Received 08/25/11 Revised 10/28/11 Accepted 02/21/12

Mindfulness-Based Interventions in Counseling

Amanda P. Brown, Andre Marquis, and Douglas A. Guiffrida
Mindfulness is a relatively new construct in counseling that is rapidly gaining interest as it is applied to people struggling with a myriad of problems. Research has consistently demonstrated that counseling interventions using mindfulness improve well-being and reduce psychopathology. This article provides a detailed denition of mindfulness, including a discussion of the mechanisms underlying mindfulness practice; explores the implementation of mindfulness as a counseling intervention; and examines literature supporting its effectiveness. Keywords: mindfulness, counseling, meditation, mindfulness-based cognitive therapy

During the last 30 years, mindfulness has attracted a great deal of attention from counseling researchers and practitioners and is the subject of a quickly growing body of research. Currently, more than 1,500 articles can be found with mindfulness in the title when searching the PsycINFO computer database. Additionally, a recent poll conducted by the Psychotherapy Networker found that over 41% of the 2,600 therapists who completed their survey reported integrating some form of mindfulness into their therapy practice (Siegel, 2011). Jon Kabat-Zinn (1994), one of the f irst and most well-known scholars to integrate mindfulness into Western healing practices, defines mindfulness as paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally (p. 4). The current body of mindfulness literature suggests that integrating this seemingly simple approach into counseling yields consistently positive outcomes with clients. One of the most striking themes in the literature is the apparent helpfulness of mindfulness in alleviating the symptoms of many distressing problems, including generalized anxiety disorder (Hofmann, Sawyer, Witt, & Oh, 2010), depression relapse (Piet & Hougaard, 2011; Teasdale & Ma, 2004), borderline personality disorder (Linehan, 1993), eating disorders (Wolever & Best, 2009), and drug addiction (Bowen, Chawla, & Marlatt, 2011), as well as improving general well-being (Hlzel et al., 2011). In addition, research suggests that counselors own personal practice of mindfulness benefits their clients, even when their clients are not themselves practicing mindfulness and are unaware that their counselor is (Grepmair et al., 2007). Yet, despite the strong empirical support for the use of mindfulness in counseling, few articles have been published on this topic in counseling journals. In this article, we define mindfulness, explore the implementation of mindfulness in counseling practice, and examine a selection of literature supporting its effectiveness.

Dening Mindfulness
Human beings have been imparting and practicing mindfulness skills as a means of easing psychological suffering for at least 2,500 years (Teasdale, 1999b). While the practice is strongly tied to the teachings of the Buddha, others have pointed out that mindfulness practices date back thousands of years before the Buddhas time, with roots in ancient yogic practices (Miller, Fletcher, & Kabat-Zinn, 1995). Although mindfulness originated from Eastern spiritual teachings, the practice of relating to ones experience in the present moment with acceptance and full awareness is by no means limited to a particular religious tradition. By its very nature, mindfulness is a mode of awareness that is universally accessible in that anyone can learn it and practice it (Bishop et al., 2004). Bishop et al. (2004) proposed that there are two essential components that constitute mindfulness as discussed in the literature: an open attention to ones present experience, accompanied by a nonjudgmental, accepting attitude toward whatever one encounters. These complementary elements can be easily identied in this concise denition: nonjudgmental moment-to-moment awareness (Miller et al., 1995, p. 193). A persons experience refers not only to what is occurring around her or him (e.g., sights, sounds, events) but also what is most often unattended to: internal experience (e.g., physical sensations, emotions, thoughts). As Epstein (1995) succinctly put it, [Mindfulness] is quite literally coming to ones senses (p. 144). It is important to distinguish between mindfulness and concentrative practices. As Epstein (1995) explained, concentration consists of rest[ing] the mind in a single object of awareness (p. 132), with the aim of achieving singlepointedness; thus, when attention strays, it is redirected to that object. In contrast, mindfulness involves a moment-tomoment bare attention to whatever arises within ones eld of awareness. At times, the mindfulness literature fails to differentiate between these two distinct meditative approaches,

Amanda P. Brown, Department of Psychology, Emory University; Andre Marquis and Douglas A. Guiffrida, Department of Counseling and Human Development, University of Rochester. Correspondence concerning this article should be addressed to Amanda P. Brown, Department of Psychology, Emory University, 36 Eagle Row, Atlanta, GA 30322 (e-mail: apbrow6@emory.edu). 2013 by the American Counseling Association. All rights reserved.

