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Mindfulness-Based Therapy

Abstract and Keywords

This entry provides an introduction to mindfulness as a therapeutic practice applied within social work, including in mental health and health settings. It describes and critiques mindfulness-based practices regarding definitions, history, current practices, best practices research, and ethical issues related to using evidence-based practices, acquiring competence, addressing social justice, and respecting diversity.

Keywords: Buddhism, ethics, health, mental health, mindfulness, religion, spirituality, stress

Within social work and the fields of mental health and health, there is a growing interest in the application of mindfulness-based treatments, such as Dialectical Behavior Therapy (DBT) developed by Marsha Linehan (Haynes, Follette, & Linehan, 2004) and Mindfulness-Based Stress Management developed by Jon Kabat-Zinn (1990; Wisner, Jones, & Gwin, 2010). Mindfulness practices, as applied in the helping professions, generally integrate aspects of Buddhist-originated meditation with cognitive-behavioral techniques for relieving symptoms of stress, anxiety, and depression (for example, Baer, 2010; Coholic, 2011; McBee, 2008). Mindfulness practices are often encouraged within holistic social work practice frameworks, such as spiritually sensitive social work (Canda & Furman, 2010) and integrative body-mind-spirit social work (Lee, Ng, Leung, Chan, & Leung, 2009). Mindfulness has received considerable attention as an emerging and promising evidence-based approach to practice. Research is exploring effectiveness of practices and the psychological processes behind how these treatments work. Efforts are being made to create specific and operational (measureable) definitions of mindfulness, although there is not universal agreement about definitions and measures (Baer, 2010).

Definition and Qualities of Mindfulness

Mindfulness is a mode of awareness in which a person pays purposeful and kind attention to oneself in the present moment and situation with nonjudgmental acceptance and without clinging to the flow of thoughts, feelings, and habitual reactions (Canda & Furman, 2010; Gockel, 2010; Orsillo, Roemer, Lerner, & Tull, 2004; Shier & Graham, 2011). As Baer (2010) summarizes, mindfulness is a complex process that includes “paying attention to present-moment experiences, labeling them with words, acting with awareness, avoiding automatic pilot, and bringing an attitude of openness, acceptance, willingness, allowing, nonjudging, kindness, friendliness, and curiosity to all observed experiences” (p. 28). Mindfulness techniques are designed to train clients to achieve and maintain this quality of awareness in order to reduce distressing mental and physical symptoms and to improve overall quality of life.

Mindfulness has applicability not only to clients but also to social workers and the general public because people often incorrectly perceive themselves and the world due to scattered attention, stress, and egocentrism. It is not unusual for people to feel, especially at challenging times of life, as though the world is deliberately acting against us and our own self-interests. Morris (2009, p. 180) describes practicing mindfulness as a “refuge from being at the mercy of our emotional states and a refuge from the culture of endless doing”. Social workers can benefit from mindfulness and other types of meditation practices by increasing “skills of concentration, attentiveness, accurate listening, empathy, and stress management” (Canda & Furman, 2010, p. 148).

The Mindfulness Attention Awareness Scale, Freiburg Mindfulness Inventory, Cognitive and Affective Mindfulness-Scale Revised, Southampton Mindfulness Questionnaire, Kentucky Inventory of Mindfulness Skills, and The Philadelphia Mindfulness Scale are examples of instruments developed by researchers to measure mindfulness. In a recent study combining five of these six questionnaires, five separate factors of mindfulness were identified: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. These were combined into a new research tool, the Five Facet Mindfulness Questionnaire (Baer, 2010).

Despite the desire of some researchers to create operational definitions of mindfulness that are conducive to measurement, Gause and Coholic (2010) caution against destroying the holistic and systemic quality of mindfulness by reducing it to manipulatable single factors. Keng, Smoski, and Robins (2011) also note that assessing clients’ mindfulness is difficult due to their assumed meanings associated with the concepts and language of mindfulness, the validity of the constructs on questionnaires, and difficulty to self-report accurately.

Kozak (2009) suggests that metaphors can be effective to convey concepts such as mindfulness that might otherwise be hard to grasp. For example, intrusive and difficult emotions or thoughts could be thought of as “visitors” that can be observed and then let go so they can leave. Metaphors for mindfulness practice can help provide a motivation for perseverance when times are difficult or confusing.

