Keywords

Over the past three decades, there has been significant growth of interest within the scientific and medical community in the application of mindfulness as a psychological intervention to enhance physical and psychological health. One of the most commonly cited definitions of mindfulness is the awareness that arises through “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). Whereas other definitions of mindfulness have been proposed (e.g., see Baer, 2003; Bishop et al., 2004; Brown & Ryan, 2003), current conceptualizations point to two primary, essential elements of mindfulness: awareness of one’s moment-to-moment experience nonjudgmentally and with acceptance (Keng, Smoski, & Robins, 2011). The word mindfulness may be used to describe a psychological trait (i.e., the extent to which individuals are mindful in their daily life), a systematic practice for cultivating mindfulness (e.g., mindfulness meditation), a mode or state of awareness, or a psychological process (Germer, Siegel, & Fulton, 2005). The practice of mindfulness, in particular, involves the ability to voluntarily direct one’s attention to the present moment experience and adopting an attitude of nonjudgment and curiosity toward the experience. As William James (1890) acknowledged in the paragraph quoted above, the ability to voluntarily bring back a wandering attention is integral to one’s character development. Not only that, such ability is also a crucial aspect of good clinical practice, psychotherapy, and/or delivery of clinical services.

Numerous studies have demonstrated that trait mindfulness is associated with a variety of indicators of psychological health, such as higher levels of life satisfaction (Brown & Ryan, 2003), vitality (Brown & Ryan, 2003), self-esteem (Brown & Ryan, 2003; Rasmussen & Pidgeon, 2011), empathy (Shapiro, Schwartz, & Bonner, 1998), and pleasant affect (Brown & Ryan, 2003), as well as lower levels of depression (Brown & Ryan, 2003; Cash & Whittingham, 2010), neuroticism (Dekeyser, Raes, Leijssen, Leysen, & Dewulf, 2008; Giluk, 2009), rumination (Raes & Williams, 2010), social anxiety (Brown & Ryan, 2003; Dekeyser et al., 2008; Rasmussen & Pidgeon, 2011), difficulties with emotion regulation (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006), and general psychological symptoms (Baer et al., 2006). A number of psychological interventions have also been developed based on practices and principles of mindfulness , notably mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1994), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002), dialectical behavior therapy (DBT; Linehan, 1993a), and acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999). Collectively, these interventions have been shown to be effective in improving psychological health in a variety of populations, ranging from nonclinical populations (e.g., healthy adults; Robins, Keng, Ekblad, & Brantley, 2012; Keng, Smoski, Robins, Ekblad, & Brantley, 2012), psychiatric populations such as patients with a history of depression (Ma & Teasdale, 2004; Teasdale et al., 2000) and patients with borderline personality disorder (BPD; Linehan, Amstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 2006), to medical populations, such as patients suffering from chronic pain (Kabat-Zinn, 1982) and cancer (Speca, Carlson, Goodey, & Angen, 2000).

While research has demonstrated the effectiveness of mindfulness-based practices and interventions in improving psychological health, little work has systematically explored the potential of mindfulness as a tool to promote treatment engagement. Treatment engagement refers to the extent to which clients participate and engage in treatment, and is reflected by various factors such as whether clients attend treatment sessions regularly and consistently, the duration of their participation in treatment, and the degree of alliance or bond established between them and the treatment provider. Treatment engagement is a crucial yet challenging part of treatment. Whereas much work in the health service field has emphasized the importance of treatment adherence (which concerns the extent to which a treatment delivered adheres to an established set of principles or protocol), relatively less attention has been given to importance of treatment engagement. The fact that the clinical utility of mindfulness has been well established suggests that it may have strong potential as a tool to facilitate treatment engagement. In particular, the degree to which a service provider is able to embody attitudes of mindfulness (i.e., being kind and nonjudgmental) as well as utilize mindfulness-based practices as appropriate in treatment may have subtle yet significant impact on a client’s ability to engage effectively in treatment.

The goal of this chapter is to highlight and discuss the potential of mindfulness as a tool to promote treatment engagement in clinical settings. The chapter will begin with a presentation of available research relevant to the value of mindfulness as a treatment engagement tool, followed by a discussion of different ways through which mindfulness may be utilized as a strategy to enhance treatment engagement. The chapter also provides a few specific examples of mindfulness exercises that a clinician may use to engage clients more effectively in treatment. The chapter will end with a discussion of cultural issues relevant to the implementation of mindfulness in treatment as well as resources that clinicians may consider if they are interested in receiving further training in mindfulness-based intervention approaches.

