Clinical Impact Statement: This article describes the results of an empirical study testing the effectiveness of having clients and therapists engage in mindfulness together at the start of their psychotherapy sessions. No significant differences were found for practicing mindfulness together compared to starting sessions with psycho-education. Future research directions are discussed.
Over the past decade, the practice of mindfulness has received a significant amount of attention in the psychotherapy research literature. The existing research on mindfulness has demonstrated that it can produce positive health and mental health benefits for psychotherapy clients (Davis & Hayes, 2011). A smaller body of research has also demonstrated that the practice of mindfulness can also positively impact therapists, resulting in enhanced health and well-being, reduced stress and burnout, and the development of professional skills and attributes associated with effective therapeutic work (Aggs & Bambling, 2010; Martin-Asuero & Garcia-Banda, 2010; Shapiro, Brown, & Biegel, 2007).
Research has also suggested that the practice of mindfulness by therapists can have a positive impact on their treatment sessions and client outcomes (Grepmair, Mitterlehner, Loew, & Nickel, 2007). For example, in one study (Dunn, Callahan, Swift, & Ivanovic, 2013) therapists were asked to engage in a five minute mindfulness exercise prior to a random set of their psychotherapy sessions. Sessions that were preceded by the therapist mindfulness practice were rated by clients as more effective compared to sessions where therapists were allowed to complete routine activities (i.e., check email, go to the bathroom, talk to other clinicians) immediately prior to the session. More recently, others (Stone, Friedlander, & Moeyaert, 2018) found that a similar pre-session mindfulness practice for therapists can have an impact on client-rated empathy and the real relationship.
Given that research has shown benefits for both psychotherapy clients and therapists who practice mindfulness, the question that follows is whether having clients and therapists practice mindfulness together can also produce positive results. In one qualitative study (Horst, Newsom, & Smith, 2013), therapist/client dyads were asked to discuss the benefits of using mindfulness in their treatment. The themes that emerged from this study indicated that the dyads believed that the mindfulness helped with the clients’ presenting problems, helped with in-session transitions, facilitated conversations, and helped bring a calm slower pace to the sessions. However, it is unclear in this study whether the mindfulness was therapist-guided or was actually practiced by the client and therapist together in the sessions. Further, given the study design, it is unclear whether the mindfulness actually caused the benefits that were reported. Thus, further research is needed to empirically examine the session impacts of having clients and therapists engage in mindfulness exercises together in psychotherapy.
Having clients and therapists engage in mindfulness exercises together in session might be beneficial for a number of reasons. First, it has been strongly suggested that therapists who encourage their clients to practice mindfulness should incorporate a “practice what you preach” model (Davis & Hayes, 2011). This demonstrates to clients that the therapist personally believes in the benefits of mindfulness. Second, practicing mindfulness together may foster a stronger therapeutic relationship. As clients and therapists engage in this type of activity together, clients may perceive a stronger sense of collaboration and connection in treatment. Third, practicing together may help both parties be more present-focused in sessions, which could lead to more positive treatment outcomes.
This study was conducted in a psychology department training clinic, with 16 therapists-in-training and 39 of their clients participating. All treatment sessions (k = 156) for these dyads were randomized to begin with either a 5-minute mindfulness centering exercise or 5-minutes of psycho-education about general healthy living topics (e.g., sleep hygiene). In the mindfulness exercise condition, the therapists were instructed to play a guided audio of the exercise while the clients and therapists listened to and engaged in the practice together. The psycho-education material was scripted and led by the therapists. After engaging in the mindfulness or control exercise, therapists were instructed to conduct their sessions as usual. At the end of the sessions, clients were asked to complete a measure of perceived therapist presence (Therapist Presence Inventory-Client; Geller, Greenberg, & Watson, 2010), a measure of the session alliance (Session Rating Scale; Johnson, Miller, & Duncan, 2000), and a measure of session effectiveness (Session Evaluation Questionnaire; Stiles, Gordon, & Lani, 2002). Additional details regarding the therapist and client demographic information, the mindfulness and control exercises, and the data analytic procedures can be obtained by contacting the first author.
The primary goal of this study was to test whether sessions that were randomized to begin with a joint mindfulness exercise would be rated more positively by clients compared to sessions that began with a psycho-education control. The average therapist presence scores (TPI-C) for sessions that began with mindfulness was M = 19.92 and the average for control sessions was M = 19.70. A multi-level-modeling analysis (sessions nested within clients who were nested within therapists) indicated that this was not a significant difference, t(1.57) = 1.20, p = 0.38. The average alliance scores (SRS) for sessions that began with mindfulness was M = 37.64 and the average for control sessions was M = 37.27. MLM analyses indicated that this was also not a significant difference, t(17.74) = 1.03, p = 0.37. Similarly, significant differences between mindfulness and control sessions were not found in clients’ ratings of session depth (SEQ-Depth), t(57.78) = 0.32, p = 0.75; session smoothness (SEQ-Smoothness), t(14.54) = 1.36, p = 0.20; or the clients’ experience of the session as positive (SEQ-Positivity), t(21.59) = 0.20, p = 0.95. Thus, the results from our experimental study suggested that sessions were not perceived by clients as being better if they started with the client and therapist practicing mindfulness together, compared to starting with psycho-education.
