44

MINDFULNESS PRACTICE
Sona Dimidjian and Marsha M. Linehan

In recent years, the practice of mindfulness has

been increasingly applied to the clinical treat
ment of both physical and mental health prob
lems. Although mindfulness practice has its roots
in Eastern meditative and Western Christian con
templative traditions, the contemporary clinical
use of mindfulness has focused largely on the
core characteristics of mindfulness, independent
of its spiritual origin and background. In this con
text, mindfulness is often understood as aware
ness simply of what is, at the level of direct and
immediate experience, separate from concepts,
category, and expectations. It is a way of living
awake, with your eyes wide open. Mindfulness
as a practice is the repetitive acts of directing your
attention to only one thing. And that one thing is
the one moment you are alive. The conceptual
ization and definition of mindfulness have been
a topic of recent attention (Baer, 2003; Bishop et
al., 2004; Brown, Ryan, & Creswell, 2007; Fletcher
& Rayes, 2005). As a set of skills, mindfulness
practice has been described as the intentional
process of observing, describing, and participat
ing in reality nonjudgmentally, in the moment,
and with effectiveness (i.e., using skillful means)
(Lnehan, 1993a). Mindfulness is thus the prac
tice of willingness to be alive to the moment and
radical acceptance of the entirety of moment.
Mindfulness has as its goal only mindfulness.
At the same time, it is the window to freedom,
wisdom, and joy.
There are many ways of teaching and prac
ticing mindfulness; in fact, methods of teaching
and practicing mindfulness in the spiritual
traditions noted above have been evolving
for centuries. Recent years have witnessed an
explosion of interest in the clinical application
of mindfulness and a rapidly expanding set
of treatments that are based on the practice of
mindfulness. In fact, a recent edited volume
included mindfulness based treatments for a

range of clinical problems including depression,

generalized anxiety disorder, eating disorders,
chronically mental illness, borderline personal
ity disorder, cancer, chronic pain, relationship
distress, intimate partner violence, and stress
(Baer, 2006). Many of these approaches, how
ever, are quite early in their development and
have not been extensively tested. In addition,
emerging work is being done on the use of
mindfulness based interventions for substance
abuse problems (Marlatt 1994;Bowen et al., 2006;
Witkiewitz & Marlatt, 2004; Witkiewitz, Marlatt,
& Walker, 2005). There exist three treatment
models that employ the use of mindfulness
strategies and that have been subjected
to
considerable empirical scrutiny; these include
mindfulnessbased stress reduction (MBSR), the
closely related mindfulnessbased
cognitive
therapy (MBCT), and dialectical behavior ther
apy (DBT)1. Because MBSR, MBCT, and DBT
have been most extensively investigated, this
chapter draws from these models to provide
a basic background in the clinical use of
mindfulness and to highlight a general
stepbystep
procedure comprised of com
mon elements found in each of the various
models.

PRIMAR Y MINDFULNESS STRATEGIES

AND THEIR EMPIRICAL STATUS
KabatZinn was the first to propose an
empirically supported clinical application of

1. Although there is significant overlap between

mind
fulness and acceptance interventions, acceptance based
models that do not principally employ mindfulness
as core practices (e.g., Acceptance and Commitment
Therapy, Integrative Couple Therapy).
425
No. 18