Research Relevant to the Potential of Mindfulness as a Tool to Facilitate Treatment Engagement

Research to date that suggests that mindfulness may be an effective tool for promoting clients’ engagement in treatment. First, there is evidence that the levels of trait mindfulness of treatment providers correlate positively with the quality and effectiveness of service delivered. One study involving four HIV speciality clinic sites in the United States (Beach et al., 2013) found that clinicians’ self-reported levels of mindfulness were associated with higher levels of patient-clinician communication quality, as assessed through audio-recorded measures and a widely established communication coding system. In particular, clinicians higher on trait mindfulness engaged in more rapport building as well as displayed more positive emotional tone when interacting with their patients. Patients of these clinicians were also more likely to give higher ratings on perceived communication quality and overall satisfaction with treatment. Trait mindfulness has also been correlated with lower levels of compassion fatigue (a phenomenon in which treatment providers experienced reduced capacity for empathy toward clients due to repeated exposure to their trauma; Adams, Boscarino, & Figley, 2006), and higher levels of compassion satisfaction among volunteers and professionals working with victims of trauma (Thieleman & Cacciatore, 2014). Taken together, these findings suggest that being mindful may enable one to be more effective in not only communicating with clients, but also in managing emotional challenges commonly experienced in certain lines of clinical work.

A number of studies have also examined the effects of systematic training in mindfulness on treatment providers’ well-being and ability to work with clients effectively. One study by Krasner et al. (2009) found that participation in an 8-week educational program in mindful communication was associated with improvements in empathy, mindfulness, burnout, emotional stability, and personal accomplishments among primary care physicians. Qualitative analysis of the findings showed that participants experienced improvements in their ability to be attentive and listen deeply to patients’ concerns, as well as respond to patients more effectively. Participants also reported experiencing reduced professional isolation and greater levels of self-awareness. In another controlled trial, primary care health professionals randomly assigned to an 8-session mindfulness course reported significant improvements in burnout, empathy, mindfulness, and mood disturbance, whereas no significant differences were observed in these variables in the control group (Asuero et al., 2014). Another study focusing on social work students further showed that incorporation of 10 min of mindfulness practice into each session of a class on clinical interviewing was associated with significant improvements in counselling self-efficacy among the students (Gockel, Burton, James, & Bryer, 2013). Further, a prospective, mixed-methods study that recruited clinical psychology trainees found that participation in an 8-week MBCT program predicted significant improvements in selected facets of mindfulness and empathy (Hopkins & Proeve, 2013). To sum up, these studies provide strong evidence that systematic mindfulness training results in beneficial changes on various dimensions of clinical skills relevant to treatment engagement, such as empathy and the ability to manage burnout.

In addition to examining clinician outcomes, research has also examined the effects of systematic training in mindfulness on clients’ ability to engage in and benefit from treatment . It is plausible that enhanced communication and degree of empathy with clients may facilitate higher therapy alliance, which may translate into greater overall efficacy of treatment. A randomized, double-blind controlled study conducted in Germany found that patients of psychotherapists in training (PiTs) who were randomly assigned to practicing mindfulness meditation reported significantly better evaluations for individual therapy (in terms of clarification and problem-solving perspectives) as well as greater overall symptom reductions, compared to patients of PiTs who did not practice mindfulness meditation (Grepmair, Mitterlehner, Loew, & Nickel, 2007). A form of mindfulness-oriented intervention, DBT , has also been shown across several trials to be more effective than treatment-as-usual or another active treatment in improving treatment adherence among patients with BPD (Linehan et al., 1991, 2006; Soler et al., 2009), a population known to have high rates of dropping out of treatment (e.g., see Bohus et al., 2004; Smith, Koenigsberg, Yeomans, Clarkin, & Selzer, 1995). While it is unknown the extent to which the higher rates of treatment retention observed among patients who received DBT were due to the mindfulness component of the intervention (given that the intervention consists of multiple components), this finding, along with that of other research, highlights the potential of mindfulness in enhancing not only clients’ engagement in treatment, but also the effectiveness of the treatment itself.

