the whole story of the therapeutic

relationship. Farber and Metzger (2009) caution that the dyadic relationships of

parent/child and therapist/client are not equivalent. Indeed, to adhere too closely to the

idea of the therapeutic relationship as secure base may be to make claims for therapy

that cannot be fulfilled, and at the same time risks infantilising the client.

Nevertheless, it holds value as a heuristic for understanding what occurs in therapy

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(particularly where there has been trauma or attachment issues in the client’s life), and

merits future empirical work, both in terms of the ‘secure base’ conceptualisation

itself, and how mindfulness qualities might contribute to this type of therapeutic

relationship.

Conclusion

Reflections on method and limitations

The grounded theory method used in this study proved to be stimulating and valuable

to the development of understanding the phenomenon in question. The use of constant

comparison led the research in directions that were not anticipated at the start of the

process. For example, despite the researcher’s (Ellwood, 2013) literature review

addressing the links between mindfulness and attachment, the first empirical study

(Ellwood, 2014) had moved away from this topic to focus on in-session joint

meditation between therapist and client. Attachment did not feature explicitly among

the themes developed from participant responses in that study, and so it was

interesting, during the current research, to witness the development of the theme of

mindfulness providing a secure base, that had featured in the original literature review.

A limitation of the study, however, was that it perhaps did not meet the

requirements to be considered a fully developed theory of how therapists bring

mindfulness into the therapeutic relationship. Theoretical sampling was used in

shaping the direction of the research, in terms of participants and directions of

enquiry, but perhaps did not reach full ‘saturation’ (although doubts may be raised as

to whether full saturation is ever possible; Dey, 1999). What became apparent during

the development of the theoretical model was that more data were required regarding

the experience of clients – which could only be achieved by interviewing clients. Due

to time limitations, this was not possible, and so perhaps the theory proposed in the

current study may best be understood as an ‘abbreviated’ grounded theory (Willig,

2008) – hence the title, ‘Towards a grounded theory’.

An issue that has been raised by participants in this study and the previous IPA

study, both explicitly and implicitly, is that mindfulness meditation and its related

phenomena have a certain ineffable quality. Coyle (2008) discusses the difficulty of

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conducting qualitative research on spiritual or religious issues, because they are

difficult to capture in language. According to Coyle (p.58), this has led to a research

bias that has neglected questions such as ‘the phenomenology of religious, spiritual or

mystical experience and its implications for the intrapersonal, interpersonal and

transpersonal dimensions of self’. A similar claim might be made for the study of

mindfulness, which has roots in a spiritual tradition and incorporates certain elements

that are difficult to adequately describe. Such a position is held by many who write

about, and teach, mindfulness – even the author of a book called Mindfulness in plain

English: ‘You can play with word symbols all day long and you will never pin it

down completely.’ (Gunaratana, 2002, p.137)

Furthermore, as with religious or spiritual beliefs, mindfulness is – according

to participants in the current study – integrated significantly in the lives of those who

practise it. It is ‘part and parcel’ (Fiona, 463-4) of who they are; it is ‘soaked into’

(Sarah, 483) their very being. As such, it may have been difficult for participants to

achieve sufficient distance from their experience of mindfulness to be able to

comment on it critically. Indeed, this was noted by participants: Arlene (564-5)

commented that she didn’t separate a mindful approach to life from a mindful

approach to therapy, while Steven found it difficult to assign the changes he had noted

in his life to learning mindfulness, training as a therapist (56-8), or simply growing

older (347-9). For these reasons, and because of methodological difficulties in

measuring mindfulness and comparing ‘mindful’ and ‘non-mindful’ people or states

(discussed in the literature review), claims made for mindfulness-informed therapeutic

work may therefore have to remain somewhat tentative and probabilistic.

Future directions

As mentioned above, a limitation of the current study is that clients of mindfulness-

informed therapists were not included in the research process. Future research is

needed on how such clients experience the therapeutic relationship, which will shed

light on how closely the perceptions of participants in the current study accurately

match those of their clients.

Another potential area of research could help establish which aspects of

interpersonal relating are specific to mindfulness, and which are the result of training

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and working as a therapist – several participants noted that many qualities associated

with mindfulness are also qualities that are characteristic of good practice in therapy.

To distinguish which aspects stem from learning mindfulness and which come from

therapeutic training and practice, further understanding could be gained from

interviewing therapists who had been qualified for a number of years before adopting

a mindfulness practice.