426

GENERAL PRINCIPLES OF COGNITIVE BEHA VIOR THERAPY

mindfulness
model,
treatment

practice

MBSR,

was

of chronic

to a diverse

(KabatZinn,
initially

1990). This
used

for

the

pain and was later applied

array of disorders. Segal, Williams,

and Teasdale (2002) proposed an adaptation

of Kabat Znn's model, MBCT, for use in the
prevention of depressive relapse. Both MBSR
and MBCT use a similar structure, which
consists of an 8week program of group sessions.
Both models emphasize the importance of
regular, formal mindfulness practices, which
include sitting meditation, walking meditation,
body scan meditation, and yoga. Clients are
asked to commit to daily periods of formal
practice, ranging between 30 and 45 minutes,
as homework. Informal practice is also a focus
of the program, as clients practice
bringing
mindfulness to daily activities such as eating,
driving, washing the dishes, talking on the
phone, etc. MBSR also includes a 1daylong
mindfulness practice session during the course,
and MBCT integrates use of some cognitive and
behavioral strategies.
Linehan (1993a, 1993b) pioneered the use of
mindfulness strategies in the treatment of bor
derline personality disorder. Lnehan's model,
DBT, employs mindfulness strategies as part of
a larger package of cognitive behavioral inter
ventions. In contrast to other models, Lnehan' s
DBT model does not teach formal mediation
practices; instead, it breaks down the meditation
process into its component parts; it thus teaches
clients the psychological and behavioral skills
comprise most Eastern meditative and Western
contemplative practices. Most DBT mindfulness
exercises emphasize opportunities for using the
mindfulness skills in everyday activities and
situations. The specific mindfulness skills taught
in DBT include "what skills" (i.e., observing,
describing, and participating) and "how" skills
(i.e., nonjudgmentally, onemindfully, and effec
tively). The mindfulness skills are acore module
of the treatment and are woven into a range of
treatment procedures used in DBT. For instance,
they are taught as "the vehicles for balancing
'emotion mind' and 'reasonable mind' to
achieve 'wise mind'" (Linehan, 1993b, 63) and
as elements of emotion regulation and distress
tolerance. Mindfulness skills are taught as part
of the weekly DBT skills groups and are also

emphasized in individual therapy sessions. As

homework, clients also monitor their daily use
of the mindfulness skills on a written diary card.
Although the role of mindfulness interventions
has been investigated across a broad range
of clinical problems, many of the studies
conducted to date have been uncontrolled. For
instance, studies on MBSR in the treatment of
the following disorders demonstrate promise,
but all have lacked random assignment to
control groups: chronic pain (KabatZinn, 1982;
KabatZinn et al., 1985; KabatZinn et al., 1987;
Randolph et al. 1999); fibromyalgia (Kaplan,
Goldenberg, & GalvinNadeau, 1993); anxiety
and panic disorder (KabatZinn et al., 1992;
Miller, Pletcher, & KabatZinn,
1995); mood
and stress symptoms among cancer patients
(Carlson, Ursuliak, Goodey, Angen, & Speca,
2001); binge eating disorder (Kristeller & Hallett,
1999); and multiple sclerosis (Mills & Allen,
2000).
The few controlled trials that have been con
ducted do suggest that MBSR is efficacious in the
treatment of psoriasis (KabatZinn et al., 1998)
and mood disturbance and stress symptoms
among cancer patients (Speca, Carlson, Goodey,
& Angen, 2000). Two controlled trials found
MBCT to be efficacious in preventing relapse
among
recovered
depressed
patients with
multiple
recurrences
of prior
depression
(Teasdale et al., 2000; Ma & Teasdale, 2004).
Recent preliminary studies have also suggested
that MBCT may have promise as an acute
phase treatment for depression (Kenny &
Williams, 2007). There have been a number of
randomized controlled trials of DBT (d. Koerner &
Dimeff, 2000), including a recent
trial that
compared DBT and treatment by expert in the
reduction of suicide! behavior among patients
with borderline personality disorder (Linehan et
al., 2006).
In addition to the methodological problems
discussed above, it should also be noted that the
practice of mindfulness is a component of the
larger
treatment packages that have
been
empirically tested; in each case other cognitive,
behavioral,
and/
or
psychoeducational
interventions are also included. Therefore, no
studies have independently investigated the role
of mndfulness per se.

No. 18

44 MINDFULNESS PRACTICE
\NHO MIGHT BENEFIT FROM MINDFULNESS
S'TRATEGIES AND CONTRAINDICA TIONS
OF THE TREATMENT

The research conducted to date suggests that

mindfulness as a clinical intervention may
have promise across a broad range of clinical
problems: however, randomized controlled
clinical trials are needed to document its
efficacy. Although there is no evidence to date
for any particular contraindications to the use of
mindfulness interventions, investigators have
suggested a number of cautions. Teasdale et al.
(2000) caution therapists against using MBCT
with clients currently in an acute depressive
episode; however, as noted above, recent data
suggest that some acutely depressed patients
may benefit from MBCT (Kenny & Williams,
2007). Linehan (1994) also notes that extended
formal practice is often not indicated for many
seriously disturbed clients and instead suggests
the use the component skills listed above and/ or
more abbreviated periods of formal practice
(e.g., a few minutes).