Mindfulness as a Tool to Facilitate Treatment Engagement

Whereas empirical research has highlighted the value of mindfulness as a tool to facilitate treatment engagement, little work has examined how mindfulness may be utilized in clinical practice or service delivery for the purpose of enhancing treatment engagement. The following section elaborates on two primary ways through which mindfulness can facilitate clients’ engagement in treatment: (1) through clinicians’ own embodiment of qualities of mindfulness , and (2) through explicit use of mindfulness practices, either as a standalone intervention or as a tool complementary to other strategies.

Clinicians’ Embodiment of Mindfulness as a Key Vehicle to Engage Clients

Within the literature on mindfulness-based interventions, there has been considerable emphasis on the importance of teachers (or instructors) of mindfulness-based interventions being able to embody the essence of mindfulness practices that they teach to clients (Crane, Kuyken, Hastings, Rothwell, & Williams, 2010). While the importance of clinicians keeping a regular, personal mindfulness meditation practice is not emphasized equally across different various mindfulness-oriented interventions (e.g., DBT ; Linehan, 1993a), it is generally acknowledged that key elements of mindfulness, such as the ability to be fully attentive to the experience in the present moment, as well as to relate to the experience with an attitude of kindness and nonjudgment , are important processes that affect the quality of a client’s experience with treatment. At a fundamental level, a client is likely not going to be very engaged in treatment if the clinician does not focus her attention fully on helping the client. Similarly, holding a judgmental attitude toward the client or his experience may result in treatment resistance on the part of the client. Therefore, to engage a client effectively in treatment, a clinician needs to bring her full presence into treatment and to relate to the client in a nonjudgmental manner, as best as she can.

There are additional ways through which embodying qualities of mindfulness may facilitate clients’ engagement in treatment. Clinicians who are mindful would likely be attentive to a client’s needs and perspectives, which would enable them to emphasize with the client and develop a strong therapeutic alliance. A client who feels supported and understood thus would likely be more willing to remain engaged in treatment. Further, as highlighted above, the ability to remain nonjudgmental is another important aspect of effective work with the client. This entails being aware of any conscious or subconscious biases one holds that may jeopardize the one’s relationship with the client, and being able to work with these biases so that they do not get in the way of treatment. Maintaining a nonjudgmental attitude may also encourage a client to open up more in general (as a client learns that she will likely not be judged if she expresses a more vulnerable aspect of herself), which would help deepen engagement in treatment. In several mindfulness-oriented interventions (e.g., MBSR and DBT ), being nonjudgmental is deemed as a key aspect of the delivery of treatment, and clinicians are explicitly trained to be nonjudgmental in their work with clients (e.g., through having a person who plays the role of a “watchdog,” who would ring a bell whenever expression of a judgmental attitude is observed in a DBT consultation team; Linehan, 1993a). Stylistically, DBT clinicians are also trained to balance the use of change-based strategies (e.g., problem solving) with the use of validation, which involves seeing a situation from the client’s point of view and expressing to the client that his or her experience, no matter how dysfunctional or painful it may seem to others, makes sense in a given context (Linehan, 1993a). The ability to validate a client’s experience calls for the ability of a clinician to be mindful of the client’s needs in the moment as well as recognize the “kernel of truth” in the client’s experience

Clinicians’ own dispositional mindfulness may also benefit clients’ engagement in treatment via enabling a more accurate assessment of the clients’ issues and emotional states. A clinician who is mindful may be more able to detect any subtle resistance (on the client’s part) that arises during the course of treatment, as well as be aware of any overt or subtle behaviors that they themselves engage in that may interfere with clients’ engagement with treatment (e.g., avoiding discussing issues that they are uncomfortable with with the client). Awareness of these therapy-interfering behaviors is crucial to address any potential conflicts or ruptures that may arise in the therapy relationship. Clinicians who are aware of their own emotions and transference are also generally more likely to be effective in their clinical work with patients.