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Mindfulness-Based Interventions in Counseling and some interventions that use concentrative techniques are mislabeled as mindfulness. It is important that there is clarication among counselors about which approach is actually being implemented. Relaxation has been identied as a measurable result of mindfulness practice and, therefore, as a potential mechanism of change, especially for stress-related disorders (Baer, 2003); however, mindfulness is not considered a relaxation technique (Bishop et al., 2004). Rather, it is a form of mental discipline that helps reduce a persons tendency to react to cognitions in ways that lead to stress responses. Thus, while stress is often reduced through mindfulness practice, the potential implications of mindfulness extend well beyond stress reduction. Likewise, mindfulness might be misunderstood as somehow fostering the suppression of thoughts and feelings. Instead, regulating ones attention in a mindful way creates an inner attitude that neither suppresses nor indulges transient cognitions and emotions (Chodron, 1997; Kabat-Zinn, 1994). In fact, the thrust of mindfulness is neither to seek pleasant experiences nor to avoid unpleasant experiences, but rather to be nonjudgmentally aware of whatever arises in ones present eld of awareness. Once again we are presented with what may seem counterintuitive about mindfulness practicewhat Baer (2003) called a paradoxical attitude of nonstriving (p. 130) and Kabat-Zinn (1990) called non-doing (p. 60). It is believed that this nonstriving attitude, accessible through a variety of mindfulness techniques, reduces reactivity to distressing emotions and thoughts, thus providing a more reective, less disturbed, and more adaptive mode of consciousness. Despite the fact that each of these approaches (a) was developed independently, (b) is targeted toward diverse client populations, and (c) integrates mindfulness principles with vastly different established counseling theories, all three approaches share much in common with regard to the ways in which the core principles of mindfulness are woven into the counseling process. It is reasonable, therefore, that mindfulness can be used by counselors from various theoretical orientationsincluding, but not limited to, those that formally integrate itto assist with a variety of client issues (Martin, 1997). Next we provide a basic overview of how mindfulness can be incorporated in counseling practice. This description is intended to provide only a broad overview of these processes. Readers are referred to Kabat-Zinn (1990), Orsillo and Roemer (2011), Segal et al. (2002), and Williams, Teasdale, Segal, and Kabat-Zinn (2007) for more detailed descriptions regarding the described activities. Counselors using mindfulness in their practice begin with psychoeducation, in which clients learn about the foundational elements of mindfulness, including the tendencies of the human mind to become preoccupied with thinking about the past, planning for the future, and labeling and making judgments about everyday experiences. It is important that counselors normalize these human tendencies so that clients realize that they are not the only ones failing to live life fully present and nonjudgmentally. Clients should also be informed about research that has supported the effectiveness of mindfulness in counseling and healing more generally, focusing specically on their particular area of distress if such literature is available. Additionally, counselors can refer clients to mainstream literature that provides a basic overview of mindfulness practice (e.g., Kabat-Zinn, 1990; Orsillo & Roemer, 2011; Williams et al., 2007) before beginning their formal mindfulness experience in therapy so that they are able to gain a more complete understanding of this unique approach to counseling and healing. After clients learn about the fundamental elements of mindfulness, the counselor can begin instructing clients in basic mindfulness-based meditation techniques. This is begun by teaching clients to sit quietly while observing whatever enters their eld of awarenesswhether thoughts, emotions, or sensationswithout emotionally reacting to or judging them. To assist in this process of nonreactivity, clients can be encouraged to view their thoughts as clouds oating by in the sky of their minds, which are allowed to gently pass without any reaction (Kabat-Zinn, 1990). Additionally, clients are instructed to use their own breath as an anchor to keep themselves from being distracted by or reacting to their thoughts. When clients begin to notice themselves becoming overly involved with a particular thought, they are encouraged by the counselor to direct their awareness to their breathing. This involves intentionally observing the sensations of their natural breathing processfrom air moving against their nostrils and the back of their throat to the changing sensations of 97