OTHER FACTORS TO CONSIDER IN DECIDING

WHETHER TO USE MINDFULNESS STRA TEGIES

One of the key questions under discussion

among treatment developers is whether ther
apists/instructors should be required to have
their own mindfulness practice (Dimidjian,
Epstein, Linehan, MacPherson, & Segal, 2001).
The MBSR and MBCT approaches require
that therapists be engaged in a daily formal
practice (i.e., sitting meditation, yoga) as
part of the model (KabatZinn, 1990; Segal,
Williams, & Teasdale, 2002). It is argued that
this prerequisite ensures both that therapists
will teach from an experiential as well as an
intellectual knowledge base and that they will
have direct understanding of the effort and
discipline required of clients. In contrast, other
models such as DBT do not prescribe a formal
mindfulness practice for DBT therapists, though
some mindfulness activities are required. For
instance, formal mindfulness is practiced at
the outset of every consultation team meeting,
which is a requisite part of DBT, and therapists

427

are required to practice particular mindfulness

exercises prior to using them with clients. In this
sense, although DBT therapists are not required
to have a personal formal practice, they are
members of a formal community of therapists
learning mindfulness. The importance of having
a mindfulness teacher, either in person or
through books, has also been discussed.
Unfortunately, there is no empirical data to
date that validates the importance of a therapist's
personal practice for competent clinical practice;
thus, the degree to which a therapist maintains
a formal practice will, in part, be guided by the
particular model used. For therapists interested
in integrating mindfulness strategies as part of
other treatment regimens, it will, at a minimum,
be important to consider one's own degree of
understanding and familiarity with mindfulness
practices.
Another important consideration is the
question: "Is mindfulness practice a means to
an end or an en~ in itself?" In the spiritual
traditions from which they are derived, an
essential quality of mindfulness practice is the
act of non-striving or nonattachment to
outcome, and the models discussed above
specifically emphasize this quality of
mindfulness. Individuals seeking clinical
care, however, are often expressly
interested in a particular outcome (e.g., feeling
better, less depressed, etc.). Therapists using
mindful ness clinically must balance this
inherent tension between the "end in itself"
quality of mindful ness and the goal directed
quality of clinical care.

HOW DOES MINDFULNESS PRACTICE WOR.K?

There is no definitive
evidence
regarding
mechanisms of change in the clinical use of
mindfulness, though
a number of theoretical
models have been discussed (Baer, 2003; Warren
Brown, Ryan,
& Creswell,
2007;
Lynch,
Chapman, Rosenthal, Kuo, & Linehan, 2006).
Specific hypothesized
mechanisms
include
relaxation
(Ben son, 1984), metacognitive
change (cf. Teasdale, Sega!, & Williams, 1995),
and replacement of a "negative addiction" with
a "positive addiction" (Marlatt, 1994). It has also
been suggested that the process of change in the
clinical use of mindfulness parallels that of the
clinical use of exposure

No.18

428

GENERAL PRINCIPLES OF COGNITIVE BEHA VIOR THERAPY

interventions

(KabatZinn,

1982;

KabatZinn

et al., 1992; Linehan, 1993a, b) and acceptance

(Linehan,
1993a,
1993b, 1994;
interventions
Marlatt,

1994).

Mindfulness

practice

may

also

work by enhancing the use of other cognitive and

behavioral procedures, such as problem solving
(Linehan,
documented

1993a).

Finally,

a range

recent

of biologcal

MBSR (see, e.g., Davidson

studies

have

correlates

of

et al., 2003; Farb et al.,

2007). A range of studies have also documented

the physiological
effects
nonclinical
populations

of meditation among
(BrefczynskLewis,

Schaefer,
Levinson,
& Davidson, 2007;
Lazar et al., 2005; Lutz, Greischar, Rawlings,
Ricard, & Davidson 2004). It is therefore likely
that sorne of the clinical benefits of mindfulness
practice may be mediated by such effects. It is
also probable that mindfulness does not operate
via one single pathway but that its effects are
mediated by numerous processes; clearly,
further investigation of mechanisms of change
will be an important next step for empirical
inquiry.
Lutz,

TABLE44.1 Seven Major Steps of the Clinical Use of

Mindfulness Practice
l. Embodiment/Modeling
2. Preparation
Selecta target activity/stimuli for mindfulness prac
tice.
Determine how long it will be practiced.
Complete personal preparation.
3. Instruction
Introduce client to the rationale and goals of mindful
ness practice.
Introduce to the client the main characteristics of
mindfulness.
Instruct the client on the specific target practice.
4. In Session Practice
Lead and participate with the client in the selected
practice activity.
5. Sharing
Elicit description from the client of his/her direct
experience of the practice.
Elicit commentary about the practice from the client.
6. Feedback
Provide corrective feedback, weaving in information
outlined in step 3 as indicated.
7. Homework
Review homework in manner consistent with proce
dures outlined in steps 5 and 6.