Mindfulness can be considered a type of meditation. Meditation refers to a wide variety of mind-training practices that involve focusing attention; letting go of preoccupations, distractions, and mental chatter; and deepening insights into life or the experience of consciousness itself (Fontana, 2003; Fuller, 2008; Newberg & Newberg, 2005; Press & Osterkamp, 2006). Many types of meditation involve integrating focused attention with smooth flow of breath (or other breathing exercises) and well-poised postures or movements. Many forms of meditation have roots in religious traditions that employ it to enhance well-being, clarify awareness, expand consciousness, or connect with a sense of the sacred, such as Zen meditation, Christian centering prayer, Hindu-originated yogas, and Daoist- and Confucian-related taijiquan (tai chi) and qigong (Canda & Furman, 2010; Lynn, 2010; Margolin, Pierce, & Wiley, 2011). Within social work settings, meditation and mindfulness practices are usually extracted from the original religious contexts and applied for relief of problematic symptoms and for enhancement of quality of life. The exception is when clients affiliate with a particular religious tradition and wish to use meditation practices specific to their tradition as part of the helping process.

Kozak (2009) provides several suggestions for practicing mindfulness meditation. The first is basic seated meditation, in which attention is focused on breathing. He suggests doing a body-scan meditation and using a “noting” technique to observe and identify different physical sensations without judgment, using the physical qualities of the body as a point of reference when the mind begins to wander. Another approach involves walking meditation, which attends to one’s movements in the environment by focusing on the exact experience of walking rather than on an idea or the destination. Another approach is relationship practice in which two partners sit together and use the awareness of breath and bodily sensations to provide a groundedness and clarity to conversation, thus reducing reactivity within social interactions. Finally, mindfulness can be extended to an informal practice of bringing mindfulness to activities throughout the day, at home, work, and other settings. This helps the person to transfer the benefits of mindfulness from formal settings of therapy or meditation into ongoing daily life.

Social Work Applications

Mindfulness techniques are increasingly found in clinical social work practice, especially in mental health settings. Hick’s (2009) edited volume summarizes mindfulness practices for social work for group work with children and youth in foster care, family therapy, work with immigrants, community-based social activism, environmental activism, cultivation of the social worker’s reflexive awareness and development of therapeutic relationship qualities, and enhancing well-being in the workplace. McBee (2008) has presented a detailed conceptual and practical guide for mindfulness-based elder care. Social workers in mental health settings commonly use DBT and other mindfulness-based practices. Turner (2009) identifies four commonly used mindfulness therapies: Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), and Dialectical Behavior Therapy (DBT).

There are common instructions underlying these various kinds of mindfulness-based practices (Baer, 2006, pp. 4–5): (1) focus attention with careful observation on an activity, such as breathing, walking, or eating; (2) engage in this practice with “an attitude of friendly curiosity, interest, and acceptance … while refraining from evaluation and self-criticism” (p. 5); (3) notice when attention wanders into distractions, such as thoughts, feelings, memories, or fantasies; (4) mentally note that this has happened and then return to the focus of attention; (5) if bodily sensations or emotions arise, observe how they feel, where they are located in the body, and how they change, without acting upon them; (6) observe internal experiences and label them concisely and clearly, such as “itching,” “sadness,” or “wanting to move.” This can also be applied to experiences of environmental stimuli, such as sights, sounds, smells, tastes, and touch.

MBSR was developed in behavioral medicine contexts, especially for helping patients manage pain and stress related to chronic or terminal health conditions and difficult medical treatments (such as chemotherapy). Most programs involve an 8-week course of weekly sessions of about 2.5 hours, plus a day-long meditation session, with up to 30 participants (Baer, 2006). Practice at home is required at least 45 minutes per day, 6 days per week. Activities include paying attention to eating, relaxed mental scanning of the body, sitting meditation, gentle hatha yoga postures, walking meditation, extending mindfulness to daily life, and group discussions of experiences.

MBCT is strongly influenced by MBSR (Baer, 2006). Since it is commonly used to help prevent relapse of major depression, special attention is given to awareness of pleasant and unpleasant events and building knowledge about depression. The format has many similarities to MBSR, tailored to the experience of depression. For example, participants learn to go into a 3-minute breathing exercise to observe what is happening, to relax, to shift out of automatic or habitual response, and to respond skillfully. Another exercise is to purposely bring to mind a difficult situation while mindfully breathing, in order to learn to overcome the tendency to avoid painful feelings. Relapse prevention action plans are also put in place. MBCT involves several skills: decentering, meaning to become present-focused in thoughts and feelings; learning to switch from preoccupation with “doing” to “being,” so that one can be more in the present rather than stuck in the past or future; purposefully paying attention with nonjudgment; and accepting and letting go of thoughts as mental events in order to extricate oneself from the cognitive routine of doing (Hick & Chan, 2010).