Mindfulness in Counseling
Mindfulness began to gain popularity in counseling and psychotherapy in the early 1990s, with the introduction of Linehans (1993) dialectical behavior therapy (DBT; Siegel, 2011). Developed as a means for working with clients with borderline personality disorder (a group previously regarded as difcult and even resistant to psychotherapy), DBT proved highly effective and, as a result, gained widespread attention from the counseling and psychotherapy community. Shortly thereafter, Segal, Williams, and Teasdale (2002) introduced mindfulness-based cognitive therapy (MBCT) to prevent depressive relapse in clients with recurrent depression. This approach combined Beck, Rush, Shaw, and Emerys (1979) cognitive therapy with fundamental techniques used in Kabat-Zinns (1990) mindfulness-based stress reduction (MBSR). MBSR is a long-standing program that has consistently demonstrated its effectiveness in alleviating stress and chronic physical pain (Kabat-Zinn, Lipworth, Burney, & Sellers, 1986). Around the same time, Hayes, Strosahl, and Wilson (1999) developed what is currently referred to as acceptance and commitment therapy (ACT), which integrates the core mindfulness concepts of awareness and acceptance with cognitive behavioral principles.

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Brown, Marquis, & Guiffrida their belly touching their shirt as the abdomen rises and falls (Kabat-Zinn, 1990). In this way, the counselor teaches clients to use their breath to anchor them to the present moment. Another more active form of mindfulness meditation that counselors can use with clients is the body scan, during which the client is guided through 45 minutes of nonjudgmental, sequential attending to physical sensations until arriving at a unied awareness of the whole body (see Kabat-Zinn, 1994). To facilitate regular practice of the body scan in daily life, clients are typically provided with audio recordings containing this and other guided exercises (e.g., sitting meditation). Additionally, counselors can help facilitate client awareness by teaching them the process of mindful eating. This activity is typically conducted using a single piece of fruit, often a raisin (Kabat-Zinn, 1990). First, the counselor encourages the client to sit comfortably and ground her attention in the physical sensations of her body. The client is then instructed to focus her awareness on the sight and texture of the raisin in her hand, later the smell, the taste, and so on. As the client swallows, she is encouraged to attend to the sensations of the raisin as it makes its way down her throat and into her stomach. The counselor reminds the client that if she realizes her attention has drifted away from her current experience of the raisin and has been engaged with thoughts, worries, or other preoccupations, she acknowledges this fact and, without judging herself, gently returns her attention to her physical experience of the raisin. In addition to formal mindfulness practices, counselors using mindfulness approaches also help clients be more present to their thoughts, emotions, and physical sensations in the midst of everyday activities. In other words, the quality of attention that is cultivated through the sitting meditation needs to be integrated into the clients daily life. To illustrate this idea, we might consider the application of mindfulness to a mundane activity like driving a car. As a woman sits and drives, she grounds her attention in one or more physical sensations, like her back against the seat, the feeling of her feet on the oor, or the rhythm of her breathing. Simultaneously, she focuses her attention on the external stimuli of the road in front of her, the surrounding cars, and so on. When she notices that her attention has drifted away from the anchor(s) connecting her to the present moment, she gently brings her attention back to her present sensations and perceptions. For instance, when