Contribution to the field

The relevance of mindfulness to relational processes in general, and to the therapeutic

relationship in particular, is apparent from the extensive theoretical connections that

have been established within the literature. However, there remains a relative lack of

empirical research on the subject, and the current study fills a gap in the field in that it

is the first research project to explore how mindfulness-informed therapists bring

mindfulness to the therapeutic relationship. Many of the components of mindfulness

and the therapeutic relationship discussed within this paper have been examined in

isolation elsewhere (see ‘Discussion’ for links with existing literature), but not, to the

author’s knowledge, within the same study. In this sense, perhaps the major

contribution of this study is that it integrates these components to bring a fuller

understanding to the processes that occur in relationship between therapists and

clients, when therapy is informed by mindfulness.

The present study has particular relevance to the field of counselling

psychology, in that the latter places emphasis, above all, on human existence and

meaning making as essentially relational (Manafi, 2010). The way of working

described by mindful therapists also has relevance for counselling psychology

practice, as it describes a way of ‘being with’, rather than ‘doing to’, the client

(Strawbridge & Woolfe, 2010, pp.10-11). Furthermore, counselling psychologists tend

to eschew adopting one particular theoretical approach, in favour of an integrative

way of working (McAteer, 2010). Similarly, working mindfully is a trans-theoretical

concept that any therapist can adopt, regardless of theoretical position. It is hoped that

this study will stimulate therapists who already use mindfulness in their personal and

professional life, and affirm to them the relational benefits of doing so. For those who

have not adopted a mindfulness practice, it is hoped that this study might encourage

147

them to do so, in a spirit of openness to ‘what is’, and to what may be possible in the

therapeutic relationship.

Acknowledgements

I would like to thank my supervisor, Linda Morison, for her guidance and support

during the research process. I would also like to express appreciation for all those I

spoke to during the interview process, for their time and enthusiasm for the subject

matter.

Ethical standards

This study has been approved by the Faculty of Arts & Human Sciences Ethics

Committee at the University of Surrey, and was therefore performed in accordance

with the ethical standards established by the 1964 Declaration of Helsinki and its later

amendments. All persons gave their informed consent prior to taking part.

Conflict of interest

The author declares that he has no conflict of interest relating to the present study.

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APPENDIX 1

Information sheet

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Information Sheet for Participants

Dear participant,

You are being asked to take part in a research study on mindfulness, conducted by Jake Ellwood, as part of the requirement for his Doctorate in Psychotherapeutic and Counselling Psychology at the University of Surrey. The study is being supervised by an academic researcher, Linda Morison, and it has been approved by the Psychology Research Ethics Committee.

Mindfulness, a concept that dates back thousands of years, refers to ‘the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment’ (Kabat-Zinn, 2003). In order to foster the ability to engage in such present-moment awareness, there exist a variety of mindfulness practices such as mindful breathing meditation and mindful movement. Beneficial outcomes of mindfulness practice include increased emotion regulation, heightened attentional skills, and increased interpersonal skills.

The current study hopes to increase understanding of how therapists use mindfulness in the therapy room, in terms of the relationship between therapist and client. In agreeing to take part in this study, you will be asked about your own experience of mindfulness (whether formally practised or informally observed), and how you bring mindfulness into your relationship with your clients.

During the course of the research I may contact you again to ask for clarification on something you have said in the interview, or to ask your opinion of certain ideas that have arisen during the course of the research. Returning to previous participants in light of new information can be very helpful for this kind of research, but I understand that you may have a busy schedule, and by agreeing to this initial interview you are under no obligation to respond to further enquiries.

All information will be kept confidential, and your identity will be kept anonymous in interview recordings/transcripts. Your responses will not be made available to your client. You retain the right to withdraw from the study at any time, without giving a reason and without prior notice.

Any complaint or concerns about any aspects of the way you have been dealt with during the course of the study will be addressed; please contact Linda Morison on 01483 686875 or l.morison@surrey.ac.uk.

Kind regards,

Jake EllwoodPrincipal Investigator

APPENDIX 2

Consent form

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Ethics Committee

Hello, and thank you for taking part in this study. Before continuing, please read the following, and sign below. Thank you!

I the undersigned voluntarily agree to take part in the study on mindfulness and the therapeutic relationship.

I have read and understood the Information Sheet provided. I have been given a full explanation by the investigators of the nature, purpose, location and likely duration of the study, and of what I will be expected to do. I have been advised about any discomfort and possible ill-effects on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.