In summary, a key way through which mindfulness promotes treatment engagement is through the clinicians’ own embodiment of qualities of mindfulness—those of moment-to-moment awareness of both intra- and interpersonal experiences, as well as relating to the experiences with an attitude of openness, acceptance, and nonjudgment. These qualities facilitate the ability of a clinician to develop empathy toward the client, forge a strong therapeutic alliance, accurately assess the client’s needs and emotions, as well as develop awareness of the clinician’s own emotions and reactions to the client. Research has shown that dispositional qualities of mindfulness can be cultivated through systematic mindfulness training (e.g., Asuero et al., 2014, Krasner et al., 2009), which is good news for clinicians interested in further cultivating their own capacity for mindfulness. The section toward the end of this chapter suggests several potential avenues through which an interested clinician can pursue further training in mindfulness .

Use of Mindfulness Practices as a Treatment Engagement Tool

Another way through which mindfulness can facilitate clients’ engagement in treatment is through explicit use of mindfulness exercises in the delivery of an intervention. In this context, mindfulness practices can be used either as a standalone tool or a complementary tool to enhance the effects of other treatment strategies.

Mindfulness Practices as a Standalone Treatment Engagement Tool

As a standalone tool, mindfulness practices can be used to increase a client’s openness to experience, or- in other words-reduce the degree of avoidance that the client may have toward their diagnosis, the treatment, or difficult feelings that may come up during therapy. Avoidance, or avoidance-based coping, has been associated with poorer adherence to treatment (Amir, 1997), higher distress (Thompson, Gil, Abrams, & Phillips, 1992), and more severe psychological symptoms (Thompson & Waltz, 2010) in a variety of medical and psychiatric populations. Mindfulness, on the other hand, has been associated with reduced experiential avoidance (Baer et al., 2006). Use of mindfulness practices may therefore facilitate greater receptivity and openness to treatment .

Mindfulness practices may also help a client develop greater awareness of his thoughts and emotions. This would be particularly useful for interventions that require psychological insight into one’s thoughts, emotions, and behavior (e.g., cognitive-behavioral therapy). Mindfulness practices may also enable clients to develop greater clarity of their values and goals. Certain mindfulness-oriented interventions , such as ACT (Hayes et al., 1999), contain exercises aiming at helping clients increase clarity of their values. According to the ACT framework, over-identification or fusion with one’s distressing thoughts and emotions often get in the way of clients developing insight into values that are important to them in their lives (Hayes et al., 2006). Mindfulness exercises therefore may help “defuse ” a client from over-identification with his distressing thoughts and emotions, which will likely enable him to gain greater clarity of his values and goals. Acquiring such clarity is an important step in promoting treatment engagement, as it enables clients to see ways in which participating in treatment is consistent with their values or life goals.

Mindfulness practices also serve the function of reducing arousal and emotion dysregulation (Baer, 2003; Robins et al., 2012), problems that can get in the way of a client engaging in treatment effectively. Therefore, skillful use of mindfulness practices in moments of clients’ distress may help them to calm down quickly and reengage in treatment . Further, mindfulness exercises help increase clients’ attentional capacity and concentration (Chiesa, Calati, & Serretti, 2011), which are important for treatment engagement. Increased attentional capacity would help a client not only in connecting with the clinician (which would likely strengthen therapeutic bond), but also in absorbing and integrating information that they learn through treatment.

Mindfulness Practices as a Complementary Treatment Engagement Tool

As a complementary tool, mindfulness practices can be used to enhance the effectiveness of other intervention tools in facilitating treatment engagement. These practices may be particularly relevant when a client shows resistance to use of an intervention approach. Mindfulness has in fact already been formally incorporated into various treatment approaches, often as a tool to promote acceptance on the part of clients in the service of making positive changes. In other words, mindfulness may be used as a tool that paves the way for easier and potentially more effective implementation of other interventions. For example, one study (de Dios et al., 2012) developed an intervention that integrated motivational interviewing and mindfulness (MI-MM) and found that just two sessions of MI-MM were effective in reducing marijuana use among adult young females. In this intervention, brief mindfulness meditation exercises (with duration ranging from 5 to 15 min) were introduced, followed by problem-solving discussions based on principles of motivational interviewing.

