Clinical Handbook of Mindfulness (9 page)

thoughts, our consciousness gradually evolves. The consistent practice of

meditation leads to the intentional suspension of every judgment and evalua-

tion we make regarding what happens around us and inside us. This allows us

to observe and accept, without wanting to change, the processes of thought

and our emotional reactions in all areas of experience. Therefore, the main

aim of mindfulness-based programs is to help individuals make a transforma-

tion at the root of their relationship with their thoughts, feelings, and physi-

cal sensations that contribute to activating and maintaining psychopatholog-

ical states.

10

Fabrizio Didonna

The issues that have been discussed demonstrate why and how, especially

in the last 20 years, there has been a natural and fruitful synthesis between

mindfulness meditation and cognitive-behavioral approaches. This synthe-

sis has made significant integrations between the two perspectives possible,

many of which will be illustrated in this handbook.

The Clinical Relevance of Mindfulness-Based Treatment

There are an estimated 10 million practitioners of meditation in the United

States and hundreds of millions worldwide. The widespread use of medita-

tion in all the major world religions is based on the experience of many that

meditation aids several processes related to personal development. Deurr

(2004) points out that meditation is one of the most widely used, lasting, and

researched psychological disciplines worldwide. In the last 20 years, there

has been a dramatic increase in clinical interventions that use meditation

skills, especially in the form of mindfulness. Salmon, Santorelli, and Kabat-

Zinn (1998) have reported that over 240 hospitals and clinics internationally

were offering mindfulness-based stress-reduction trainings as of 1997. This

number has certainly significantly increased today.

One of the most significant problems psychology has had in drawing upon

the practices of Eastern and Buddhist cultures is that until 15–20 years

ago, the word “meditation” was considered by many to be suspect and

associated with images of fraudulent mysticism (Kabat-Zinn, 1990). Medi-

tation was almost demonized and considered solely as an esoteric aspect.

In part this was due to cultural and conceptual ignorance regarding these

techniques, which have only recently started to be considered in scientific

research in psychology and neurology. This led some authors (Benson &

Proctor, 1984), especially in the 1990s, to recommend separating medita-

tion from its Eastern roots in order to make this practice more appealing

and acceptable within Western psychotherapy practice (Carrington, 1998;

Shapiro & Walsh, 1984) and in order to overcome suspiciousness and preju-

dices. However, leaving out the spiritual aspect of meditation practice may

limit a complete understanding of the potential of this practice (Kabat-Zinn,

1990).

Eastern roots need to be manifested in a universal way and language as skill-

ful means, so that people who are suffering can understand why meditation

might be helpful to them without all the cultural and ideological baggage that

invariably accompanies the whole Eastern gestalt, and for that matter, spiritu-

ality as it is often spoken about (Jon Kabat-Zinn, personnal communication,

2008).

The clinical areas of use of mindfulness-based treatment today are

extremely broad, and various outcome studies have highlighted the clinical

relevance of these forms of treatment with respect to a variety of disorders.

Mindfulness is a key component of several standardized therapy models,

most of which are included in the cognitive-behavioral approach as will be

widely illustrated in this handbook: the Mindfulness-Based Stress Reduction

(MBSR) protocol (Kabat-Zinn, 1990), perhaps the first model involving a

Introduction

11

clinical application of mindfulness, which has been found to be effective in

the treatment of various anxiety disorders, especially GAD, panic disorder,

and social phobia (Kabat-Zinn et al., 1992; Borkovec & Sharpless, 2004;

Miller, Fletcher, & Kabat-Zinn, 1995); the Mindfulness-Based Cognitive

Therapy (MBCT) model (Segal et al., 2002), an integration of cognitive

therapy and MBSR, which has been found to be effective in significantly

reducing the relapse rate in major depression; the integration between

evolutionary psychology and compassion in psychotherapy by Paul Gilbert

(2005);

Marsha

Linehan’s

Dialectical-Behavioral

Dialectrical-Behavioral

Theraphy (DBT) model, which comprises an important mindfulness-based

treatment component and which has demonstrated significant effectiveness

in reducing multi-impulsive and suicidal behaviors in patients suffering from

borderline personality disorder (Linehan, 1993a, b); and the Acceptance and

Commitment Therapy (ACT; Hayes et al., 1999), which is consistent with

mindfulness approaches though it does not explicitly include mindfulness or

meditation training. In this last therapy method, patients learn to recognize

an observing self able to see their own thoughts, emotions, and body

sensations and view them as separate from themselves. In addition to these,

as will be well described in Parts 3 and 4 of the handbook, there are at this

moment several other relevant application of mindfulness-based approaches

for many different psychological disorders in various clinical settings and

across diverse populations.

Regarding the state of the art (see also Chapter 3 of this volume), Baer’s

(2003) judgment after reviewing the empirical literature is that “mindfulness-

based interventions can be rigorously operationalized, conceptualized, and

empirically evaluated” (p. 140) and that at present they meet the American

Psychological Association Division 12 designation as “probably efficacious.”

Studies of the effectiveness of these approaches are encouraging, but further

investigation with more randomized and controlled studies is still required.

It would be important to conduct methodologically sound empirical evalua-

tions of the effects of mindfulness interventions for a range of problems, both

in comparison to other well-established interventions and as a component of

treatment packages.