I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998). I agree that I will not seek to restrict the use of the results of the study on the understanding that my anonymity is preserved.

I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice.

I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.

Name of volunteer (BLOCK CAPITALS) ........................................................

Signed ........................................................

Date ......................................

Name of researcher/person taking consent (BLOCK CAPITALS) ........................................................

Signed ........................................................

Date ......................................

APPENDIX 3

Initial interview schedule

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General details Client baseYears since qualifyingTherapeutic approach and length of therapyPersonal experience of mindfulness practice and understanding of the term ‘mindfulness’

Main question The topic of my research is ‘Bringing mindfulness into the therapeutic

relationship’. What do you make of this?

Other potential questions When starting with a new client, is mindfulness something that you use to

build the therapeutic relationship? Consciously? Unconsciously? Do you think it helps in any way? Do you teach mindfulness techniques to your clients? Do you use the term

‘mindfulness’? Have you ever meditated before or after sessions? How do you think mindfulness ‘fits in’ with your theoretical approach? Do you maintain a formal mindfulness practice? Do you meditate regularly?

Are there times when you don’t keep up your practice, and if so, do you notice a difference in how you are in your personal relationships, or in the therapy room?

Mindfulness has been characterised as promoting nonstriving, nonevaluation, and openness… how does this relate to the way you practise therapy?

APPENDIX 4

Sample interview transcript (first two pages only)

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showing initial stage of analysis

Name: ‘Arlene’Sex: FemaleAge: 45Client base: GeneralWorks short, medium and long-termCore process psychotherapyQualified in 2005First meditated in 1998

Interviewer: I’ve been reading up on Core Process psychotherapy, so I know a little bit about it, but I’d just like to ask you for your take on it, because I understand it’s a relational way of working, that is based in mindfulness, but it also brings in psychodynamic elements as well.

Participant: Yeah, so it’s the first, Core Process was the first mindfulness-based training in the UK. There’s only one other actually recognised mindfulness-based psychotherapy, and that’s Tara Rokpa.

I: Tara Rokpa?

P: Yeah. There are other trainings out there but they don’t have the recognition of the UKCP. So Core Process, when it was founded, recognised that there was something in the relational that could support change, support transformation. So it takes as its starting point that there is an inherently well core, and depending on what tradition you come from, you could call it many things, but you know we [inaudible] tend to call it ‘brilliant sanity’, a sort of a ‘wellness’ which is available to all of us at any moment, but the way that a personality develops – and this is more traditional Western development theory of object relations – it obscures and layers over that inherently well core. And the work actually is to bring awareness to the process of knowing, which is why it’s called ‘Core Process’ – there’s the core and there’s the process. So it’s using awareness as the main tool.

I: Okay, and I like the idea of that, it reminds me of the kind of Rogerian idea of, the, well the idea that we’re all born with a, you know, inherent aspiration towards actualisation, self-actualisation. Um… and I also read that it’s not interpretative as such, it’s not about making…

6 Core Process ‘first mindfulness-based training in UK’

12-13 Working relationally to support change15 Starting from position that there is ‘inherently well core’16-17 Seeing commonalities with other therapeutic approaches18-19 Believing that ‘wellness’ is achievable by all, at any moment (present-moment perspective) 19-22 Believing that the ‘well core’ is obscured by developmental factors; seeing commonality with psychodynamic concept of object relations22-3 Bringing awareness to the process24-5 Using awareness as the ‘main tool’

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P: No. It takes very much the premise that the client is the expert on themselves. The therapist is there as a joint process, it’s not the therapist, we don’t use the word ‘patients’; we call them ‘clients’. Because we’re not coming from the position where one might do in an analysis, which is that there is something that needs to be ‘fixed’ in the other. So it’s very much a joint relational practice, you know, the therapist learns an awful lot too, in the process.

I: Well, given that you said it’s a joint process and it’s co-constructed, and that it’s based in awareness and mindfulness, that’s very relevant to my research topic, which is ‘Bringing mindfulness to the therapeutic relationship’. So I mean, how do you – it’s a very broad question – but how do you bring mindfulness to the therapeutic relationship?