Other intervention approaches such as DBT have also formally incorporated mindfulness as part of their treatment package. In the context of DBT, mindfulness falls under the “acceptance” side on the core dialectic of acceptance and change (Linehan, 1993a). It is taught as a skill to promote awareness and acceptance of difficult thoughts and emotions , so that clients learn not to over-engage with these thoughts and emotions (and as a result resort to impulsive or maladaptive acts). Within the context of ACT , practices and principles of mindfulness are expressed through two aspects of the ACT hexaflex model (Hayes et al., 2006), a model that outlines key psychological mechanisms through which ACT exerts its clinical impact. These aspects encompass contact with the present moment and observing of self as context—processes deemed as crucial for defusing a client from being overly attached to difficult thoughts, emotions, and memories, all of which can get in a way of engagement in actions that are consistent with their goals.

Examples of Specific Mindfulness Exercises that May Be Used to Promote Treatment Engagement

The below section outlines examples and scripts of specific mindfulness exercises that may be utilized to promote treatment engagement. It is recommended that a clinician gains a solid experiential understanding of mindfulness in order to implement these exercises in a skilful, effective, and context-appropriate manner.

Three-Minute Breathing Space

Three-minute breathing space is a brief mindfulness exercise that originated from MBCT (Segal, Williams, & Teasdale, 2002). This exercise involves first bringing one’s attention to the physical sensations, thoughts, and emotions in the present moment, shifting the attention to one’s breath, and then expanding the attention to the entire body. The purpose of this exercise is to enable a client to step out of the automatic pilot mode (in which individuals engage in actions habitually and without much conscious awareness) and cultivate a more mindful way of relating to the present moment experience. The exercise is intentionally designed to be brief (only 3 min long) so that it can be implemented even amid a busy daily schedule. Because of its brief nature, it tends to be a rather popular mindfulness exercise or tool among participants taking part in MBCT courses. It is also especially suitable for implementation in brief clinical sessions. In times when a client appears dysregulated or dis-engaged from the session, the exercise may be introduced to help calm down the client or to help the client re-engage in the session. Below is a script that a clinician may refer to when guiding a client through this exercise. The script also contains a brief introduction to the practice of mindfulness.

What this exercise involves is to simply pay attention to our experiences in the present moment in a nonjudgmental manner , to allow them to be as they are, without engaging in thinking about them, or pushing them away.

Typically, our natural tendency when we experience difficult thoughts and emotions is that we tend to think about them over and over again, judge our experiences as good or bad, or we try to push them away. Mindfulness involves letting go of these tendencies. Instead of ruminating on our thoughts and emotions or pushing them away, we practice bringing a kind of gentle, friendly awareness to these experiences, and recognizing them as simply mental events, or as physical sensations. The idea is to acknowledge and register our experiences in this moment as they are, whether it is our thoughts, feelings, or bodily sensations, in an accepting and nonjudgmental way .

Now, close your eyes, if that feels comfortable for you, and allow the body to relax. See if you can adopt a relatively upright yet relaxed posture… (PAUSE) The first step is becoming aware of what is going on with you right now… (PAUSE) Bringing the focus of awareness to your inner experience and notice what is happening in your thoughts, feelings, and bodily sensations.

Notice if there are any physical sensations in the body… for example, the weight of the body against the chair, or the hands touching the lap… (PAUSE). Next, becoming aware of any thoughts that are going through the mind… (PAUSE). Take a moment to register any of the experiences that you noticed (PAUSE). Becoming aware of how you are feeling in this moment (PAUSE)… Noticing any emotions that are present… If what you are experiencing is sadness , see if you can acknowledge the feeling as it is… perhaps saying at the back of your mind , “A feeling of sadness is arising”. Acknowledging whatever that you are experiencing in this moment, even if it is unwanted or unpleasant. [Note: This portion of the exercise should last for about 1 min.]

Now, gently Redirect your full attention to the breath. Follow the breath all the way in and all the way out. If you like, you may note at the back of your mind: “Breathing in, breathing out.”

Focus on the actual sensations of breath entering and leaving the body. There is no need to think about the breath—just experience the sensations of it. When you notice that your awareness is no longer on the breath , gently bring your awareness back to the sensations of breathing. [Note: This portion of the exercise should last for about 1 min.]

Lastly, allow your attention to expand to the whole body—especially to any sense of discomfort, tension, or resistance. If these sensations are there, then take your awareness there by “breathing into them” on the inbreath. Then, breathe out from those sensations , softening and opening with the outbreath. Say to yourself on the outbreath, “Whatever it is, it’s OK. Let me feel it.”

