For the first years of this century, mindfulness-based interventions generated a lot of enthusiasm from the general public and researchers alike. Research on mindfulness treatments for education, health, and mental health increased exponentially (Farias & Wikholm 2016). Recently, however, reviews of mindfulness-based interventions have re-assessed the data, especially because of small effect sizes and a lack of real control conditions (Farias & Wikhom 2016). A serious, methodological problem common to most of the studies is the lack of a standard operational definition for mindfulness (Lutz 2015).
One of the most studied treatments, Mindfulness Based Stress Reduction (MBSR) includes formal meditation, body scan, and non-strenuous yoga, as well as listening to guided meditations (Kabat-Zinn 1990). Participants may do these practices for anywhere from ten to forty-five minutes each day (Kabat-Zinn 1990). MBSR has been shown to improve coping with stress and chronic pain, among other benefits (Praessman 2008). A similar treatment, Mindfulness Based Cognitive Therapy for Depression (MBCT), has been shown to be helpful with recurrent depression (Van Aalderen 2012). MBCT also employs mindfulness meditation and guided meditations (Segal et al 2013).
It is challenging to compare MBSR and MBCT to other treatments that include mindfulness but are structured differently, such as DBT. DBT does not teach mindfulness meditation but instead focuses on mindful awareness in daily life through use of the “what” and “how” skills (Linehan 2014). DBT does have certain traits in common with MBSR and MBCT, however, in that they all encourage the practice of unbiased, intentional observing (Linehan 2014, Kabat-Zinn 1990, Segal 2003). As of yet, there are no studies that specifically examine what role DBT mindfulness skills play in the treatment’s overall effectiveness.
Self-report measures of mindfulness offer another framework for understanding how mindfulness research can inform our teaching. These measures look at specific characteristics ascribed to mindfulness such as awareness in the moment and acceptance of internal experiences. Because there are individual differences in the ability to be present and non-reactive, one client may look very different from another at the outset of treatment. Measuring these differences at baseline and during treatment may help us understand our clients better and improve our mindfulness teaching.
How is Mindfulness Measured?
There are two aspects of mindfulness we should recognize: state mindfulness and trait mindfulness. State mindfulness is the actual experience of being focused in the present moment, awake and aware, and not evaluating or reacting to our experience (Shapiro 2011). Trait mindfulness is how much a person tends to be mindful, even when they aren’t really trying (Shapiro 2011). State mindfulness is what we hope clients will experience in the short exercises we lead in DBT skills group. Trait mindfulness is what we hope our clients will develop over time through skills generalization.
As early as 2012, there were eight validated measures of mindfulness for adults (Bergomi et al, 2012). While each measure is different, they do have some characteristics in common. I’d like to highlight three measures that relate to what we teach in DBT skills group.
The Five Factor Mindfulness Questionnaire (FFMQ), originally called the Kentucky Inventory of Mindfulness Skills (KIMS), is one of the oldest measures and was first developed to measure increases in mindfulness in DBT participants. As a result, it uses some terms quite familiar to DBT therapists (Baer 2004). The FFMQ includes five factors: observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience (Baer 2008). In DBT skills class, we teach each of these factors explicitly with the exception of the last one, which we target more in individual therapy. We know these states can be learned with lots of practice, even by highly dysregulated persons (Baer 2004, Linehan 2014).
A second measure of mindfulness, the Toronto Mindfulness Scale, asks people to participate in a meditation exercise and then answer ten questions about their experience (Lau 2006). Originally a measure of state mindfulness solely, the instrument measures two factors, curiosity about inner experiencing and “decentering,” or the ability to step back from negative thoughts, emotions, and bodily sensations that arise during an exercise. Curiosity (in contrast to experiential avoidance) and decentering (in contrast to restructuring) are key concepts in cognitive therapy (Lau 2006). Curiosity has similarities to “mindfulness of current emotion” and decentering is similar to “Teflon mind” in DBT. When we are teaching these skills, we are actually building the experience of state mindfulness (Lau 2006). A later version of the Toronto Mindfulness Scale incorporated questions that measure trait mindfulness (Davis 2009).
Probably the simplest measure of mindfulness, the Mindful Attention Awareness Scale (MAAS), uses one factor called attention and awareness, which measures mindfulness over cognitive, emotional, physical, and general domains with 15 questions. Using the MAAS, one can measure a person’s baseline “trait” mindfulness, such as how much they act on autopilot or how closely they pay attention to the present moment while undertaking daily tasks. High trait mindfulness, as measured using the MAAS, is associated with lower reactions to stressful situations (Weinstein 2009) and improved mental health outcomes (Shapiro 2011). Further, the practice of state mindfulness appears to increase trait mindfulness (Shapiro 2011).
Applying the Research on Mindfulness
Our clients who experience pervasive emotion dysregulation often exhibit low trait mindfulness at the outset of treatment (Baer 2004). However, as we teach observing and describing and entering into the moment nonjudgmentally, we are instructing clients in how to experience state mindfulness. The more they practice state mindfulness by observing, describing, or acting in awareness, the more they develop their trait mindfulness. In research measuring MAAS, high levels of trait mindfulness have been shown to help people cope better with stress, reduce depressive relapse, and improve well-being (Shapiro 2011).
Why mindfulness is associated with these outcomes is not fully understood. One hypothesis is that actually experiencing the present moment as it is, whether you are having your blood drawn or waiting to hear about a job application, is less stressful than ruminating, worrying, or trying to avoid your experience in the moment. What if it turns out that just accepting the moment over time can change your life for the better? I recommend you share this hypothesis with your clients. It just might build motivation to practice these skills daily until they become traits.
And what about our own practices? I like to consider how I am cultivating trait mindfulness by really listening with my full awareness in session and bringing my attention back again and again to present-moment awareness, even if I’ve been feeling bored, irritated, or distracted. Also, when I notice my inner experience non-judgmentally and do not react to it or push it away, I feel my mindfulness muscles getting stronger, whether I am seated on my cushion at home or coaching a client over the phone. Stronger mindfulness traits increase my appreciation of the moment, decrease my burnout, and make me a better therapist. And that means I enjoy my life more!
For more on mindfulness, read here.
Cedar Koons, MSW, LISW, is the co-founder and team lead of Santa Fe DBT, LLC, an outpatient private practice group that provides comprehensive Dialectical Behavior Therapy (DBT) and other evidence-based cognitive-behavioral treatment to adults and adolescents in Santa Fe, New Mexico. A senior trainer for Behavioral Tech Institute, she has conducted DBT trainings, intensives and consultations all over the United States and in Australia and Japan. While in private practice, Ms. Koons has also developed an adaptation of DBT for the vocational rehabilitation of persons with severe personality disorder and conducted a pilot study of the treatment. A meditation student of Pat Hawk, Roshi, and Sensei Marsha Linehan, Ms. Koons has also taught mindfulness and assisted with many mindfulness retreats. Read more about Cedar Koons here.
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