ACT is a general psychotherapeutic approach applied to a wide range of issues (Baer, 2006; Montgomery, Kim, & Franklin, 2011). Mindfulness and acceptance skills are used to encourage behavior changes that support well-being. An important ACT principle is to attend to experiential avoidance. This refers to unwillingness to experience negative internal feelings, sensations, thoughts, and urges and therefore acting to avoid, escape, or eliminate the experiences in ways that are dysfunctional. This mistaken behavior pattern is understood as a root of many problems, such as substance abuse, eating disorders, and phobias. Numerous kinds of mindfulness activities are taught to help the person to accept what is, to overcome deeply rooted values and goals that are unhelpful, and to commit to changes of goals and behaviors that will lead to greater life satisfaction. ACT does not require that clients alter their thinking and feelings; rather it promotes acceptance of their experiences and ability to stay present with difficult emotions. ACT examines how clients struggle with problems and helps them to let go of struggles that are worsening their situation. ACT promotes psychological flexibility to be fully aware in the present moment and one’s reactions to it, and then, to continue or change behavior in order to meet one’s carefully chosen goals.

DBT was developed originally for working with clients who have been diagnosed with borderline personality disorder and who have suicidal or self-harming ideation (Baer, 2006; Dimeff & Koerner, 2007). It is now applied to a wide range of practice issues in outpatient and inpatient mental health settings, including forensics, intimate partner violence, substance dependence, depression and anxiety in older adults, eating disorders, family therapy, and adolescents with self-injury or suicidal ideation. Standard outpatient DBT requires commitment to at least a year of therapy, including individual and group sessions. Skills include basic mindfulness practices, improving interpersonal effectiveness, regulating emotions, and learning to tolerate distress. For example, a module on “states of mind” helps participants to distinguish three states: reasonable mind, emotion mind, and wise mind. Reasonable mind is rational, logical, and cool. Emotion mind is dominated by feelings that interfere with accurate perception of reality and may impair judgment. Wise mind integrates and balances reason and emotion in a centered and grounded way, thus encouraging clear awareness and appropriate responses. Mindfulness practices develop wise mind.

Since DBT is so widely used by social workers in mental health settings, a more detailed example is useful here. McKay, Wood, and Brantley (2007) offer a DBT Skills Workbook that presents instructions for DBT training in a user-friendly, concrete, and carefully planned way. The final chapter, “Putting It All Together” (pp. 225–227), illustrates how DBT practices are intended to be infused into daily life. After going through preparatory training, participants are expected to continue a set of practices for a total of about 15 minutes every day in order to establish a routine. The practitioner is to select from a menu of choices. (a) mindfulness for 3–5 minutes: choose either mindful breathing or wise-mind meditation; (b) deep relaxation for 3 minutes: choose cue-controlled relaxation (that is, practicing a learned relaxation response to a cue word such as “peace”), band of light (that is, relaxed breathing with visualization of a band of light that moves from top of head down through the body, allowing the person to scan sensations without judgment), or safe-place visualization; (c) self-observation for 3 minutes: choose thought defusion (that is, using imagination of a metaphor for releasing thoughts, such as clouds floating away) or be mindful of emotions without judgment; (d) affirmation: repeat a self-affirmation five times along with slow, long breaths; (e) committed action for 3 minutes: plan to implement a committed action or plan an action to connect to a higher power (that is, a source of support and inspiration greater than oneself—such as God, a mentor, or nature—which may or may not be religiously or theistically based). This illustrates the way DBT combines cognitive-therapy techniques with mindfulness, visualization, and commitment to action plans for personal improvement.

Examples of Adapted Mindfulness Practices

In many social work settings, strict adherence to standardized mindfulness protocols may not be appropriate or feasible. Mindfulness practices may be adapted to particular settings and populations.