Becoming aware of your posture, facial expression and body as a whole. [Note: This portion of the exercise should last for about 1 min.]

When you are ready, you can open your eyes and bring your attention back to the room.

Mindful Breathing

Mindful breathing, or awareness of breath , is another mindfulness practice very commonly used in various mindfulness-based interventions (e.g., MBSR , MBCT , and DBT ). This exercise involves bringing one’s full attention to the physical sensations of breathing, maintaining the attention there, and repeatedly redirecting the attention back to the breath whenever one notices that the attention has wandered away from the breath to thoughts, fantasies, stimuli in the environment, emotions, and so on. This exercise, if practised over time, may help clients develop the ability to regulate attention more effectively. Also, even though this is not the goal of the practice , the practice may have a calming effect on the individual practising it (Baer, 2003). The practice may also help individuals develop the ability to de-center from their thoughts and emotions; in other words, over time, individuals may learn to see their thoughts and emotions more as simply mental events rather than facts. The practice can be carried out for varying lengths of time, depending on an individual’s preference and the purpose of practice. Shorter exercises (e.g., 10–20 min) can be helpful when an individual does not have time to do longer exercises and would like a brief practice to cultivate momentary awareness of the present moment experience. Longer exercises (e.g., 30 min to 1 h) may function to help an individual develop the ability to sustain attention for longer periods of time. In the context of treatment engagement, such an exercise can be very helpful for the client in becoming more focused on the treatment session, cultivating greater awareness of intra- as well as interpersonal processes in the session, and developing clarity of their goals and values. The following is a script that a clinician may refer to when engaging a client in a short mindful breathing exercise. The exercise is written for approximately 10 min of practice, but can be easily extended to a longer exercise (e.g., 20 min), by extending moments of silence during the guided session as well as interspersing the exercise with gentle reminders to maintain one’s attention on the breath.

Now, close your eyes , if that feels comfortable for you, and allow the body to relax… see if you can adopt a relatively upright yet relaxed posture… Place both your hands on your lap… (PAUSE) The first step is becoming aware of what is going on with you right now… (PAUSE) Bringing the focus of awareness to your inner experience and notice what is happening in your thoughts, feelings, and bodily sensations.

Now, gently Redirect your full attention to the breath. Follow the breath all the way in and all the way out. Focus on the actual sensations of breath entering and leaving the body. There is no need to think about the breath—just experience the sensations of it.

You may become aware that the air that you breathe in is slightly cooler, and that the air you breathe out is slightly warmer and perhaps more full of moisture (PAUSE). Maintain your awareness on the constant flow of your breath (PAUSE). You may also notice that there is often times a slight pause between an out breath and the next in breath.

From time to time, you may notice that your attention wanders away from the breath to thoughts, emotions, other sensations in the body, or stimuli in the environment. This is completely normal, as this is what minds do. It wanders naturally. When you notice that your awareness is no longer on the breath , gently bring your awareness back to the sensations of breathing. There’s also no need to judge yourself for having experienced distractions. The purpose of this practice is not to get anywhere necessarily; rather, the intention is to simply be aware of the experience in the present moment, whatever it may be. [Note: Throughout the practice, you may choose to repeat these instructions a few times to remind the client to redirect their attention continually back to the breath .]

When you are ready, you can open your eyes and bring your attention back to the room.

Leaves on a Stream Exercise

“Leaves on a Stream” exercise is a mindfulness exercise that originated from ACT (Harris, 2009). In brief, this exercise involves visualizing one’s thoughts and feelings as leaves floating by on a stream, with one watching the leaves float on by without interfering with the process. This exercise may be particularly appealing to clients who are receptive to use of metaphors or visual imagery in the delivery of interventions, and for clients who may struggle with other more traditional types of mindfulness exercises, such as mindful breathing . Like other mindfulness exercises that also utilize metaphors (e.g., the metaphor of clouds against the sky, or waves on the ocean), this exercise aims to help clients dis-engage from over-identifying with thoughts and feelings and refocus on the experiences in the present moment. Implementation of the exercise may facilitate treatment engagement especially when a client has a tendency to ruminate on negative thoughts and feelings that get in the way of her participating more fully in treatment. The practice can be done in varying lengths of time , e.g., ranging from 10 to 20 min. Below is a script that a clinician may refer to in guiding this exercise.

