Training Teachers to Deliver Mindfulness-Based Interventions: Learning from the UK Experience

North America and the UK have had different developmental pathways in this time of expanding interest in mindfulness-based interventions. Within the USA, the potential for mindfulness-based interventions reached public attention from the late 1980s onwards through Jon Kabat-Zinn’s work in developing MBSR as an addition to participants’ existing medical care (Kabat-Zinn 1990). MBSR is offered as an eight-session generic skills training course for people with a wide range of physical and psychological conditions. Participants engage in an intensive training in mindfulness meditation, which they learn to apply to the challenges of their daily lives. From the beginning, the effectiveness of the work was demonstrated through both open and randomised research trials and the program was the subject of a high-profile television program (Moyers 1993). In addition, a series of books for the general public describing the potential of mindfulness were very impactful (e.g., Kabat-Zinn 1990, 1994, 2005). All this triggered a groundswell of interest from the general public and health care professionals.

The developmental path has been different in the UK. Here, a dramatic expansion in interest was driven by the publication in 2000 (Teasdale et al.) of the results of the first clinical trial of MBCT for the prevention of relapse in depression, the publication of the treatment manual (Segal et al. 2002), and the subsequent account of MBCT for the general public (Williams et al. 2007). Although this particular research was confined to depression, it triggered (particularly within mental health professions) interest in the potential range of applications of mindfulness-based interventions. Similar to MBSR in its form, structure, and teaching style, MBCT integrates aspects of CBT for depression into the MBSR program, thus targeting the learning towards particular client populations. The early research on MBCT was in relation to its effectiveness not in treating acute depression but in preventing depression for those known to be vulnerable to recurrence. MBCT is now being researched and used with people with a range of other conditions including chronic fatigue (Surawy et al. 2005), residual depression (Barnhofer et al. 2009; Eisendrath et al. 2008; Kingston et al. 2007), suicidality (Williams et al. 2006), and cancer (Bartley in press). Alongside these developments, supported by visiting teachers from the Center for Mindfulness in Massachusetts, USA, there has been a corresponding expansion of interest in the use of MBSR in the UK.

Research has demonstrated that MBCT halves the relapse rate in recovered patients with three or more episodes of depression (Ma and Teasdale 2004; Teasdale et al. 2000) and produces outcomes comparable to maintenance antidepressants (Kuyken et al. 2008). MBCT is now recommended by the UK’s best practice advisory board for the NHS-NICE (National Health Service-National Institute for Health and Clinical Excellence) — as a treatment of choice for preventing future depression in those individuals who have experienced three or more episodes (NICE 2004). NICE’s recommendation of a new evidenced-based psychological therapy does not immediately translate into its availability on the ground to NHS patients. It does, though, have the effect of raising interest and expectations in a new approach amongst health care professionals and the general public. We find ourselves in the middle of a wide gap. On the one hand, there is plentiful grassroots interest in mindfulness-based approaches as demonstrated by patients wanting to access the approach, GPs wanting to refer patients (Mental Health Foundation 2010 — see also www.bemindful.co.uk), and increasing numbers of trainees joining training programs. On the other hand, there are too few teachers who are competent in its delivery and a lack of organisational and service commissioning support for the integration of mindfulness into psychological therapy service provision. Increasing the capacity to deliver MBCT takes time and, given the particular nature of the approach, also requires particular thought and care.