P: Well yeah mindfulness is now very popular, but it actually is part and parcel of the teachings of Buddhist psychology, of the Buddha. We don’t denature it, so we’re not looking at it as just a tool to work with, we’re recognising that it’s part and parcel of the relational way of being, so that there becomes the opportunity to be aware of what’s arising in each and every moment. I may invite my clients to practise some form of… something that resources them, and in my experience mindfulness is incredibly quick to show results. And most of my clients who are struggling – and there’s a lot of research to show this – it’s very useful to apply it to anxiety, to depression, to difficulties, because it gives clients a tool. But it’s not all that there is. Because you can teach mindfulness until you’re blue in the face, but if there are underlying patterns that are relational, it won’t affect them, in my experience. So how do I work with it? When a client arrives, we might sit for a few moments – at the beginning of the session I often do – just so that there can be the opportunity to become present. Because the narrative of the mind can often take people away, so they’re thinking about what they want to say in the session and they’ve got it all planned out – in my experience that doesn’t lead to change, because they talk around it rather than be in it. You can be incredibly insightful about your process and know what’s going on, but you can still carry on doing the same things. In my experience, in order for real change to occur, there needs to be an awareness of how these patterns manifest, and often – certainly the portal that I use, and the one that Core Process uses – is the body. So mindfulness of body is one of the four foundations of mindfulness.

[…]

APPENDIX 5

31 Considering the client to be the ‘expert’

32 Participating in a joint process33-4 Emphasising wellness35 Drawing contrast with analytic approach36-8 Engaging in joint relational practice; involving self in the work; gaining from the process

45-6 Drawing link to Buddhist beliefs47 ‘Denaturing’ – decontextualising? 48-49 Rooting mindfulness in relational way of being50-1 Being aware of what is arising in ‘each and every moment’51-3 Encouraging clients to practise mindfulness; has quick results56 Giving clients a tool to help them; but also giving them something more57-59 Teaching mindfulness alone not enough to address underlying relational patterns60 Sitting with client at start of session, in order to become present (together – joint process)62-3 ‘Narrative of the mind’ can take one away from… experience? Emotions?

66 Talking around one’s experience, rather than being in it66-68 Insight not enough for change69-70 Bringing attention to how relational patterns manifest70-1 Believing in her therapeutic approach 71 Using body to access one’s experience of relating

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Final interview schedule

General details Client baseYears since qualifyingTherapeutic approach and length of therapyPersonal experience of mindfulness practice

Main question The topic of my research is ‘Bringing mindfulness into the therapeutic

relationship’. What do you make of this?

Other potential questions Operationalising terms

o What does mindfulness mean to you? What is ‘being mindful’?o What constitutes a ‘good’ therapeutic relationship? What are the most

important elements in achieving this? o How do you define ____? [other terms as they arise, e.g. [‘presence’,

‘resonance’, ‘attunement’`] How does mindfulness fit in with you personally, and also the way you work?

o Are there times when you don’t keep up your practice, and if so, do you notice a difference in how you are in your personal relationships, or in the therapy room?

Is meditating with someone else or in a group qualitatively different from meditating on your own?

You mentioned _____. How does mindfulness help you to you achieve that? How do you think the client experiences you, when you are bringing these

mindful qualities into the work? Do you use your own sensations in the therapy room as guidance? Do you hold attachment processes in mind when you are with a client?

o Can a therapist act as a ‘secure base’? When starting with a new client, is mindfulness something that you use to

build the therapeutic relationship? Consciously? Unconsciously? Do you teach mindfulness techniques to your clients? Do you use the term

‘mindfulness’? Have you ever meditated before or after sessions? How do you think mindfulness ‘fits in’ with your theoretical approach?

APPENDIX 6

Ethical approval

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Ref: FT-PSY-88-15

Dear Jacob Yes thank you I am very well and although it seems a long time ago, I had a good Christmas. Thank you for submitting your ethics proposal form to the Faculty of Arts and Human Sciences Ethics Committee via the Fast Track procedure. I am pleased to confirm that your proposal, as stated in your application, does not raise any issues that would necessitate a full review and you are therefore able to proceed with your study. Please keep your original proposal with the reference given above together with a copy of this email, as no copies are kept by the ethics committee. If there are any significant changes to your proposal which require further scrutiny, please contact the Faculty Ethics Committee before proceeding with your Project. Many thanks Kind Regards Julie Julie EarlFaculty Administrator (Faculty Office)Administrator Faculty Ethics CommitteeFaculty of Arts and Human SciencesUniversity of SurreyTel: 01483 689175Email: j.earl@surrey.ac.uk

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