Children and Youth

For example, since most mindfulness practices have been developed for use with adults, applications to children and youth require adjustments for their developmental level, interests, and communication styles (Wisner et al., 2010). In this regard, Coholic (2011) developed an arts and mindfulness-based intervention program for children involved with foster care, child protective services, or mental health services. Activities included arts-based games, snacks, and making friends in order to teach children to develop self-awareness and to regulate their emotions. Through a qualitative study, Coholic explored whether this program is suitable for children in need, especially for improving self-esteem, awareness, and other facets of resiliency. The study included following 50 children (8–15 years old) over 3.5 years, who participated in 6-week or 12-week groups, each consisting of four members. The goals of the program were to teach children how to pay attention to their own feelings and thoughts, use their imaginations, and develop tools and strengths for improved coping skills, emotional regulation, and greater resiliency.

Mindfulness training activities were tailored to children. For example, a jar was filled halfway with water. Children dropped rocks or marbles into the jar to represent feelings or thoughts. The jar was then passed around and swirled and shaken in order to represent how our minds are sometimes swirling with thoughts and cluttered so that we cannot think clearly. When the water stops swirling and the rocks are resting, our thoughts are clear and understandable. Another exercise instructed children to draw a circle with paint, and then to construct their feelings inside the circle with stronger feelings taking up more space. Discussion followed about how to make some of the feelings smaller or larger as desired by the children.

A follow-up study was conducted to include control and comparison groups. It sought to explore whether there was evidence to support their holistic, arts-based program for children (Coholic, Eys, & Lougheed, 2012). So that all children participating in the program could receive the mindfulness-based intervention, children were again grouped in fours, then “streamed” into the program at different times. The quantitative portions of the mixed-methods data collection and analysis indicated that the program reduced self-reported emotional reactivity while self-concept was not significantly improved. Qualitative interviews indicated that the participants felt happier, more confident, and better able to talk about their feelings. These studies show that arts-based and mindfulness-based group programs are promising and engaging and may benefit youth who may not otherwise have access to resources such as counseling.

Greco and Hayes (2008) make a poignant connection between mindfulness and youth. They refer to the Zen concept of “beginner’s mind” (that is, fresh, clear, open awareness) as being similar to the natural state of a child’s mind—open, curious, ready and willing to learn. This similarity can be engaged in treatment. For example, a treatment group applied MBCT to youth struggling with anxiety. Children learned to practice mindfulness by paying attention to breathing, eating, listening, seeing, touching, and smelling.

Social Work Education

Social work educators are beginning to adapt mindfulness practices for use in the education of students and the continuing education of professionals. This may be to prepare them to apply the practices in their work with clients; to enhance their learning experience within the classroom; and to encourage students in their roles as students and as future helping professionals to engage in ongoing self-care (Canda & Furman, 2010).

McGarrigle and Walsh (2011) contend that human service workers should practice what they preach, that is, to practice mindfulness in their own lives, especially if they wish to advocate and use it with clients. They taught “contemplative practices” to 12 human service workers through the evidence-based CARE Model—Cultivating Emotional Resiliency in Education, which involved 8 weeks of 2-hour contemplative practice sessions addressing self-care, awareness, and coping. A correlational study using the Perceived Stress Scale and Mindfulness Attention and Awareness Scale was followed by qualitative thematic analysis of participants’ journals and a concluding focus group interview. The quantitative analysis indicated that as contemplative practices were increased, stress was decreased.

Qualitative analysis of the journals and focus groups produced three themes that showed participants’ concerns about accountability, mindfulness, and workplace context. Accountability was described as having a responsibility to oneself to practice self-care, to one’s clients to give appropriate attention to their needs, and to the workplace to provide ethical and professional service to the clients. Some participants felt that the workplace has a reciprocal obligation to employees to provide opportunities to manage stress in healthful ways such as having explicit permission, a time, and a place in which to practice mindfulness within the work confines. Mindfulness as a theme was referred to as a tool for self-care as well as a tool to use with clients when the practitioner feels confident and it is presented to others in a way that is congruent with their philosophical, religious, or spiritual traditions. Contemplative practices can support spiritual renewal in a way that traditional methods that are focused only on cognitive-behavioral or behavioral techniques cannot. They conclude that integration of spiritual and traditional techniques within social work practice can encourage meaning making and self-care. Agency administrators have an important role in assuring that social workers are practicing self-care so they can do their jobs well and with reduced distress.