she realizes that she has lost the awareness of her feet on the oor and has been planning tomorrows dinner, she acknowledges this observation and, without judging herself, returns her attention to her perceptions of the driving conditions and the sensations of her body. To assist clients in integrating mindfulness into their daily activities, counselors can help clients identify activities that lend themselves most easily to mindfulness practice, which, in addition to driving a car, can include other mundane tasks, such as doing dishes, ironing clothes, gardening, walking, and so forth. Practicing mindfulness, whether in formal meditation or in regular daily activities, is often challenging for clients 98 at rst, because intentionally working with awareness in this way is in direct conict with habitual modes of human functioning and with many cultural norms. Only after one attempts to practice mindfulness does it become clear, through direct experience, that our conditioned mode of operating is dominated by automatic internal processes that ultimately obstruct living fully in the present moment. This inevitable struggle with deeply ingrained patterns is partly why diligent practice to sustain nonjudgmental, open attention is a critical component of mindfulness training. Successful mindfulness interventions, therefore, require clients to maintain a level of discipline and regular, systematic practice. Thus, clients are encouraged to devote some timeeven if only 5 to 10 minutesevery day to a formal mindfulness practice, such as a sitting meditation, body scan, or mindful eating, in addition to regularly integrating mindfulness into their daily activities. This formal practice strengthens their capacity to cultivate mindfulness throughout the day. Many mindfulness programs also incorporate homework journals or daily worksheets as a tool to support clients in developing a regular practice. Several authors have noted that the simple practice of observing oneself with a nonjudgmental, accepting attitude toward ones experience seems to create a state of emotional nonreactivity that is powerful and healing in and of itself (Chodron, 1997; Kabat-Zinn, 1994; Martin, 1997; Welwood, 2000). Being able to step back from ones internal processes with an inner posture of nonattachment, nonidentication, and acceptance can lead to a state of psychological freedom (Martin, 1997, p. 291). Thus, for some clients, especially those with less severe or nonpathological problems, the basic mindfulness interventions described above may be all that is needed for them to successfully negotiate the difculties that brought them into counseling. Mindfulness-based intervention (MBIs), however, can also be used to enhance the effectiveness of most traditional talk therapies. A recurrent theme in counseling and psychotherapy literature is the observation that mindfulness training overlaps with many established empirically supported treatments, with respect to their mechanisms of action. In fact, Martin (1997) has proposed that mindfulness is a core process that underlies seemingly diverse therapeutic approaches (p. 292). While different authors may use distinct frameworks and terminology to describe core processes that undergird successful therapeutic interventions (e.g., Beck et al.s [1979] decentering or Bohart and Tallmans [1996] detachment), the underlying process that seems to allow for their effectiveness is similar. By providing clients with a means for exploring unpleasant thoughts, feelings, or behaviors, many of which may have previously been unnoticed or perceived as too overwhelming for them, mindfulness can help counselors from virtually any theoretical orientation facilitate change processes in their clients (Martin, 1997). In this way, the internal state of attentional freedom that is facilitated by mindfulness training can be considered a core process that is necessary in order for clients to engage in meaningful change.