STEPBYSTEPGUIDELINES FOR THE CLINICAL

USEOF MINDFULNESSPRACTICE

Although there is significant overlap between mindfulness

and acceptance interventions, acceptance based models that
do not principally employ mindfulness as core practices (e.g.,
Acceptance and Commitment Therapy, Integrative Couple
Therapy).

Although the primary clinical models utiliz

ing mindfulness strategies are unique in many
respects, they also share basic common elements.
These common elements are distilled here as a
set of seven steps to employ in the clinical appli
cation of mindfulness practice (see Table 44.1).
This guideline is offered to acquaint the reader
with the practice of mindfulness; however, cli
nicians should be cautioned to recall that these
steps have not been empirically tested ndepen
dent of the larger models from which they are
derived.

inquiry after meditation practices. DBT places a

strong emphasis on the importance of modeling
and specific strategies such as being radically
genuine, nonjudgmental, and awake to client
in session behavior. In all of these ways, the
therapist's understanding of mindfulness is a
key element and forms an essential foundation
for the six remaining steps.

Step 1: Embodiment or Modeling

Embodiment or modeling of mindfulness con

sists of acting with mindfulness in one's imple
mentation of the intervention model. MBSR and
MBCT place heavy emphasis on the impor
tance of embodying mindfulness in one's teach
ing, both through leading the specific medita
tion practices as well as guiding the process of

Step 2: Preparation

Preparation consists of three main parts. First, the

Therapist must decide what activity the client will
practice. It is important to recall that mindfulness
is not a particular activity (e.g., sitting quietly
with crossed legs on a cushion), it is the quality
of awareness that one brings to any activity, to
any internal or external stimuli. Therefore, the
activities or experiences that can serve as targets
far mindfulness practice are endless. Awareness

No.18

44 MINDFULNESS PRACTICE
of breathing is perhaps
most
commonly
associated with mindfulness (and it is a core
element of most traditions and clinical models),
but other possibilities for mindfulness practice
abound, including: eating, walking,
physical
movement in yoga or dancing, laughing, singing,
listening, seeing, driving,
answering the
telephone, and so forth.
Second, the therapist must decide how long
the client will practice. Among the models dis
cussed in this chapter, the duration of practice
varies greatly, ranging from a single minute
of practice to ten days. Duration of practice
also varies across different interventions within
one model; for instance, MBCT assigns 3minute
"breathing space" practices as well as 45minute
sitting meditations. At present, no empirical data
exist to guide the selection of target activity
and/ or practice duration; therefore, therapists
should be guided by the sequencing guidelines
of the treatment model employed and/ ar their
assessment of the individual needs, motivation,
and capabilities of their clients.
Third, it is important for therapists to prepare
personally for the use of mindfulness strategies.
At a minimum, it is important for therapists
to practice the target activity that will be used
before teaching it to one's clients. Beyond this,
the extent of personal preparation suggested
varies a cross the primary models, as noted above.
There is consensus, however, as noted above,
on the importance of modeling ar embodying
mindful ness in one's interactions with the client.
Toward this end, Segal, Williams, and Teasdale
advise therapists to take the time necessary to
begin
sessions, not hurriedly, but with a balance of
"openness and 'groundedness'" (2002, p. 84).

429

presenting
problems,
most
models
incorporating mindfulness
interventions
also
emphasize the general goal of helping the client
to access a sense of wisdom and a corresponding
experience of decreased struggle or suffering.
In DBT, this
is referred to as "wise mind" (Linehan, 1993a,
b ); MBCT refers to "inherent wisdom" (Segal,
Williams, & Teasdale, 2002).
The second level of instruction involves the
introduction of mindfulness and its key char
acteristics. Although each model uses slightly
different language, there is considerable concep
tual overlap in the key qualities of mindfulness
that are emphasized. A brief summary of these
qualities is outlined below. Consistent with the
DBT conceptualization of mindfulness (Linehan,
1993a), the first three qualities refer to activities
that one <loes when practicing mindfulness; the
next three refer to the style in which the first
three activities are undertaken.
Noticing/Observing/Bringing Awareness
This is one of the core characteristics of what
one does when practicing mindfulness. It is
paying attention to direct experience, at the
level! of pure sensation, without concepts or
categories. Therapists can explain that, most often,
we move without awareness from the level of
direct experience and sensation to conceptual
description (and often from there quickly to
judgment). For instance, we hear sounds from
the tree above and think, "Ah, a bird, what a
lovely song." Noticing, however, is hearing the
bird's song as just the elements of sound (e.g.,
timbre, pitch, pace, melody, etc.) without
classifying or categorizing the experience of
hearing as "bird" (or judging it to be "lovely").
Labeling Noting/Describing