Begin by allowing your eyes to close, and bringing your awareness to your body. Becoming aware of sensations in the body in the present moment, as you are breathing in, and breathing out. Take the time to anchor yourself in the experience right in this moment (PAUSE).

Now, bring to mind the image of a clear flowing stream in a forest. Imagine that you are sitting by the stream , while watching the leaves on the stream float on by.

For the next few moments, take whatever thoughts that come to mind and put each thought on a leaf on the stream, and watch the leaf float on by.

For example, if you have a thought about what happened yesterday, go ahead and place the thought on the stream . Or you may have a thought about this session, for example, the thought that “this is boring,” or “this is pleasant.” Once you notice the thought, simply place the thought on the leaf that floats on by. Do the same regardless of whether the thought is pleasant or unpleasant.

Notice any tendency to want any particular leaf (or thought) to float on by, or go away quickly. Also, occasionally, you may observe certain leaves getting stuck in the stream. There is no need to hold on to any particular leaf, nor make the leaves go away quickly. Simply watch the flow of leaves as they float on by on the stream , at their own speed.

Occasionally, you may find your attention wander away from this exercise; when this happens, simply acknowledge that your attention has wandered and gently bring yourself back to this exercise. [Note: Throughout the practice, you may choose to repeat these instructions a few times to remind the client to redirect his or her attention back to the exercise.]

In a moment, this practice will come to an end. Take a moment to bring your attention to your experiences in this moment, noticing if there is any difference in how you feel before you engage in this exercise , and now.

When you are ready, you can open your eyes and bring your attention back to the room.

Cultural and Diversity Issues in the Implementation of Mindfulness -based Approaches

To date, mindfulness-based interventions have been implemented successfully and widely in many settings, due to their increasing popularity and accumulating evidence base. It is important to note, however, that mindfulness practices or meditation trace their roots most systematically to certain spiritual or religious traditions, in particular, Buddhism (Keng et al., 2011). Clinicians should be aware of the historical and spiritual origins of mindfulness and of potential responses that they may receive when introducing mindfulness-based practices to a diverse group of clients. The fact that mindfulness practices have been most associated with Buddhism in terms of their origin may result in some clients feeling uncomfortable with the practices, especially if the client is not familiar with Buddhism or perceive a conflict between mindfulness practices and teachings of the religion they identify with. For a detailed discussion of ways in which mindfulness practices fit into the context of Buddhism, and of ideas to reconcile the spiritual origins of mindfulness and its secular adaptation, one may refer to Kabat-Zinn (2003).

There are several ways through which a clinician may introduce or orient a client to mindfulness-based practices and exercises in a culturally sensitive manner. The clinician may choose either not to highlight at all the spiritual origins of mindfulness, or to associate the origins of mindfulness with a variety of spiritual traditions, instead of with one predominant spiritual tradition (Linehan, 1993b). In fact, mindfulness practices or closely related practices can be found in spiritual traditions other than Buddhism , such as Sufism, Judaism, and the Christian Contemplative tradition. For a client who may be more sensitive to use of the word “meditation” (given its spiritual or religious connotations), a clinician may choose alternative terms to describe the practice introduced (if the practice involves traditional meditative practices, such as mindful breathing ). For example, a clinician may describe the practice (in the case of mindful breathing) as a form of attentional training. It would also be helpful if clinicians can explore with clients ways in which mindfulness practice is consistent with their goals, worldview, and/or beliefs. For some other clients, mindfulness practices may in fact be already in line with their worldview and can be easily incorporated into their lifestyle . With these clients, a clinician may explore the possibility of integrating mindfulness into the client’s own cultural or spiritual framework (for example, supporting a Christian client’s engagement in contemplative practices to cultivate a closer relationship with God) to enhance his engagement in treatment.