All psychological approaches place a strong emphasis on the importance of rigorous therapist training. Indeed, there is evidence that certain training methodologies and longer trainings for cognitive therapy trainees deliver more effective outcomes for clients (e.g., Shafran et al. 2009). Mindfulness-based interventions are no different — the consistent and strong stance held by Kabat-Zinn and others who have followed is that the quality of the teaching (and therefore the training of the teacher) is a key ingredient associated with the delivery of successful outcomes for participants. The distinctive aspect of this in the current context is the emphasis placed on a particular form of development process — the teacher’s embodiment of the key ‘therapeutic ingredients’ of MBCT/MBSR and the personal mindfulness practice that supports this. Alongside developing competence in the ‘technicalities’ of delivering the approach, teachers engage in a highly personal process of exploring their own experience through the lens of their mindfulness practice on a continuing basis. This represents a shift in emphasis from other CBT approaches, in which there is a strong emphasis on the therapist developing skill and expertise, but less emphasis on personal practice as an essential aspect of the therapeutic encounter. The rationale for this priority placed on the mindfulness-based teacher’s embodiment and personal mindfulness practice is discussed below. To offer context for the discussion, we turn now to an overview of the distinctive origins of mindfulness-based applications and to the ways in which the influence of the mindfulness-based teacher is addressed in the literature.

Kabat-Zinn (1990) pioneered the integration of mindfulness practice and teaching with contemporary approaches to stress and life challenges in his creation of the MBSR program. In this process, he drew on his own experiential immersion in mindfulness practice in the Buddhist tradition and on the scientific tradition in which he was trained. Kabat-Zinn also drew on medical and clinical understanding and a particular pedagogical approach to experiential learning. In this process, some very different intellectual and learning environments found themselves cohabiting. On the one hand, the medical, scientific paradigm emphasises theory, translating theory into practice, the cost-effectiveness of interventions, a focus on health outcomes, and a quest for ‘evidence-based practice’; on the other, the meditative contemplative paradigm emphasises the cultivation of particular ways of being, non-attachment to outcome, non-striving, and an apparently paradoxical turning towards painful experiences with an attitude of acceptance. On the face of it, these are unlikely bedfellows. There are tensions inherent in the process of applying a paradigm that emphasises measurement and outcome to a paradigm that has many dimensions that appear inherently unquantifiable. As challenging and complex as this process is, these integrations are informing an enriching discourse (McCown and Reibel 2009). When training mindfulness-based teachers, a key aim is to enable them to draw skilfully from each of these streams of learning (Box 1).

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The literature on the pedagogy of mindfulness-based approaches places considerable emphasis on the paramount importance of the teacher embodying the spirit and essence of the meditation practices being taught — of how this is the vehicle through which the teacher communicates the radical potential of bringing mindfulness to personal experience (e.g., Crane 2009; Kabat-Zinn 1990, 2003, 2005; McCown and Reibel 2009; Kabat-Zinn and Santorelli 2005; Segal et al. 2002). By contrast, within the outcome and effectiveness literature on mindfulness-based interventions, there is a dearth of information on the influence of the teacher — the emphasis (as in much of the literature on psychological approaches) is on the ingredients of the approach itself. Within the psychotherapy literature, there is an example of an exception to this. A randomised controlled trial of psychotherapists gives a strong indication that if psychotherapists meditate before therapy sessions, the treatment outcomes for their clients are more positive (Grepmair et al. 2007). Two influential meta-analyses of mindfulness-based interventions (Baer 2003; Grossman et al. 2004) highlight the lack of investigation of treatment fidelity and teacher effects. Indeed, these review conclusions are examples of a general movement within the wider literature on psychological interventions, towards greater acknowledgement of the importance of taking treatment fidelity into account when investigating effectiveness of an approach and when making the transition from research to everyday clinical practice.

Direct experience through clinical observation consistently indicates that teachers’ personal engagement with mindfulness practice offers a basis from which they can develop the required competencies — that they are effectively not in a position to facilitate others in cultivating mindfulness, if they themselves have not brought it into their personal way of living and working. It is clear also that the impressive research findings to date are based on outcomes created by teachers who have experience and who personally draw on the foundations that gave rise to mindfulness (Kabat-Zinn 2003; Teasdale et al. 2003). Until there is empirical evidence backing up the key importance of particular competencies, there is some room for open-minded scepticism in this area, but current best practice by individuals and organisations offering mindfulness-based teacher training is based on the understanding that distinctive and particular training processes are required.