Napoli and Bonifas (2011) created a classroom curriculum with the goal being to promote and teach mindfulness practice for social work students. The intention was to maximize students’ abilities to begin where the client is, to help them recognize countertransference, to minimize secondary trauma when exposed to clients’ traumas, and to gain empathy. They describe a mindful classroom as built on several elements: “empathetically acknowledging, intentionally paying attention, accepting experience without judgment, and enhancing sensory awareness” (p. 638). The curriculum incorporates methods that will help students to become competent and capable in using these skills. They state that competence is what people know how to do, while capability is the extent to which one can use that knowledge to generate new learning and to improve skills. This Quality of Life graduate course is 16 weeks long with 3 hours each week in the classroom and two 1-hour sessions per week outside of class. These incorporate mindfulness exercises and workbook exercises to learn self-care and mindful practice. The Kentucky Inventory of Mindfulness (KIMS) was administered pre and post class to determine whether students were able to apply the curriculum. Scales were named: accepting without judgment, acting with awareness, describing, and observing. Paired sample t tests showed statistically significant improvement on three of the four scales: Accepting without judgment, acting with awareness, and observing. The largest gains were made on four of the items from the observing scale, and one from the describing scale. Despite the limitations of this as a small-scale exploratory study, the authors conclude that the Quality of Life curriculum holds promise for increasing social work students’ personal and professional skills.

Research on Best Practices

Literature review studies and meta-analyses of research findings summarize many benefits of mindfulness-based activities. Most systematic research on effectiveness of mindfulness has focused on adults (Greco & Hayes, 2008). Numerous studies can be identified on the Web sites of the Cochrane Collaboration (http://www.cochrane.org) and the National Institutes of Health National Center for Complementary and Alternative Medicine (http://nccam.nih.gov/). Several examples are offered here.

Turner (2009) cites many studies that support the efficacy of mindfulness therapies for both clinician and client. For the clinician, mindfulness techniques are said to improve mindful presence, attention, affect regulation, attunement, and empathy. For clients, they may assist with pain management, anxiety, depression, binge eating, borderline personality disorder, suicidal tendencies, chemical dependency, psychosis, incarceration recidivism, and dissociative and posttraumatic stress disorders.

Keng et al. (2011) review many empirical studies and other literature that address the effects of mindfulness on mental health. They identify three types of studies: correlational; controlled studies that are peer reviewed, published, and include randomized, controlled trials; and laboratory research on the immediate effects of brief mindfulness interventions. Numerous inventories are listed as tools used to assess mindfulness with study participants: for example, the Freiburg Mindfulness Inventory, Kentucky Inventory of Mindfulness Skills (KIMS), Mindfulness Attention Awareness Scales (MAAS), Five Facet Mindfulness Questionnaire, Cognitive Affective Mindfulness Scale—Revised, Toronto Mindfulness Scale—Trait Version, Philadelphia Mindfulness Scale, and the Southampton Mindfulness Questionnaire.

In their review of controlled studies of MBSR, MBCT, DBT, and ACT, the authors determined that all four are supported by evidence. However, the authors call for more research to include isolation of the mindfulness components from the other components that are integral to each of these methods and to consider the level of expertise of the facilitator. In their review of brief interventions, they noted that laboratory studies in which participants were subjected to various stressful stimuli, including affectively valenced images (an emotional stressor) or carbon dioxide–enriched air (a biological stressor designed to invoke emotional stress), suggest that it does not take extensive training for people to benefit immediately from brief mindfulness interventions for many diagnoses and problems. Overall, the authors suggest that mindfulness is positively associated with improved functioning and mental health. Yet Keng et al. (2011) note that little is known about what settings and specifically for whom mindfulness interventions are effective.

According to Godfrin and van Heeringen (2010), MBCT appears to be a cost-effective treatment for relapse prevention of depression, but not necessarily for acute depression. Hick and Chan (2010) found that MBCT may be useful in mitigating mental rumination and dysphoric mood that can signal the beginnings of a depressive relapse.

Bohlmeijer, Prenger, Taal, and Cuijepers (2010) reviewed the effectiveness of MBSR on populations with diagnoses of depression, anxiety, and other psychological distress in addition to somatic diseases using eight Randomized Controlled Trial studies. The overall effect on depression was found to be 0.26. The overall effect size for anxiety was found to be 0.47. When two low-quality studies were removed from the analysis, an overall effect size of 0.32 was found. The authors conclude MBSR is somewhat efficacious on depression, anxiety, and other psychological distresses in people who have other physical diseases.

An effect size analysis based on 39 studies of MBSR or MBCT found that these treatments may be helpful in addressing anxiety or depression (Hofmann, Sawyer, Witt, & Oh, 2010). They suggest that mindfulness-based therapies may be useful for a variety of disorders and are not diagnosis specific.