Training Resources for Use of Mindfulness -based Approaches in Treatment Engagement

As highlighted in an earlier section of this chapter, an aspect crucial to the effective use of mindfulness in clinical practice relates to the clinician’s ability to embody qualities of mindfulness, not just in the way she relates to patients, but also in the way she relates to her own experiences. Unlike some other intervention approaches that involve teaching specific skills to the clients but do not necessarily require clinicians to also practice or engage with the skills regularly, a mindfulness-based intervention approach calls for a sincere intention on the clinician’s part to learn about mindfulness not only intellectually, but also experientially. This requires understanding not only the technical aspects of facilitating the practices, but also more fundamental aspects relating to the philosophical context of the practice and ways of working with difficulties that may come up during the practice. The importance of clinicians having an experiential understanding of mindfulness in order to deliver a mindfulness-based intervention effectively and skilfully is highlighted aptly by Kabat-Zinn (2003, p. 150) in the below paragraph:

Unless the instructor’s relationship to mindfulness is grounded in extensive personal practice, the teaching and guidance one might bring to the clinical context will have little in the way of appropriate energy, authenticity, or ultimate relevance, and that deficit will soon be felt by program participants. For how can one ask someone else to look deeply into his or her own mind and body and the nature of who he or she is in a systematic and disciplined way if one is unwilling (or too busy or not interested enough) to engage in this great and challenging adventure oneself, at least to the degree that one is asking it of one’s patients or clients? How will one know how to respond appropriately and specifically to their questions if one cannot draw on one’s own lived experience, not just on book knowledge and concepts, when the practice itself is all about seeing clearly and transcending (not getting caught up in and blinded by) the limitations of the conceptual mind while, of course, not rejecting the conceptual mind or the power and utility of thought within the larger context of awareness?

Therefore, whereas a clinician may utilize aspects of mindfulness practices to achieve limited goals in engaging clients (e.g., helping a client to be more focused in session), a more complete and skilful application of a mindfulness-based approach requires the clinician to also have an experiential understanding of mindfulness. Such experiential understanding may be obtained through several potential avenues. To start with, a clinician may gain a “taste” of mindfulness by attending one or several introductory mindfulness sessions. For a more immersive experience of mindfulness practices, a clinician may consider attending a standardized 8-week program , such as MBSR , which typically involves 8 weeks of 2–2.5 h of experiential mindfulness sessions (in which participants are taught a variety of mindfulness exercises, such as body scan meditation, mindful breathing , and walking meditation), in addition to a half day silent mindfulness retreat. Within the US context, the website of the American Mindfulness Research Association contains a directory of mindfulness training and research programs across the country: https://goamra.org/resources/find-program/. Attendance of a standardized 8-week mindfulness program is often times one of the prerequisites for enrolling in higher level training, such as teacher training for MBSR (for an example, see UCSD’s Center for Mindfulness’ Teacher Training Program: http://mbpti.org/mbsr-teacher-qualification-and-certification/). Additionally, there are programs that have been designed specifically to train therapists or mental health professionals in mindfulness-based approaches. These programs include an 8-week Mindful Therapy program (Aggs & Bambling, 2010) and MBSR adapted for healthcare professionals (Irving et al., 2014).

Conclusion

As a psychological intervention that has gained much empirical support in terms of its efficacy in treating a variety of conditions (Baer, 2003; Keng et al., 2011), mindfulness holds much promise as an effective treatment engagement tool. Qualities fundamental to mindfulness, such as present-moment awareness, acceptance, curiosity, and nonjudgment , are all qualities fundamental to good clinical practice and treatment. Recent research has also provided promising evidence that incorporation of mindfulness in clinical practice enhances the quality of and effectiveness of the service. This chapter is among the first attempt to explore how mindfulness may be utilized systematically as a treatment engagement tool. It proposes that mindfulness can promote treatment engagement in one of two primary ways: (1) through clinicians’ own embodiment of qualities of mindfulness, and (2) through the use of mindfulness practices as a standalone or complementary treatment engagement tool. A mindfulness-based approach to treatment engagement serves a variety of potential functions, ranging from increasing a client’s receptiveness to treatment, enhancing clinicians’ empathy, to increasing clinicians’ awareness of treatment interfering behaviors on the part of the client and also the clinician himself. Given that mindfulness has its roots in spiritual traditions, clinicians should exercise certain caution when introducing mindfulness exercise to clients of diverse cultural backgrounds. Lastly, to utilize mindfulness effectively as a treatment engagement tool, it is recommended that a clinician obtains not only intellectual understanding, but also a deeper, experiential understanding of mindfulness through participating in introductory mindfulness classes or more intensive mindfulness training programs.