Step 3: Instruction and Orientation

There are three levels of instruction and

orientation that the therapist must provide:
(1) instruction on the goals and/ or rationale of
mindfulness practice, (2) instruction on the key
characteristics of mindfulness and (3) instruction
on the selected practice activity.
The first level of instruction requires the
therapist to provide a rationale to clients
far the use of mindfulness interventions.
Although this should be specifically tailored
to the client's

This refers to the activity of observing and

then adding a descriptive label to the
experience. Again, specific examples will be
helpful in explaining this characteristic. For
instance, if one is practicing mindfulness of
washing the dishes and thinks, "I forgot to
pay the phone bill!" labeling/ noting/
describing would be to say simply, "thinking" or
"remembering" or "a thought went through my
mind." If pain in the shoulder arises, labeling/
noting/ describing would be to attend to the
specific sensation and say, for

No. 18

430

GENERAL PRINCIPLES OF COGNITIVE BEHA VIOR THERAPY

instance, "tightness." It is important to under

stand and convey that labeling occurs at the level
of process, and thus avoids getting stuck in con
tent. Thus, labeling/ noting/ describing allows
one to step back from experience with aware
ness, to "decenter" (Segal, Williams, & Teasale,
2002). It is this act of mindfulness that gives
rise to the direct experience of "I am not my
emotions," "Thoughts are not facts," and so on.
Participating
This refers to throwing oneself fully into an
activity or experience. It is becoming one with
experience without
reservation
it is
characterized by spontaneity. This quality is an
important one for clients to learn, but it is also
a critical quality for therapist to bring to the
teaching of mindfulness.
Nonjudgmentally/with Acceptance and Allowing
These refer to three closely related and central
aspects of mindfulness practice. Judgment is the
act of labeling things as good or bad. Most often,
we live with great attachment to that which we
judge as "good" great aversion to that which we
judge as "bad." Nonjudging is bringing a gentle,
open, and noncritical attitude to experience. It
is "assuming the stance of an impartial witness
to your own experience" (Kabat Zinn, 1990, 33).
Nonjudging
also
facilitates letting
go or
becoming nonattached, which means not trying to
hold onto that which is "good" or push away
that which is "bad"
(e.g., difficult, painful,
boring, etc.). Nonjudging is also a form of
accepting. Accepting is seeing what is. It is not
trying to be or get anywhere or anything else;
it is not trying to be more relaxed, more joyful,
less in pain, more enlightened, and the like. It is
ceasing efforts to control or to make things
other than they are.
It is important to explain to clients that we
practice nonjudging/ accepting/ allowing with
all aspects of mindfulness practice even the act
of judging (e.g., don't judge judging!). Asking
clients to focus on the "facts" (e.g., who, what,
when, and where) can be a helpful way of
practicing nonjudgment (Linehan, 1993b).
Therapists may a1so need to clarify that
nonjudging does not mean replacing negative
judgments with positive judgments. Nonjudging means not

making judgments at all, as opposed to being

"Pollyannaish." It is also important to explain
that nonjudging and accepting can be very
difficult to do; in fact, Linehan (1993a, b) uses
the term radical acceptance to connote "that the
acceptance has to come from deep within and
has to be complete" (102). Therapists may need
to address perceived obstacles to accepting; these
often include thinking that acceptance confers
approval and/ or that acceptance will foreclose
future opportunities for change (Linehan, 1993b;
KabatZinn, 1990).In DBT, the skills of "turning
the mind" (or actively choosing to accept) and
"willingness" as opposed to "willfulness" are
presented as paths toward acceptance.