Another meta-analysis examined 39 studies of mindfulness-based practices from 10 countries that used experimental or quasi-experimental designs. Between-group comparisons indicate that Mindfulness-Based Interventions (MBIs) show a significant improvement in symptoms of depression over standard care. Effect sizes indicate that length of intervention is important (that is, more sessions are better) and that quality of the study was not a factor. Included in the analysis were studies over various modifications of MBSR, MBCT, DBT, and acceptance-based behavioral therapy (ABT, aka ACT) to address diagnoses, including binge eating, attention-deficit/hyperactivity disorder, depression, and social anxiety to name a few. Exposure-based cognitive therapy (EBCT), MBSR, and ABT showed the strongest effect sizes, while MBCT and DBT modified for attention-deficit/hyperactivity disorder were least effective (Klainin-Yobas, Cho, & Creedy, 2012).

Montgomery et al. (2011) conducted a systematic review of studies of ACT’s impact on psychological or physiological illness outcomes. For 18 studies that met their inclusion criteria for rigor, effect sizes were calculated. The authors found ACT to be promising to help clients with “psychosis, anxiety disorders, pain management, trichotillomania, chronic skin picking, and epilepsy” (p. 178). The studies of impact on depression indicated possible effectiveness, but research designs were not rigorous enough to determine the extent.

A recurrent theme in all of the outcome studies is that mindfulness-based therapies appear promising for a wide variety of health and mental health issues. However, this research is still in an early stage. Many more studies with rigorous research designs are needed of particular types of mindfulness-based therapies used with particular issues and types of participants.

Ethical Issues

Overall the intention of mindfulness practices is very consistent with the National Association of Social Workers (NASW) Code of Ethics statement that a major goal of our profession is to enhance client well-being (NASW, 2008). However, in order for social workers to decide whether it is appropriate to apply these practices in particular helping situations depends on more specific ethical considerations. This section raises questions, reviews positions of various authors, and offers suggestions; but it does not intend to dictate a particular resolution of any dilemmas posed.

Evidence-Based Practice

Social workers are enjoined to utilize practices whose efficacy is supported by evidence. As indicated by the review of best practices research, mindfulness-based practices are garnering considerable attention among researchers. In general, there is support for the efficacy of the four most commonly studied practices (that is, MBSR, MBCT, ACT, and DBT) for a wide range of mental health issues and for stress accompanying health challenges. However, this body of research is in agreement that many more studies, with rigorous designs, are needed for further explorations. When practitioners wish to apply mindfulness-based practices to particular conditions (for example, depression, anxiety, suicidal ideation) and populations (for example, elders, children, religious or ethnic groups), they should explore the extent to which particular kinds of mindfulness-based practices have evidence to suggest they may be useful in those situations. Yet overall, these practices appear to be promising. There may likely be benefits valuable to any person because the skills are pertinent to basic features of human existence. Clarification of awareness, loosening the grip of distracting and harmful thoughts, learning acceptance of pleasant and unpleasant experiences, enhancing appreciation for life in each present moment, and linking mindfulness-generated insights to action plans for enhanced well-being (as defined by the person) are skills that have intrinsic value.

In addition, some mindfulness advocates emphasize that mindfulness should be understood and practiced in a holistic way, pervasive of one’s life. Conventional research methods based on standardizing mindfulness practices and isolating factors of mindfulness for comparison and measurement purposes may be missing the point of mindfulness itself, which attends to the quality of awareness connected to the spontaneous flow of each moment in each particular situation, unfettered by presumptions. In any case, social workers who employ such practices would be wise to obtain regular feedback from clients to ascertain whether the particular practice is yielding benefits in terms of the clients’ goals.

Competence

Social workers are expected to develop sufficient competence with a particular helping activity before employing it. In part, this requires the social worker to have sufficient training in the particular methods of the various mindfulness practices and also to be able to tailor them to specific clients and situations, as we have seen in the examples of children and social work education. On a deeper level, mindfulness is not simply a matter of mastering technical skills. It is a matter of enhancing the quality of awareness and responsivity in ongoing life. This level of competence calls the social worker to engage in a process of self-transformation, so that he or she is sufficiently mindful in order to model and to guide clients in their practice of mindfulness (Canda & Furman, 2010).