We also need to better understand which mindfulness-based interventions

work and for whom, and which strategies work best for particular patients

and conditions. It will be possible to reach these goals by developing valid

and reliable measures of mindfulness (see Chapter 9 of this volume), allow-

ing measurement of mindfulness and its components and the associations

between them and clinical change.

Another central issue to be investigated in working with psychological

problems is whether or not there are particular brain processes associated

with specific clinical conditions that mindfulness practice either augments or

reduces. We also have to improve our understanding of the cognitive, emo-

tional, behavioral, biochemical, and neurological factors that contribute to

the state of mindfulness and investigate what mechanisms of action of mind-

fulness training actually lead to clinical change (exposure, relaxation, cogni-

tive, and behavior change). In order to reach these goals we need to stimulate

and increase the dialogue between mindfulness-based perspectives, Eastern

traditions, and neuroscience.

12

Fabrizio Didonna

Outline and Aims of the Book

One of the major stimuli behind the development of this project was the

need to bring together, in an operative, pragmatic, and easily accessible form,

the ever-increasing amount of knowledge and experience now available from

research and practice about mindfulness and its clinical application. This

book illustrates the links between theory, science, and the therapeutic appli-

cation of mindfulness for psychological and physical problems, highlighting

the connections of these themes with Eastern tradition. The book is divided

into four parts.

Part 1 (Chapters 1–4) covers theoretical issues and includes chapters on

the origin and conceptualization, phenomenology and state of the art of

research on the constructs of mindfulness and meditation. This part provides

an important theoretical framework and rationale for the clinical sections of

the book.

Part 2 (Chapters 5–9) addresses the relationships between mindfulness

and clinical problems, especially regarding psychopathology, explaining the

rationale of the use of mindfulness practice for mental diseases. Several rel-

evant clinical and phenomenological issues are also discussed, such as the

use of compassion and metaphor in psychotherapy, and the feeling of empti-

ness. The possibilities to assess and measure mindfulness components and

the possible effects of mindfulness-based interventions for non-clinical and

clinical populations are also illustrated.

Part 3 (Chapters 10–20) illustrates several mindfulness-based interventions

for a wide range of psychological disorders, but also for some severe medical

problems (cancer, chronic pain), for which this kind of approach has shown

clinical relevance and effectiveness. The chapters include a clear explana-

tion of the rationale for using mindfulness-based therapy with the specific

diseases discussed, illustrations of case studies, and descriptions of the limi-

tations and obstacles of the interventions as well as the strategies and tech-

niques that can be used to deal with problems and to implement mindfulness

interventions.

Part 4 (Chapters 21–25) shows how it is possible to implement and pro-

vide mindfulness-based interventions for specific populations (children, the

elderly) and in specific clinical settings (individual, inpatient treatment).

The last chapter in this part illustrates and explores some of the implica-

tions for clinicians wishing to use mindfulness-based approaches in terms

of the training that they need to be able to competently deliver the clinical

intervention.

Appendix A illustrates some classic mindfulness exercises that can help

readers both to more thoroughly understand mindfulness-based approaches

as well as to start developing their own meditation practice. Appendix B lists

a number of resources in several countries helpful for readers who wish to

train themselves in mindfulness-based approaches or maintain and deepen

their own meditation practice.

All the chapters were written by well-known experts and leaders in sev-

eral fields of mindfulness-based approaches and by clinical researchers with

extensive experience in the implementation of this kind of treatment with

their respective population and in their respective setting.

Introduction

13

This book will hopefully provide readers with a comprehensive and

integrated volume that illustrates the current development and evolution of

third wave approach
in cognitive-behavioral therapy, as well as a practical

and valuable tool for practitioners interested in applying mindfulness in a

wide range of clinical settings. I hope and wish that this book will serve

as a helpful source of information for clinicians, researchers, and scholars

from a wide range of disciplines, in particular psychology, psychiatry, and

the social sciences, who wish to learn and/or more thoroughly understand

mindfulness and its clinical applications. The handbook can also serve

as a reference text for university students and for trainees in psychology,

psychiatry, social work, psychiatric nursing, counseling, and in general for

all mental health professionals.

I sincerely hope that this book will inspire future creative and novel appli-

cations of mindfulness-based approaches on the part of clinical practition-

ers, as well as stimulate further research that investigates the effectiveness

and power of mindfulness practice in achieving clinical change. This could

favor the opening of at least some of the many “closed doors” in the complex

understanding of mental functioning and human suffering.

The true value of a human being is determined primarily by the measure

and sense in which he has attained liberation from the self. We shall require

a substantially new manner of thinking if humanity is to survive.

Albert Einstein (From The World as I see it, 1934)

References

Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and

empirical review.
Clinical Psychology: Science and Practice, 10
(2), 125–143.

Benson, H., & Proctor, W. (1984).
Beyond the relaxation response
. New York: Put-

nam/Berkeley.

Borkovec, T. D., & Sharpless, B. (2004). Generalized anxiety disorder: Bringing

cognitive-behavioral therapy into the valued present. In S. C. Hayes, V. M. Follette,

M. M. Linehan, (Eds.),
Mindfulness and acceptance
. New York: Guilford Press.

Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and