.
ii

Effectively
This refers to the quality of mindfulness that has
as its chief emphasis "what works." Mindfulness
is not concerned with opinions or ideas about
"right" or "wrong." A mindful approach is one
that is concerned with being effective, one that
easily abandons ''being right" in favor of ''being
effective." This quality stems from the notion of
"using skillful means" found in most Eastern
meditative traditions.
In the Moment/with
Mind

Beginner's

Being in the moment refers to being in this

moment without reference to pastor future; only
this moment exists, Being in the moment also is
the opposite of doing one thing while thinking
about something else or attempting to do several
activities at once. Kabat Zinn (1990, 35) explains
the quality of beginners mind, "No moment
is the same as any other. Each is unique and
contains unique possibilities. Beginner' s mind
reminds us of this simple truth."
It should be noted that the presentation of the
key characteristics is rarely completed in a
single presentation.
Instead,
certain
characteristics may
be emphasized
in the
instructions for specific mindfulness practices
and/ or woven into the process of sharing and
feedback. In fact, the style of instruction varies
considerably across models. MBSR and MBCT
place a heavy emphasis on experiential learning
and the process of discovery; thus, the role of
didactic
instruction is minimized. In contrast,
group leaders help to guide clients through a
process of inquiry to a
No. 18

.
ii

ii

44 MINDFULNESSPRACTICE
new experience and understanding. In contrast,
the skills training context of DBT places a heavy
emphasis on didactic instruction and mindful
ness skills and practices are taught in a manner
consistent
with
a traditional
classroom
environment. DBT places a similarly heavy
emphasis on client's direct experiential practice in
sessions; however,
the therapist's
style is
commonly more didactic in nature. Across ali
approaches,
stories, metaphors,
poetry, and
concrete examples from clients' own lives are often
useful methods of conveying the key characteristics
of mindfulness.
At the third level of instruction, the
therapist needs to instruct the client in the
specific insession or at home practice activity.
The instructions should be delivered before the
practice and may also be repeated, in full or
part, at several points during the practice.
Instructions should be clear, specific, and
simple. It is also common to begin man y
mindfulness instructions with an invitation to
focus on body position or
posture; specific instru7tions about whether to

open or close the eyes should also be included

if relevant to the activity. Instructions should
also include information about the length of the
practice and how the beginning and end will
be identified; ringing a mindfulness bell may be
useful for this purpose.
It is also often helpful, depending on the
client's level of skill, to anticipate and pro
vide instruction on common difficulties that may
arise. Chief among these is the experience of
wan daring attention. Therefore, the therapist
may anticipate the wandering of attention to
thoughts (e.g., "I can't do this," "I forgot to put
money in the parking meter," etc.), strong
emotions (e.g., boredom, frustration,
hopelessness, excitement, anxiety, etc.),
physical sensations (e.g., itch on your left foot,
soreness in your shoulders, hearing noises in
the hall, etc.), and/ or action urges (e.g., the
urge to end the practice, to distract, etc.). In
each case, the therapist should reassure the
client that the wandering of attention is normal
and even inevitable for most practitioners of
mindfulness. The therapist can also explain that
the wandering of attention does not indicate that
the client is doing the practice "wrong;" in
contrast, responding to the wandering of
attention is, itself, part of the practice of
mindfulness. The instruction is simply to
observe that attention

431

has wandered and to bring it gently, without

judgment, back to the target activity.
Step 4: In Session Practice

Mindfulness is not something that can be taught

(or learned) simply by talking about it. Mindful
ness is an experientially based skill that needs
to be developed over repeated trials of practice.
Therefore, in session practice is critical, as such
practice provides the chief context for teaching
and learning. Step three is, thus, leading the
selected practice. In addition, it is important for
the therapist to engage in the target practice
with the client. Doing the practice with the client
models the mindful behavior, decreases client
self-consciousness (Marlatt & Kristeller, 1998),
and helps to ensure that the therapist teaches
from an immediate "moment to moment
experience" (Segal, Williams, & Teasdale, 2002,
89).
Step 5: Sharing

After the target activity has been completed,

the therapist asks the client to share his/her
experience, including any difficulties
encountered. Segal, Williams, and Teasdale
(2002) emphasize the importance of using openended questions and an attitude of curiosity in
this process. In this way, the activity of sharing
may itself present opportunities for further
mindful ness practice. For instance, if clients
report their experience with judgmental
language (e.g., "I tried to be mindful of walking,
but I did a terrible job."), therapists can guide
them to describe their experience without
judgmental terms, thereby creating an
opportunity for practicing non judging (e.g., "I
intended to be mindful of walking, but my
mind kept wandering to other things."). MBCT
formalizes this distinction by asking clients first
"to describe their actual experience during the
"comments on their experiences" (Segal,
Williams, & Teasdale, 2002, 89).
Step 6: Feedback

Although this step is discussed as a separate step

for heuristic purposes, in actuality, client
sharing and feedback are often closely
intertwined.