In summary, there is no clear evidence base detailing the elements of mindfulness-based teacher competence and its relationship to participant outcome and there has been little theoretical development and empirical research on the training of mindfulness-based teachers. There is, though, a body of literature written primarily by MBCT/MBSR teachers in the field drawing on their direct experience of the process, within which there are clear descriptions of the essential elements of competence and a consistent emphasis on certain values that underpin the teaching process. An overarching principle is that the central mechanism through which mindfulness-based approaches have their effect is through enabling participants to be able to choose to shift from a ‘doing’ to a ‘being’ mode of mind, that this learning is communicated in the class through the teacher's direct personal experience of ‘being’, and that this experience is gained through mindfulness meditation practice.

A key understanding that underpins mindfulness-based clinical practice is that our mind can operate in different modes (Williams 2008). Participants are learning that the avoidant and ruminative patterns of mind that trigger and maintain their depression, their stress, or other psychological distress are maladaptive aspects of their ‘doing’ mode of mind. They begin to see that any strategies they employ that involve further engagement of the thinking, conceptualising, problem solving, analytic ‘doing’ mode of mind can serve to keep the depression or stress-producing patterns and tendencies in play. Participants are learning to step aside from the struggle with these patterns by approaching them in a completely new way — through ‘being’ mode of mind.

The intention of the particular style of the teaching process in a mindfulness-based class is to create the conditions in which participants can sample this new doorway to their experience — this ‘being’ mode of mind. Rather than processing experience through the medium of their conceptual, analytic mind, participants are developing the skill to approach experience through a new mode — anchoring the attention to a present moment awareness of physical sensations to enable a disengagement from a ruminative avoidant style of processing, followed by an engagement with an acceptance-based, approach-orientated style of experiencing. Two means are employed to facilitate this process. First, participants both within the sessions and daily as part of their home practice engage in mindfulness meditation practice, which offers repeated opportunities to develop the skills of attending to experience in this new way. Second, this new orientation is communicated in the class through the teacher demonstrating it in action within the process of the teaching: the teachers themselves are in the mode that participants are being invited to experiment with. This process of ‘embodiment’ is a key feature of the teaching in a mindfulness-based class; it influences every aspect of the delivery of MBSR/MBCT and, thus, consequently, the training of the teachers who will be delivering it. Teachers are thus able to teach others about being mode through their own personal familiarity with it so that the whole teaching process becomes an ‘in vivo’ experience of mindfulness. Segal et al. (2002, pp. 65–66) write that: “The MBCT instructor’s own basic understanding and orientation will be one of the most powerful influences affecting this process [helping individuals make a radical shift]. Whether the instructor realises it or not, this understanding colors the way each practice is presented, each interaction handled.”

It is through their own personal mindfulness practice that MBSR/MBCT teachers develop this familiarity and the confidence in the use of mindfulness as an effective and tenable way of working with personal challenge. This confidence gained personally — direct knowing of the ‘landscape’ of ‘being’ mode — becomes an important ingredient, which enables the teacher to persist when supporting MBSR/MBCT participants who are struggling with the real challenges inherent with bringing mindfulness to their experience. The depth of experience that teachers have in exploring their own personal process through their mindfulness practice and through other personal development processes is thus held to be directly related to their ability to ‘meet’ the participants in a mindfulness-based class in this radically new way, thus creating a space in which participants can inquire into the actuality of their experience with compassion and free from the constraints of the inevitable ideas that arise about what could or should be happening. Following the lead therefore of the Center for Mindfulness at the University of Massachusetts Medical Center where Jon Kabat-Zinn and colleagues originated MBSR, the training programs that are developing in the UK context also place considerable emphasis on the development of ‘the person of the teacher’ through fostering an engaged inquiry into personal experience through mindfulness meditation practice (Box 2).