The purpose of this study was to empirically test whether having clients and therapists practice mindfulness together during treatment would have a positive impact on treatment sessions. Contrary to our hypotheses, the results indicated that compared to control condition sessions (sessions that began with psycho-education), beginning treatment sessions by practicing mindfulness together had no added benefit in terms of clients’ perceptions of therapist presence, the alliance, or session effectiveness.
The results of this study seem to contradict earlier research findings indicating that client and therapist mindfulness is related to positive treatment outcomes (Aggs & Bambling, 2010; Davis & Hayes, 2012; Dunn et al., 2013; Grepmair, Mitterlehner, Loew, & Nickel, 2007; Horst, Newsom, & Smith, 2013; Martin-Asuero & Garcia-Banda, 2010; Shapiro, Brown, & Biegel, 2007; Stone et al., 2018), but there may be several reasons for the difference. First, this was the first study that we are aware of in which clients and therapists were asked to engage in the mindfulness exercises together. Perhaps practicing together is not as effective as having either party engage in mindfulness alone. This hypothesis could easily be tested by conducting a study with four different conditions—client practices mindfulness alone at the start of the session, therapist practices mindfulness alone at the start of the session, client and therapist practice together, and control. Second, it is possible that psycho-education was not the most appropriate control condition for the study. Although it provides a control in terms of starting the session with a structured activity that deviates theoretically from mindfulness, previous research has indicated that psycho-education alone can have a positive impact on depression, anxiety, and psychological distress (Donker, Griffiths, Cuipers, & Christensen, 2009). Thus, the results of this study may indicate that beginning sessions by practicing mindfulness together is just as effective as starting the sessions with another effective brief intervention—in this case, psycho-education. Third, there may be limitations with studying session-level impacts. Although this type of design does have its advantages (Stone et al., 2018), it is possible that the benefits from practicing mindfulness together in some sessions carried over to the sessions where mindfulness was not a component. Finally, it is possible that mindfulness may not be an appropriate intervention for everyone. While some clients and therapists may respond positively to mindfulness practices, others may believe that it is a waste of their valuable session time. In this study, condition assignment was based on randomization, but in real world settings it is important for treatments to be tailored to the individual client.
Although this study failed to find significant results, further research is needed to explore different ways for using mindfulness in psychotherapy. This research should focus on both the clients’ and therapists’ use of mindfulness. In addition to studying session level impacts, future research should also further study for potential effects on treatment outcomes.
Cite This Article
Swift, J., & Ivanovic, M. (2018).Does having clients and therapists practice mindfulness together have a positive impact on psychotherapy sessions?. Psychotherapy Bulletin, 53(3), 29-35.
Aggs, C., & Bambling, M. (2010). Teaching mindfulness to psychotherapists in clinical practice: The mindful therapy programme. Counselling & Psychotherapy Research, 10, 278-286. doi:10.1080/14733145.2010.485690
Davis, D. M., & Hayes, J. A. (2011). What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy, 48, 198-208. doi:10.1037/a0022062
Donker, T., Griffiths, K. M., Cuipers, P., & Christensen, H. (2009). Psychoeducation for depression, anxiety, and psychological distress: A meta-analysis. BMC Medicine, 7, 79. doi:10.1186/1741-7015-7-79
Dunn, R., Callahan, J. L., Swift, J. K., & Ivanovic, M. (2013). Effects of pre-session centering for clinicians on session presence and effectiveness. Psychotherapy Research, 23, 78-85. doi:10.1080/10503307.2012.731713
Geller, S. M., Greenberg, L. S., & Watson, J. C. (2010). Therapist and client perceptions of therapeutic presence: The development of a measure. Psychotherapy Research, 20, 599-610. doi:10.1080/10503307.2010.495957.
Grepmair, L., Mitterlehner, F., Loew, T., & Nickel, M. (2007). Promotion of mindfulness in psychotherapists in training: Preliminary study. European Psychiatry, 22, 485-489. doi:10.1016/j.eurpsy.2007.02.004
Horst, K., Newsom, K., & Stith, S. (2013). Client and therapist initial experience of using mindfulness in therapy. Psychotherapy Research, 23, 369-380. doi:10.1080/10503307.2013.784420.
Johnson, L. D., Miller, S. D., & Duncan, B. L. (2000). The Session Rating Scale 3.0. Chicago, IL: Author.
Martin-Asuero, A., & Garcia-Banda, G. (2010). The mindfulness-based stress reduction program (MBSR) reduces stress-related psychological distress in healthcare professionals. Spanish Journal of Psychology, 13, 897-905.
Shapiro, S. L., Brown, K., & Biegel, G. M. (2007). Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, 1, 105-115. doi:10.1037/1931-39220.127.116.11
Stiles, W. B., Gordon, L. E., & Lani, J. A. (2002). Session evaluation and the Session Evaluation Questionnaire. In G. S. Tryon (Ed.), Counseling based on process research: Applying what we know (pp. 325-343). Boston, MA: Allyn and Bacon.
Stone, M., Friedlander, M. L., & Moeyaert, M. (2018). Illustrating novel techniques for analyzing single-case experiments: Effects of pre-session mindfulness practice. Journal of Counseling Psychology. Advanced online publication. doi:10.1037/cou0000291