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Mindfulness and the therapeutic relationship: does it make any difference?

I've been asked to give a talk on "Mindfulness and the healing relationship" at a seminar later this autumn.  The brief is to approach the subject via the emerging research evidence.  The seminar organizer may well reduce the number of words involved, but the information I sent him read:

"James Hawkins looks at the research evidence exploring the value of mindfulness for really helpful healing relationships.  Currently we have a glass that's half full & half empty.  It's half full because there are so many good reasons to expect high levels of mindfulness to support effective therapy both directly via the healing relationship and indirectly via the health professional's state of wellbeing.  It's half empty because the best current synthesis of twenty relevant research studies reports that  'The results are inconclusive as to whether those trained in formal mindfulness practices or who possess higher levels of mindfulness have better treatment outcomes than those who do not.'  Part of the challenge is because it's not clear what aspects of mindfulness are most important in promoting better healing relationships.  In this talk we'll review the most recent research and discuss ways that mindfulness may support healing through improvements in empathy, awareness, emotion regulation, conflict resolution, attachment security and compassion.  James is an Edinburgh-based medical doctor and integrative psychotherapist.  He has a personal mindfulness practice dating back over forty years and he is deeply interested in the healing relationship.  He also feels that clear meditative insight and good science have a lot in common - they both seek to see more clearly to the heart of things, despite our conditioning and preconceptions."

"The best current synthesis of twenty relevant research studies" that I mention is the 2011 paper by Escuriex and Labbé "Health care providers' mindfulness and treatment outcomes: A critical review of the research literature" with its abstract reading "A systematic and critical review of the research literature evaluated studies on whether mindfulness-based training for health care providers improves their psychosocial functioning. In addition, studies were critiqued that examined whether health care providers who either practice mindfulness or possess greater levels of mindfulness experience better results with their patients than those possessing lower levels of mindfulness or those who do not engage in formal mindfulness practices ... Twenty studies met the inclusion criteria. The results tentatively indicate that mental health and health care providers benefit from mindfulness training with no negative results reported. The results are inconclusive as to whether those trained in formal mindfulness practices or who possess higher levels of mindfulness have better treatment outcomes than those who do not. Additional research using randomized controlled designs is needed to further evaluate the role of health care providers' mindfulness in treatment outcomes."

This strong note of caution - about any over-simple claims that more mindful practitioners are more effective - is further underlined by another recent paper "What are the benefits of mindfulness? A practice review of psychotherapy-related research".  The authors Davis & Hayes encouragingly write "Research suggests that mindfulness practices offer psychotherapists a way to positively affect aspects of therapy that account for successful treatment. This paper provides psychotherapists with a synthesis of the empirically supported advantages of mindfulness. Definitions of mindfulness and evidence-based interpersonal, affective, and intrapersonal benefits of mindfulness are presented. Research on therapists who meditate and client outcomes of therapists who meditate are reviewed. Implications for practice, research, and training are discussed."  This all sounds fine and, when one actually reads the full text of the paper, it's clear that the authors have done a great job in assembling a diverse collection of research findings demonstrating a whole series of ways that increased mindfulness can improve factors that could well then boost therapist effectiveness.  These include affective benefits (better emotional regulation, decreased reactivity & increased response flexibility) and other intrapersonal effects (here the authors present a bit of a shopping list including improvements in self-insight, morality, intuition, fear modulation, physical health, information processing speed, and ability to manage distractions).  They also include a variety of potential interpersonal benefits citing research suggesting that mindfulness protects against the emotionally stressful effects of relationship conflict, is positively associated with the ability to express oneself in various social situations, and predicts relationship satisfaction.  And they further discuss potential improvements in empathy, compassion and other health professionals attributes.

So far, so rosy.  Then in a somewhat tucked away section of the paper, the authors get down to the real nitty-gritty - what research evidence is there looking directly at the central question "Does increasing therapist mindfulness actually translate into better therapeutic outcomes for clients?"  Well, happily there is some encouragement in the much cited 2007 paper "Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study".  However they then go on to say "Despite these promising results, three other studies suggest that the relationship between counselor trainees' mindfulness and client outcomes is not so encouraging. Stanley et al. (2006) studied the relationship between trait mindfulness among 23 doctoral-level clinical psychology trainees in relation to treatment outcomes of 144 adult clients in a university community clinic that used manualized, empirically supported treatments. Contrary to expectation, therapist mindfulness was inversely correlated with client outcome.  This is consistent with other findings that suggest an inverse relationship exists between therapists' mindfulness and client outcomes (Bruce, 2006; Vinca & Hayes, 2007). Still other research suggests that no relationship exists between therapist mindfulness and therapy outcome (Stratton, 2006)."  Sadly most of these four papers are hard to obtain unpublished doctoral dissertations.  The cynic in me would say that it's often negative outcomes that end up as "file drawer" papers that don't see the light of day - see for example the biased literature on antidepressant research where negative outcome papers may well get hidden away by the interested drug companies.  However the Stanley et al research - "Mindfulness: A primrose path for therapists using manualized treatments?" - potentially illustrates a point I intend to enlarge on in a later blog post.  Mindfulness in this study was assessed with the MAAS which only looks at awareness in the moment and pays no attention to the key "non-judge", "non-react" mindfulness components additionally assessed in instruments such as the Five Facet Mindfulness Scale.  Fascinating.

Hmm ... overall these "direct-test" studies are not a ringing endorsement to get health professionals queuing up to learn mindfulness for the way it might improve their general client outcomes (this is not the same as the potential value of teaching clients mindfulness to help with selected disorders like recurrent depression).  I've sounded a note or two of caution myself with blog posts like "Jon Kabat-Zinn in Glasgow: has mindfulness got too "sexy"?", "Personal directions in mindfulness teaching: should we really only be training mindfulness for diverse group populations?" and "Is interpersonal group work better than sitting meditation for training mindfulness?".  However I do think that "There are so many good reasons to expect high levels of mindfulness to support effective therapy both directly via the healing relationship and indirectly via the health professional's state of wellbeing ... Part of the challenge is because it's not clear what aspects of mindfulness are most important in promoting better healing relationships.  In this talk we'll review the most recent research and discuss ways that mindfulness may support healing through improvements in empathy, awareness, emotion regulation, conflict resolution, attachment security and compassion."      

Research emerging this year - "Therapist mindfulness, alliance and treatment outcome" - presents a more nuanced and encouraging picture, while studies like "Interpersonal mindfulness informed by functional analytic psychotherapy" highlight that standard mindfulness training may have its interpersonal effects enhanced by carefully thought out additional components - compassion-orientated, goodwill & loving-kindness practices are obvious examples.  There would be no harm as well in stepping back and asking ourselves just what aspects of the therapeutic relationship itself have been shown to impact most helpfully on client outcomes.  This is likely to give us pretty strong indications as to where mindfulness interventions may or may not be relevant in enhancing these benefits.

I intend to write further about "Mindfulness and the therapeutic relationship" in further posts this autumn.

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