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Mindfulness-Based Interventions in Counseling The idea of a core therapeutic process can also be understood through an examination of the relationship between MBIs and cognitive therapy. While both attend primarily to cognitions, the key difference between these two frameworks lies in their designated targets of change and corresponding therapeutic techniques. Cognitive therapy explicitly focuses on changing the content of negative or maladaptive beliefs and thoughts through strategies such as cognitive restructuring to change clients beliefs in automatic negative thoughts and dysfunctional assumptions (Teasdale, 1999a). Alternatively, MBIs make explicit that the goal of sessions is not to change beliefs, thoughts, or feelings, but rather to change the clients relationship to these psychological phenomena. In fact, mindfulness training specically discourages the judging or labeling of thoughts (e.g., as maladaptive, dysfunctional, irrational). In applying mindfulness with clients, it is essential for counselors to understand this principle to accurately identify the correct target of change: the relationship toward thoughts, not the thoughts themselves. It may be that although cognitive therapy explicitly focuses on changing negative beliefs and thoughts, it implicitly leads to a change in relationship to these beliefs and thoughts (Teasdale, 1999a). Thus, the resulting change in the clients relationship to her thoughts (i.e., increased mindfulness) may be the core process responsible for changing thought patterns in cognitive therapy. This distinction is of particular importance and highlights the paradoxical nature of mindfulness training: By simply observing ones thoughts without intending to change them, one can create the experience of recognizing any cognitive phenomena as both separate from oneself and not necessarily reective of any particular reality or truth. Ultimately, mindfulness provides the opportunity for clients to recognize that their thoughts and emotions are transient and often insubstantial; because of this, they can choose to relinquish their attachment to them and begin to consider alternative ways of being. This radical shift in relationship to ones thoughts and emotions can provide the foundation needed for successful psychotherapy from any theoretical approach. Although we do not fully understand the mechanisms by which mindfulness skills operate (see Hlzel et al., 2011), such models provide a working foundation to guide counselors in understanding the application of this promising modality. tion (Arch & Craske, 2006), and reduced compassion fatigue and burnout (Christopher & Maris, 2010). Hofmann et al. (2010) recently conducted a meta-analytic review of the efcacy of mindfulness-based therapies for relieving mood and anxiety symptoms in populations with a variety of psychiatric and medical conditions. Effect size estimates were derived from a sample of 39 studies, which included a total of 1,140 clients. Incorporating data from both controlled and uncontrolled studies, prepost effect sizes were in the moderate range for improvement of anxiety and depression symptoms (Hedgess g = 0.63 and 0.59, respectively). Hedgess g is a variation of Cohens d that corrects for biases resulting from small sample size (Hedges & Olkin, 1985). For clients with diagnosable anxiety disorders and depression, however, large effect sizes were reported (Hedgess g = 0.97 and 0.95 for anxiety and depression, respectively). These ndings indicate a robust treatment effect, suggesting that mindfulness-based therapies are efcacious for improving depression and anxiety symptoms in heterogeneous clinical populations. Furthermore, results indicated that these effects were maintained over an average 27-week follow-up period. Interestingly, the authors of this review acknowledged that, before conducting the meta-analysis, they had adopted a critical view toward the efcacy of MBIs. There have also been a number of studies that focus on examining the effectiveness of the aforementioned counseling approaches that specically integrate mindfulness into the therapeutic process. In the following paragraphs, we provide a brief review of salient outcome research on two of the most widely studied mindfulness-based clinical interventions: MBSR and MBCT, and we discuss research on two other approaches that integrate mindfulness as a part of the therapeutic intervention (dialectical behavior therapy, acceptance and commitment therapy). As described earlier, one of the rst and most cited mindfulness intervention programs in the literature is MBSR, designed in the 1980s by Kabat-Zinn, who originally coined it stress reduction and relaxation program, or SR-RP (KabatZinn, 1982). Compared with other treatment interventions of its kind, MBSR has been subjected to the most empirical testing and has garnered the most evidence supporting its effectiveness. A number of independent studies demonstrate that this outpatient, 8- to 10-week intervention signicantly improves participants psychological functioning and reduces distress across a variety of domains, from increasing self-compassion to reducing binge-eating behavior (Birnie, Speca, & Carlson, 2010; Hlzel et al., 2011; Kristeller & Wolever, 2011). One study in particular evaluated an intervention program modeled closely after MBSR that aimed to reduce and prevent stress symptoms in a nonclinical population of 28 undergraduates (Astin, 1997). This study is noteworthy because it used a randomized control design, which is generally lacking in the mindfulness research literature. Participants were randomly 99