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Having explored some principles underpinning mindfulness-based teaching and teacher training, we turn to a description of what a mindfulness-based teacher training program looks like in practice.

The aims and intentions of this stage are to put in place the basic building blocks for teaching mindfulness-based classes at an advanced beginner level, with appropriate ongoing supervision.

An additional requirement for trainees planning to teach MBCT is training in a structured evidenced-based psychotherapeutic approach such as cognitive behaviour therapy.

These characteristic phases of training are represented in Fig. 1.

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1. 4.

   Continuing professional development

    

Using the characteristic teaching style employed within MBSR and MBCT courses and teacher training programs (guided formal practice in sessions and at home, interactive dialogue between participants and teacher, group exercises and explorations), these three elements of personal engagement with practice offer the practitioner a comprehensive methodology through which to explore experience. They are also a way of offering mindfulness practice in a secular way that ensures that the critical aspects of mindfulness (within its original Buddhist context) known to bring about change are not lost (Teasdale et al. 2003).

A key part of an MBSR/MBCT teacher training process is an engagement with an inquiry into the ways in which the approach enables participants to effect changes in their lives that reduce symptoms and the occurrence of existing conditions and increase general well-being and life skills. This takes place in two broad ways. Firstly, through engagement with a personal mindfulness practice: this enables an investigation on a personal level of what arises during moments of inattention (mindlessness or automatic pilot) and during moments of mindfulness as kindly attention is brought to the unfolding of experience, and through the recognition of the universal nature of these mind patterns. In this way, trainees are engaging in an exploration of the general vulnerability that we all carry by nature of being human. Mindfulness practice and teaching illuminate our understanding of the traits (shared by all humans) that tend us towards unhappiness and distress (for example, our use of language, our ability to operate in automatic pilot and to move our thought processes into the past and the future, and our physiological response to threat that does not discriminate between internal and external stimuli). The practice also offers us a way of working with these traits — enabling us to recognise them for what they are, thus reducing our tendency to add suffering to unavoidable pain (Williams 2008).

A mindfulness-based class offers participants a series of experiential learning opportunities. There is then a dialogue with the participants to draw out their experience of these and to support them in connecting their direct experience to a context of learning, which is relevant to their daily life. Mindfulness-based teacher training processes are no different. Through the participatory, experiential nature of the teaching process, trainees are highly active in their own learning. A key ingredient of this is the opportunity to practice teaching skills and to receive structured feedback on this. Importantly, these teaching practice sessions are also used as a springboard from which trainees can inquire more deeply into their own process and through this to attune their ability to pay attention to the inner and outer processes that affect the teaching. This process offers a built-in supervisory experience as trainees gradually build their skills and confidence first with the training group and then with client groups.

There is a broad consensus amongst the training courses represented by the authors on the competencies that need to be developed by teacher trainees (Crane et al. in press), and the framework outlined above elucidates a well-tested method for developing these. It is also clear that practitioners develop these competencies through other means than engagement with formal training programs. An alternative training model that some follow either alongside a formal course or as an alternative is an informal apprenticeship process. This typically involves participating in an 8-week course, developing a personal mindfulness practice, taking the 8-week course again from a perspective of ‘participant-observer’ (experiencing from the inside whilst simultaneously seeing the wider process of teaching and learning), assisting an experienced mindfulness-based teacher and receiving mentoring on this, and repeating this process while gradually taking on more direct responsibility for the teaching process. It is worth noting that as formal training programs in mindfulness-based approaches are relatively new, the developers of MBSR and MBCT (first-generation teachers) and now trainers (second-generation teachers) themselves went through this process just described.

What are the particular areas that need to be addressed by the field now to support good-quality expansion of mindfulness-based training and clinical opportunities in the future? In this final section, we briefly describe the current status of MBSR/MBCT training opportunities in the UK, discuss some of the challenges faced by the organisations delivering training, and explore some potential directions for the future.