Gockel (2010) suggests that when social workers become more mindful, they are better able to form the therapy relationship by having important qualities such as empathy, the ability to pay attention in the moment, and lowered anxiety about the ability to do one’s work well. Mindfulness is useful for social workers to practice self-care, which is a feature of competence given that an incapacitated professional is not able to practice well. Many social workers are susceptible to burnout because of ill-defined roles, secondary trauma, compassion fatigue, few supports within their agency environment, large caseloads, and clients with many problems and few resources.

Promoting Social Justice

Gause and Coholic (2010) have pointed out a concern expressed by some critics regarding spiritually oriented social work practices that they might be too individualistic and neglectful of larger issues of social justice and structural oppression. Mindfulness-based practices, as they are commonly used, might be subject to this charge. Most of them focus on helping individuals to ameliorate symptoms of stress and illness. The outcome-oriented research has so far not explored impacts of mindfulness-based practices on people’s ability to challenge and change macro-level power dynamics of discrimination and oppression. However, Gause and Coholic point out that “spiritual and holistic goals such as acceptance … do not have to be at odds with social change and justice” (p. 11). They offer several examples where mindfulness contributes to social justice activism, such as in deep ecology. Pyles (2014) points out how principles of Buddhism, including the importance of cultivating clarity and compassion, contribute to nondivisive and peace-promoting activism within the socially engaged Buddhism movement. Given the social work profession’s commitment to social justice, it would be ethically congruent to explore the justice implications of mindfulness further.

Respect for Diversity

Spiritual Diversity

Given that mindfulness-based practices have originated from Buddhism, there are inevitably some assumptions embedded within them that reflect a Buddhist worldview. As with any social work practices (and especially spiritually oriented practices), care must be taken to be sure that a given mindfulness activity is tailored to the comfort, readiness, interest, goals, and beliefs of the client (Canda & Furman, 2010). If the very term “mindfulness” is off-putting to a client, then some other descriptive term could be used. If particular practices are objectionable, then they certainly should not be used. For example, for some religious clients, practices involving meditation and visualization may be perceived as being contrary to their own beliefs. Or perhaps visualization is acceptable, but the particular symbolic content for visualization would need to be tailored to the person’s worldview. These considerations help explain why mindfulness-based practices as applied in conventional health, mental health, and social service settings generally divorce the practices from the Buddhist context.

On the other hand, if a client is Buddhist and is familiar and interested in using Buddhist terms and practices thoroughly in the helping process, then the Buddhist origins of mindfulness practices could be made explicit and explored in more detail. If the client prefers, the social worker might collaborate with the client’s current Buddhist community (if any) or could refer to a relevant Buddhist community that might serve as a support system for his or her pursuit of enlightenment, which goes far beyond the typical goals of symptom relief or well-being within social work settings (for example, Canda & Phaobtong, 1992).

Cross-Cultural and Cross-Religious Borrowing

Divorcing mindfulness practices from their Buddhist origins poses an ethical dilemma: how to balance the helpful application of a religiously originated approach to non-Buddhist professional helping settings while also being honest about the origins and respecting the original tradition. Gause and Coholic (2010) are concerned that this divorce results in mindfulness being viewed reductionistically and not being used to its full potential.

Mindfulness is an English translation of the Buddhist term smriti (Sanskrit; or sati in Pali). Mindfulness means practicing clear conscious awareness in all activities, whether during formal sitting and walking meditations or other daily activities (Fischer-Schrieber, Ehrhard, Friedrichs, & Diener, 1994). Mindfulness helps to bring the mind under control and to rest in clarity. It leads to insight into the transitory, interdependent, and non-self-existent qualities of all things. It opens the person to insight into the nature of reality and compassionate regard for all beings. As Vietnamese Buddhist monk and teacher Thich Nhat Hanh (1976) describes it, “Mindfulness … is the miracle which can call back in a flash our dispersed mind and restore it to wholeness so that we can live each minute of life” (p. 14). Elsewhere, he says, “This is the secret treasure of mindfulness—it leads to the realization of liberation [from suffering] and enlightenment” (1991, p. 121).