Research and Empirical Support

Within the past 30 years, there has been a proliferation of research investigating mindfulness training, and this body of literature is rapidly growing. Many researchers across various specializations have designed and tested interventions that either incorporate or are based on mindfulness techniques. Overall, results support the use of mindfulness for many clinical conditions, such as panic attacks (Miller et al., 1995), and with nonclinical populations along dimensions such as empathy and self-esteem (Hlzel et al., 2011), emotion regula-

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Brown, Marquis, & Guiffrida assigned to either an experimental group that received MBSR or a waitlist control group. After the 8-week period, participants in the experimental condition experienced signicantly greater reductions in overall psychological symptomatology, increased overall domain-specic sense of control, increased use of an accepting control mode in their lives, and had higher ratings on a measure of spiritual experiences. Although similarly encouraging results have been published from many other studies of mindfulness-based approaches, a well-controlled evaluation such as this instills greater condence in the outcomes. The small, almost entirely female sample, however, was one methodological weakness of the Astin (1997) study. Also, like most published mindfulness research, this study used a waitlist control design instead of an alternate control group design (e.g., health skills training), which did not allow the researchers to distinguish between the effects of group membership and mindfulness training more specically. These results simultaneously highlight the need for comprehensively sound methodology and provide preliminary support for mindfulness as an effective intervention. MBCT is another frequently and comprehensively evaluated MBI in the literature. Unlike MBSR, however, MBCT was specically designed as a prophylactic, psychotherapeutic intervention. Originally developed to prevent relapse in people with recurrent major depressive disorder (MDD), this program combines elements of cognitive therapy with MBSR training, and its techniques are taught in groups of up to 12 participants that meet for eight weekly sessions. Participants are instructed to complete various daily homework exercises on their own that are intended to cultivate a mindful cognitive processing mode. The aim of MBCT is to foster what the authors call metacognitive awareness, metacognitive insight, or a cognitive set in which negative thoughts and feelings are seen as passing events in the mind rather than as inherent aspects of self or as necessarily valid reections of reality (Teasdale et al., 2002, p. 285). This approach is essentially a delimited use of mindfulness in that it focuses most heavily on negative thoughts and feelings, in contrast to the entire range of ones internal and external experience. In a recent meta-analysis, Piet and Hougaard (2011) evaluated the effect of MBCT on recurrent MDD in remission. Six randomized controlled trial (RCT) studies were systematically screened and selected based on a specic set of inclusion criteria (e.g., RCT study published in a peer-reviewed journal). Data from a total of 593 participants with recurrent MDD in remission contributed to the nal analyses (74% women, mean age = 46). The authors found that MBCT participants relapsed signicantly less (38%) than control participants (58%), who received either treatment as usual (TAU) or placebo, for an overall mean risk ratio of 0.66. Two out of the six total studies compared MBCT to maintenance antidepressant medication (m-ADM); on the basis of the results from these two studies (Kuyken et al., 2008; Segal et al., 2010), Piet and Hougaard (2011) also concluded that because the risk of relapse associated with MBCT (45%) was not signicantly different than the risk of relapse associated with m-ADM (56%), MBCT is at least as effective as m-ADM for preventing depressive relapse. The authors further noted that MBCT appears to be a cost-efcient strategy when compared to m-ADM and may even require as few as 3 therapist contact hours per client. MBCT appeared to be particularly effective for individuals with three or more prior depressive episodes. However, for individuals with only two prior episodes of depression, the ndings indicated a nonsignicant trend in favor of TAU over MBCT (49% risk reduction). The authors suggest that while MBCT is clearly an effective prophylactic program for recurrent depression when an individual has had three or more prior episodes, future research is required to better understand the distinct responses of certain subgroups (e.g., those with low versus high risk of relapse, those whose relapses are triggered by signicant life events in contrast to ruminative thinking). Teasdale et al. (2002) compared the effect of MBCT to TAU in a study in which participants with a history of recurrent major depression were randomly assigned to either group. In the TAU condition, participants sought help from their family doctor or other sources as they normally would. The authors noted that the MBCT program is intended to cultivate metacognitive awareness (a change in ones attitudes toward or relationship with ones thoughts) in participants without any explicit attempts to change the content of ones beliefs or thoughts. Following the intervention, metacognitive awareness, as measured by the Measure of Awareness and Coping in Autobiographical Memory (MACAM), was signicantly greater in the MBCT group compared with that in the TAU group. Furthermore, compared with TAU, MBCT signicantly reduced relapse in major depression for participants with three or more previous episodes. In a similar RCT study reported in the same article, these authors compared cognitive therapy to antidepressant medication and demonstrated that lower levels of metacognitive awareness predicted earlier relapse. Not only did cognitive therapy signicantly reduce relapse compared to antidepressant medication, it also signicantly increased metacognitive awareness as measured by the MACAM. While Teasdale et al. (2002) were able to perform only partial mediation analysesbecause of the timing of assessmentstheir results suggested that both cognitive therapy and MBCT may operate through the same mechanism of increasing metacognitive awareness. It appears that MBCT, however, has the power to signicantly reduce relapse in MDD without attempting to change the content of beliefs in negative thought patterns or in the underlying assumptions of those thought patterns. Instead, increased mindfulness, or metacognitive awareness, in itself, seems to lead to reductions in relapse rates. Although this study did not compare the cost-effective MBCT group program