No. 18

432

GENERALPRINCIPLESOF COGNITIVEBEHAVIOR THERAPY

In fact, the careful weaving of client sharing

to do it" (KabatZinn, 1990; Segal, Williams, &

and therapist feedback presents one of the most

powerful opportunities for the therapist to teach
mindfulness. Therapists are typically able to
address obstacles to learning most effectively
when instruction is linked to immediate and
specific client experiences. Again, as previously
noted, in MBS Rand
MBCT, providing
feedback often occurs in the for roof asking
questions about clients' experiences, whereas in
DBT, feedback may be of a more direct,
corrective nature.
A number of difficulties are frequently ad
dressed during feedback. For instance, being
"distracted" (e.g., by thoughts, noises, emotions,
urges, physical sensations, etc.) is a very
common experience that clients describe during
sharing. It is often helpful in providing feedback
to remind clients that the wandering of one's
mind from the target activity is not a sign of
failure, but part and parcel of the practice.
Clients often report, "I couldn't do it" following
a mindfulness practice. To this, therapists can
inquire, "Veered you aware of "not doing it"?
Frequently the response is "yes." At this point,
therapists can explain, "You did it!," and again
explain that the practice is to simply be aware
of whatever arises during the practice.
Feelings of frustration or discouragement
(and corresponding self judgment) may also be
common. Clients may feel frustrated that they
do not see immediate results in reaching their
therapeutic goals (e.g., "It didn't work; I don't
feel any better."). Clients may think that being
mindful is too difficult and feel frustrated with
the need to practice what is seemingly such a
simple activity again and again. In response
to both of these concerns, therapists can
highlight the inherent dialectic of mindfulness
practice between goal orientation and letting go.
Therapists can also remind clients that repeated
practice is also an inherent part of learning
mindfulness. Clients should be cautioned at the
outset that mindfulness rarely "just happens."
It is simple, but not easy. As in the learning
of all new skills, it requires rehearsal and
overlearning to master. It thus demands inten
tion, concentration, commitment, and discipline.
It requires effort even when one may not feel like
exerting effort. MBCT and MBSR both explain to
clients, "You don't have to like it; you just have

Teasdale, 2002).It also requires repeated practice

and a corresponding attitude of patience. It will
often feel like one is starting over, again and
again. Often, reference to stories and metaphors
that illustrate other skills that require repeated
practice and the ineffectiveness of self-judgment
and criticism in the process can be useful.
Step 7: Homework

Ali models utilizing mindfulness strategies

emphasize at home practice. As in all cognitive
and behavioral therapies, a heavy emphasis is
placed on the generalization of skills learned
in sessions and the role of homework toward
this end. Specific homework practices can be
structured as part of the treatment program, as
in MBSR and MBCT, which use a
combination of formal and informal practices as
well as instruction via CDs. Homework can
also be individually tailored to particular
clients, as in DBT. In general, homework
assignments should be clear and specific, and
potential obstacles to completion should be
anticipated and discussed. Toe next session
should include a review of homework that is
conducted in a manner consistent with the
guidelines above for sharing and feedback
discussed above.
Further Reading
KabatZnn, J. (1990). Full caiasirophe living: Using the
wisdom of your body and mind toface stress, pain,
and illness. New York: Dell Publishing.
Linehan, M. M. (1993). Cogniiioe-behaoioraltreatment of
borderline personality disorder. New York: Guilford
Press.
Linehan,M. M. (1993). Skills training manualfar treating
borderline personality disorder. NewYork: Guilford.
Segal, Z., Williams, J. M. G., and Teasdale, J. D. (2002).
Mindfulness-based cognitive therapy far depression:
A new approach to preventing relapse. New York:
Guilford.

References
Austin, J. H. (1998). Zen and the brain: Toward an
understanding of meditation and ccnsciousness. Cam
bridge, MA: MIT Press.
Baer, R. A. (2006). Mindfulness-based treatment approaches. Oxford, UK: Elsevier.

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