When mindfulness is separated from these larger Buddhist purposes and contexts, this “changes them in a profound way” (Canda & Furman, 2010, p. 332). The Western treatment approach, focusing on measurable outcomes, such as symptom relief and strengthening self-esteem, may even be antithetical to the Buddhist tradition’s emphasis on nonattachment to egoism. Indeed, Buddhist philosophy and meditation practices include deconstruction of the very concept of a separate self, as one’s awareness, through mindfulness, becomes attuned to the interdependent coarising and dissipating of all things and processes (Canda, 2001; Hanh, 1991). Further, many Buddhist meditation practices can be expected temporarily to increase anxiety as the person’s egoistically limited view of self and world is challenged. This experience of anxiety would not be a mental health problem, but rather a spiritual growth pain. Indeed, many mindfulness-based therapeutic and social work activities are adapted, improvised, or invented by the professional helpers. Therefore, these might more accurately be described as inspired by, rather than based on, Buddhist mindfulness meditation.

Consider the way that Thich Nhat Hanh (1991) describes a mindfulness practice of eating a tangerine: “A person who practices mindfulness can see things in the tangerine [when eating it] that others are unable to see. An aware person can see the tangerine tree, the tangerine blossom in the spring, the sunlight and rain which nourished the tangerine. Looking deeply, one can see ten thousand things which have made the tangerine possible. Looking at a tangerine, a person who practices awareness can see all the wonders of the universe and how all things interact with one another” (p. 129). This activity bears similarity to the popular MBSR exercise of mindfully eating a raisin. But the extension of awareness to cosmic interdependence goes beyond its clinical purposes.

The contrast between traditional Buddhist mindfulness practices and clinically applied practices is strongly illustrated by meditations on the constitutive and disintegrating parts of the body, as in contemplation of a corpse. A scripture on contemplation of one’s own body (Satipatthana-sutta, Pali) includes the following instructions: “a monk reflects on this very body enveloped by the skin and full of manifold impurity from the sole up, and from the top of the head-hair down” (Fischer-Schrieber et al., 1994, p. 228). Parts of the body are placed into awareness, including hair, skin, nails, bones, teeth, flesh, organs, blood, sweat, and various kinds of excretions. Although this is consistent with the clinically applied mindfulness practice of body scan, the vividness and focus on realizing the impermanence of the body goes beyond it.

Although clinically applied mindfulness practices are congruent with these traditional Buddhist meditations, they are targeted to a much reduced goal of improving symptoms of distress and mental illness. Yet the main goal of Buddhism is to help practitioners attain enlightenment and to help relieve the suffering of all beings. So if clinically applied mindfulness practices can help a person to relieve some distress, this is not contrary to Buddhist values. It might be a step for the person to pursue a deeper goal of spiritual development, if so desired.

This relates to a caution raised by Canda and Yellow Bird (1996) regarding “superficial or exploitive borrowing or misuse of spiritual activities” (p. 1). Canda and Furman (2010) expand on their discussion of ways that cross-tradition exchange might be inappropriate or appropriate for social workers. Stealing involves appropriating spiritual practices from a tradition without permission and/or without acknowledgment. Given that the founders of mindfulness practices such as DBT and MBSR have themselves been Buddhist practitioners, they have acknowledged Buddhism as a source in some writings. It is, however, not standard for trainers to explain the roots in Buddhism or to acknowledge whether they or those who apply the practices have sought permission from Buddhist authorities.

Some Buddhist authorities, such as the Dalai Lama, have encouraged scientific study and helpful applications of Buddhist meditation practices in research and therapeutic settings (Lopez, 2008). Many Buddhist teachers have a very generous attitude about sharing practices. For example, a manual on Vipassana Insight Meditation (which uses mindfulness) from the Theravada Buddhist tradition starts with this introductory statement: “The powers of Vipassana-Bhavana or Development of Spiritual Insight occur and are usable not only by Buddhist meditators, but by meditating people in general, irrespective of nationality, religion, sex and age, who by performing methodical and regular meditation may enjoy similar benefits” (Yupho, 1987, p. 7). If one grants general latitude for this, clinically applied mindfulness practices are clearly a case of borrowing (and adapting). Canda and Furman suggest that in such cases, the origin and original intention of practices should be acknowledged with appreciation and respect. They should not be distorted or applied to contrary purposes. This caution resonates with the concern of Gause and Coholic (2010) mentioned previously. Canda and Furman also recommend that sharing mutual benefits between traditions be practiced. In the case of mindfulness, social workers who appreciate the usefulness of mindfulness-based practices could demonstrate this by becoming involved in offerings of thanks and assistance to Buddhist communities, especially those that are experiencing severe challenges, as with recent immigrants, refugees, or oppressed Buddhist minorities in various countries.

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