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Mindfulness-Based Interventions in Counseling with traditional individual cognitive therapy, these results inform a comparison of the two approaches. Two other cognitive behavior approaches that integrate mindfulness into their therapeutic strategies are DBT (Linehan, 1993) and ACT (Hayes et al., 1999). While there is insufcient research to conclude that ACT is more effective than other active psychotherapy treatments (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), that is far from the case for DBT; in fact, a growing body of well-controlled studies is establishing DBT as a particularly effective modality for clients with borderline personality disorder and a history of suicidal behavior (Linehan et al., 2006). Mindfulness also appears to be relevant to culturally diverse clients. According to Miller et al. (1995), [Mindfulness] . . . is something that virtually all participants are capable of if sufciently motivated (p. 197). Likewise, Christopher and Maris (2010) argued that the experience of mindfulness is universal and found in virtually all cultural, spiritual, and religious traditions (p. 115). Although the cultivation of mindfulness in individuals with extreme cognitive impairment, profound developmental disability, or severe psychological disturbance (e.g., psychosis), may be more difcult, it seems fair to assume that anyone with intact, basic cognitive functioning should be capable of cultivating his or her attention in this manner. For example, Singh et al. (2011) described successfully using mindfulness with adolescents with autism to self-manage physical aggression. Although there is evidence that the open, insight-oriented forms of mindfulness (e.g., Vipassana) are contraindicated for individuals who are suicidal, have recently suffered a trauma, or are suffering from underregulated ego functions (i.e., a highly unstable, emotionally vulnerable, or fragmented sense of self), concentrative forms of meditation appear helpful to such people (Boorstein, 1997). Several measures of mindfulness have been created to operationalize and assess the construct and can serve as useful tools to monitor clients changes in mindfulness over the course of treatment. One of the most widely used of these measures is the Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006), a 39-item self-report measure designed to assess ve factor analytically derived facets of the broader construct of mindfulness: observing, describing, acting with awareness, accepting without judgment, and nonreactivity. The FFMQ takes roughly 10 minutes to complete. The items (e.g., I think some of my emotions are bad or inappropriate and I should not feel them) are rated on a 5-point Likert scale from 1 (never or very rarely true) to 5 (very often or always true). In a study assessing the psychometric properties of the FFMQ, 1,017 individuals completed the questionnaire, including regular meditators, demographically similar nonmeditators, nonmeditating undergraduates, and a community sample of nonmeditators (Baer et al., 2008). Results indicated adequate to good internal consistency (alpha coefcients ranged from .72 to .92). Even when controlling for age and education level, results supported the construct validity of the FFMQ; meditation experience was signicantly and positively correlated with four of the mindfulness facets (all except acting with awareness; correlations ranged from .14 to .35). All facets except observing demonstrated incremental validity in predicting psychological well-being, together accounting for 39% of the variance in scores on the Ryff (1989) Scales of Psychological Well-Being. Although the FFMQ has not yet been validated with socioeconomically diverse samples or individuals who are new to meditation, it is presently one of the leading instruments for assessing mindfulness. A second popular instrument is the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003), which is intended to measure dispositional or trait mindfulness specically open or receptive present-moment awareness. Each of its 15 items (e.g., I rush through activities without being really attentive to them) represents mindless states and is rated on a 6-point Likert scale. The MAAS has a unidimensional factor structure and takes roughly 5 minutes to complete. In a sample of 414 undergraduates, Van Dam, Earleywine, and Borders (2010) reported good internal consistency for the MAAS (Cronbachs alpha of .88). Brown and Ryan (2003) reported high testretest reliability in a sample of undergraduates (intraclass correlation of .81) and signicant differences in the MAAS scores of experienced Zen meditators when compared with those of matched nonmeditators, t(98) = 2.45, p < .05, Cohens d = .50. Both the MAAS and the FFMQ are accessible and free to download online (www.mindfulnessandacceptance.vcu.edu/ tools.html). Other instruments have been designed to measure mindfulness also, including the Freiburg Mindfulness Inventory (Walach, Buchheld, Buttenmller, Kleinknecht, & Schmidt, 2006), the Kentucky Inventory of Mindfulness Skills (Baer, Smith, & Allen, 2004) and the Cognitive and Affective Mindfulness Scale (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007). Mindfulness assessments intended for children have also emerged, such as the Child and Adolescent Mindfulness Measure, a 10-item questionnaire designed for youth over age 9, which has demonstrated preliminary evidence for adequate reliability and convergent and discriminant validity (Greco, Baer, & Smith, 2011). As with most measures using self-report data, counselors using these instruments with clients should keep in mind that self-report measures of mindfulness can be limited by individuals abilities to accurately report their states of mind. Research suggests that construct validity may be threatened both by a general lack of meta-awareness regarding ones absence of mindfulness as well as a response bias to deny these mindless states (Van Dam, Earleywine, & Danoff-Burg, 2009). Notwithstanding these potential limitations, the assessment instruments described earlier provide counselors with useful tools for assessing baseline levels of mindfulness and the efcacy of their mindfulness interventions over time. 101

