raised in this discussion, two in particular stand out, as relevant today as they were then: First, what is mindfulness? And second, how does mindfulness work? Concerning the nature of mindfulness, our current understanding of the concept is based largely on questionnaire measures intended to identify key characteristics and derive a widely agreed-upon operational defi nition, in keeping with traditional Western scientifi c prac- tice. But as noted by Grossman (2008) and others, mindfulness is an elusive construct, one that is historically unfamiliar to Westerners. Rational science can only go so far in defi ning mindfulness—a state of being that is widely acknowledged to be largely preconceptual in nature. As recently noted by Shapiro (2009, p. 555), “. . . we must fi nd ways of translating its nonconceptual, nondual, and paradoxical nature into a language that clinicians, scientists, and scholars can understand and agree on.” Current reliance on verbally mediated self-assessment questionnaires limits sampling of mindfulness correlates to a single domain, and, according to Grossman, raises signifi cant concerns about validity as well. We concur with his view that MBSR research should expand the range of outcome domains. Th is could include, for example, qualitative, interview- based assessments of novice and experienced practitioners. Detailed phenomenological investigations of the elusive “present moment” could be incorporated into mindfulness research, perhaps using the intriguing microanalytic interviewing technique developed by Stern (2004), in which a very brief (approximately fi ve-second) “slice of life” is sub- jected to detailed exploration. Th e capacity of MBSR to systematically alter a range of physiological responses should be thoroughly investigated. Immune function, sleep pat- terns, and autonomic reactivity are examples of assessment domains that are practical to monitor. Current use of imaging technologies like fMRI to study cognitive and even social correlates of mindfulness is of course an especially promising avenue for research (Siegel, 2007; Stein et al., 2008).
Th e second question posed by Dimidjian and Linehan (2003) concerned the mechanism(s) by which mindfulness interventions operate. We have summarized con- temporary responses to this question, and updated the original transactional model on which MBSR was based in this chapter. It is our hope that the current formulation will provide a useful framework for subsequent research. Nonetheless, it is important to remember that trying to uncover “mechanisms” is a characteristically Western approach to discovery that implies the existence of structures or processes that are amenable to empirical discernment and verifi cation. Inherent limitations in this approach may delay true understanding of how mindfulness “works.” Nevertheless, there are clear indica- tions that we are further along in this process than was the case when Dimidjian and Linehan fi rst proposed their research agenda.
wave” of empirically oriented psychotherapy, evolving beyond earlier behavioral and cognitive behavioral intervention models. Several lines of infl uence and evidence appear to underlie this evolutionary development. First, psychotherapy increasingly focuses on inner experience, rather than merely on overt behavior. Cognitive behavior therapy’s early emphasis on mental representations (schemas) and cognitive mediators of behavior and emotions launched this trend. However, its traditional reliance on an information processing, content-oriented focus frankly does not do justice to the richness and com- plexity of mental life, as noted by Teasdale and Barnard (1995).
Increased integration of MBSR-based and related contemplative practices into CBT will help expand the range of investigative tools available to patients and therapists alike. Second, current clinical practice standards are likely to infl uence the evolution of MBSR in terms of encouraging use of more dedicated pre- and post-program measures, and ensuring that new instructors are suffi ciently skilled at recognizing and working eff ectively with psychologically challenging conditions that participants may bring to the table. Th ird, applications of MBSR will evolve beyond the current medical orienta- tion to focus on negative psychological states, such as stress, anxiety, and depression, as well as the broader arenas of health promotion, wellness, and exercise science. New variants of the program, emphasizing health and wellness, will underscore the capabil- ity of the program to bring about healthy lifestyle changes that are independent of a medical or clinical context. Current program content related to physical activity (Yoga) and nutrition (mindful eating; see, for example, Kristeller, 1999) could be emphasized from the very outset of the program as a means of fostering healthy lifestyles. MBSR elements are likely to be incorporated into briefer, more fl exible interventions. As noted recently by Carmody and Baer (2009), program session time is not signifi cantly related to outcome eff ect size, suggesting that other elements, perhaps home practice time and quality, may be of greater importance. Th is opens up the intriguing possibility of devel- oping individually tailored MBSR interventions that are less reliant on the traditional class-based group format.
We have little doubt that MBSR is a viable and vital clinical intervention. Despite its ancient Buddhist origins, it is still a relatively new addition to the Western repertoire of health management practices. Research on MBSR documentation has advanced from early descriptive to randomized controlled studies based on an increasingly diverse range of clinical populations. MBSR has had a substantial, catalytic impact on current CBT practices, along with early pioneering work by Hayes, Linehan, and others (e.g., Hayes, Jacobson, Follette, & Dougher, 1994). Th e program originated in a major Western medi- cal center where it has fl ourished over the years, and MBSR practice has moved from the periphery into mainstream contemporary behavioral medical and psychotherapy. MBSR- based clinical research continues to be published at an accelerating pace, with favorable outcomes prevailing, even as the sophistication of research methodology increases.
Th e central focus of mindfulness—present-moment, nonjudgmental awareness—is simple and direct, having the potential to reach a broad and increasingly diversifi ed range of people. Putting this message into practice in a meaningful way is not a simple
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undertaking, nor has it been particularly easy to convincingly demonstrate to the satis- faction of the Western scientifi c community that mindfulness has benefi cial eff ects on stress management and health. But the persistence of the concept in Western medical care and now psychotherapy bodes well for its future. At the same time, it is worth not- ing, consistent with the Buddhist scheme of things, the importance—the inevitability, really—of not-knowing. Becoming overly attached to the idea that we can somehow
“fi gure out” mindfulness is a recipe for egotistical frustration. In this regard, it would be well to keep in mind Rosch’s (2007, p. 263) remark that “Acknowledging not knowing is what evokes the genuine humbleness prized by every healing and contemplative tradi- tion. It is also the basis of science.”
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