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Brown, Marquis, & Guiffrida

Conclusions and Implications

Is it possible that mindfulness is something of a panacea, akin to cardiovascular exercise, in its ability to improve wellbeing across multiple domains? A closer examination of the literature reveals that while mindfulness training indeed seems to be effective in improving well-being and reducing distress, researchers agree that it should not serve to replace widely used or empirically supported therapies; rather, it is likely most effective for clients when integrated with other counseling approaches. Relatively speaking, mindfulness is a newcomer in the eld of counseling outcome research. Consequently, it is not surprising that a number of researchers have called for better controlled studies, operational denitions of the constructs, and reliable assessment tools (Fjorback, Arendt, rnbl, Fink, & Walach, 2011). There is also a need for studies that compare mindfulness training both to active control conditions and to conventional counseling approaches such as cognitive behavior therapy, to both ascertain comparative effectiveness and discern the active ingredients of MBIs. Furthermore, researchers should explore the effectiveness of mindfulness training when incorporated into individual counseling sessions. One underdeveloped topic of particular interest involves the long-term effect of mindfulness practice. One wonders, for example, does an 8-week mindfulness training intervention such as MBSR produce lasting change for clients, or is some level of ongoing, intentional (i.e., consistent and disciplined) practice necessary? Some studies have demonstrated lasting positive outcomes as far as 3 years postintervention (Miller et al., 1995). One explanation, posed by Epstein (1995), is that once mindfulness has been developed, the self can never be thought of in the same spatially based manner again. Mindfulness is seen as the pivotal ingredient, the catalyst for a profound change in the way self is experienced (p. 142). While research has not yet unequivocally demonstrated this assertion, the effects of mindfulness training tend to hold up quite well when evaluated in follow-up studies. However, further research is required to examine the long-term effect of mindfulness as a function of the duration and intensity (how much time per day) of practice (e.g., with longer follow-up periods and detailed data collected on practice behavior). Additionally, although a great deal of research has been published on the application of mindfulness training to certain specic populations (e.g., depressed clients, females), few studies have included an ethnically diverse clientele. For instance, only one study in a meta-analytic review of 21 MBIs focused on an inner-city or Latino population (Baer, 2003). Similarly, the vast majority of MBI research is conducted with adults ages 18 to 65; the literature on younger children and older populations is far less developed (Greco et al., 2011; Splevins, Smith, & Simpson, 2009). Future research is needed to study the effects of mindfulness with more diverse groups of clients. 102

Another limitation of the current mindfulness literature is that most articles fail to discuss the qualications, training, or standards for counselors to use mindfulness skills with their clients. How do we ensure that intervention programs are designed and taught by competent people with an adequate understanding of mindfulness practice? Addressing this issue, Baer (2003) pointed out that the literature as a whole does a poor job of assessing and communicating the integrity of these interventions, which is evident, for example, in the omission of descriptions regarding counselors training in mindfulness and the delity with which the interventions are implemented. This concern is related to the problem of assessment and measurement: How are we to assess the various dimensions of mindfulness, including the integrity of the instruction and each individual clinicians knowledge and understanding of the practice? Many important questions for future research remain, such as Is there a certain level or threshold of mindfulness practice required for clients or counselors to reap substantial benets? If so, what is that threshold? Are certain types of clients more likely to respond positively to mindfulness practices? Are specic practices that use mindfulnessfrom meditation and yoga to Qigong and body scanmore effective for different types of people? How does living mindfully affect counselor self-care, compassion fatigue, and burnout? What is preventing more counseling training programs from implementing mindfulness in their training? What are the best ways to do so? Despite its limitations as an emerging area within the eld of counseling, research in mindfulness has sparked growing interest, and it seems clear that its application as a counseling intervention is powerful and widely applicable. Whether being used to augment traditional counseling approaches or as a stand-alone prevention strategy, mindfulness has demonstrated great promise and warrants further investigation.

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