DELANY DEAN, JD, PhD
INTRODUCTION: While I was teaching at Avila University in the master of science (counseling psychology) degree program, I was Practicum Director. I decided to develop a curriculum within which the Practicum students (those who were about to go out on Internship in community agencies) learned some techniques, or interventions, based on what is now being called Third-Wave Cognitive Behavioral Therapy. I chiefly focused on Mindfulness-Based Cognitive Therapy (MBCT) and Acceptance and Commitment Therapy (ACT), because they have been and continue to be researched by competent professionals, because they appear to be effective for a wide variety of presenting problems, and because their core interventions can (I believe) be easily taught and implemented. I designed a four-session protocol within which the beginning counselor could take a history from her client, identify a presenting problem, and teach the client to use mindfulness, acceptance, and values-based goal-setting to address the problem. Along with one of my students (now a wonderful colleague), Matt Arnet, I tested the protocol with patients at the Kansas City Free Health Clinic. I then introduced the curriculum to Avila University Counseling Practicum students. At first, there was some resistance, because students had become accustomed to “doing their own thing,” and I was asking them to learn a required, fixed set of skills, and to demonstrate proficiency in those skills. However, by the end of our first semester with this curriculum, the students were very pleased, both with themselves (they felt that they had become much more competent and confident in their clinical skills), and with the results that they were seeing in their work with clients.
I called the program “Mindfulness In Action Training” (MIAT), in part because it wasn’t really MBCT, and it wasn’t really ACT, and I felt I had to call it something. MIAT training continued at Avila University (and was very popular with the students), until I left my faculty position in January, 2008.
I am posting this page to preserve some of the blog entries I published about the MIAT program, as it was happening.
MINDFULNESS IN ACTION: COUNSELING PRACTICUM
PRESENTATION GIVEN TO MISSOURI COUNSELORS
[note: this was originally posted on my blog in November of 2007]
This past weekend I presented a talk at the Missouri Mental Health Counselors Association at Lake of the Ozarks, MO. The topic of my talk was Mindfulness In Action Training; this is the model I use at Avila University to teach our counseling graduate students in the Practicum course. The Practicum is the transition course between traditional content-laden coursework (learning “about” counseling) and the internship (actually “doing” counseling).
My goal in Practicum is to teach the students as much as possible about the “how to” of counseling. That’s no small task, in one semester, especially given the broad array of mainstream theoretical orientations available out there, each with its own somewhat particular set of interventions. Given the impossibility of teaching all the “how to’s” of everything from psychodynamic to gestalt, we teach interventions that are (1) well-supported in the peer-reviewed literature; (2) broadly applicable to an array of presenting problems; and (3) consistent with most, if not all, theoretical orientations.
We teach a model called Mindfulness In Action, which includes Mindfulness intervetions (drawn from various sources, including Mindfulness-Based Cognitive Therapy) as well as Values-Based Behavioral Activation (adapted from various sources, including the literatures on Behavior Therapy, Positive Psychology, and Acceptance and Commitment Therapy).
This model has proven very successful from the standpoint of my Practicum students, and very satisfactory to their clients, as well.
COUNSELING PRACTICUM CHRONICLE, Part 1:
[Note: this was written and posted in my blog early in the spring semester of 2008. Unfortunately, there never was a “Part 2,” because I was unable to finish the semester at Avila University.]
Spring Semester 2008 has begun at Avila University, and I’m planning on writing a chronicle of one class, the Practicum in Counseling Psychology, for this semester.
Some background information: The Practicum course for psychologists and counselors is very much a bridge course between course work and the internship (in which, often for the first time, students have the responsibility and privilege of working with “real people, with real problems, in a real clinic”). In Practicum, students take a first run at using theories and interventions they have learned about in class, mostly from textbooks, and applying them to the live clinical situation. In most cases, students are not given specific training in a particular theory of psychotherapy, or in a set of interventions (other than “essential counseling skills”), but rather are given free rein to “choose a theory” and apply it, as best they can, with coaching and supervision from the practicum instructor. Accordingly, in any given Practicum class, you are likely to see students who are claiming allegiance to several different theories and methods of psychotherapy: psychodynamic, gestalt, adlerian, existential, cognitive, cognitive-behavioral, and so forth. Each of them is expected to do his or her best to figure out how to effectively apply the theory to practice.
This typical Practicum situation is what I was exposed to when I underwent my own training. I found it lacking in many ways, and my sense that it could be improved only intensified as I became a professor in a counseling psychology graduate program. The problem lies in the crucial difference between teaching someone “about” something, and teaching someone “how to do” something. In other professions, this distinction is thoroughly honored. In medicine, students generally have two years of pre-clinical book work, plus labs, before they begin to be taught and shown how to actually “do” things with patients. In law, students have nearly all of their three years of training in theoretical book work; but afterwards, if they are becoming trial lawyers, there is a strong tradition in which young lawyers are shown how to try a case (they go to trial as “second chair” assistants), and then they are closely supervised and assisted by experienced trial lawyers, as they try their first cases in the courtrooms.
One way to appreciate the difference between the “teaching about” and “teaching how to” approaches is to think about teaching someone to play golf, or to do surgery. These are skills that certainly have theoretical components: you can think about, and read about, the physics and mechanics and techniques involved in the golf swing; and the anatomy, physiology, and techniques of surgery. But they also have a large “doing” component. Nobody ever became competent at golf or surgery by reading about it, thinking about it, or being told about it. You simply have to DO it, in order to be ABLE to do it, and you need someone to demonstrate it, and SHOW YOU HOW to do it.
My first career was as a trial lawyer, and having been thoroughly and effectively trained in that profession by way of a “show me how, and then watch me and help me as I try to do it” approach, I have always felt that this approach would greatly improve the training of counselors and psychotherapists of all types.
Accordingly, when I became Practicum Director, I re-designed the Practicum Course. I developed a curriculum called Mindfulness In Action, in which students are directly taught a limited number of interventions that are (a) effective with a wide variety of presenting problems; (b) supported in the peer-reviewed, mainstream literature; and (c) consistent with most theoretical orientations in psychotherapy. In addition to “essential counseling skills” (listening skills, rapport building, etc.), students are trained in the use of mindfulness-based interventions, and values-based behavioral activation, with their clients. The Practicum instructors not only teach the theory behind, and empirical support for these interventions, but also model the interventions (showing “how it is done”), and supervise the students as they practice doing the interventions with each other, in the classroom, under supervision, before using them with clients.
This semester will be our fourth semester using this curriculum. The response has been extremely positive, both from the students who complete the course, and from the practice clients who serve as volunteers for our practicum students. We have also heard very strong positive feedback from internship supervisors at clinical placements in the community, who tell us that our students are much better prepared for internship than many of the counseling and counseling psych students who come from other universities.
So we are off and running again with Practicum. First class session was Thursday, January 17. I am teaching the course with Matt Arnet, MSCP, LPC, who is well-trained in these methods and very ably teaches them. We have a total of 10 students in our (combined) two sections. In our first class, we gave an introduction to the course, its methods and rationale(s), and Matt led the class in a guided body scan meditation. For this week, homework will include daily practice of the body scan, with daily journaling about that experience; and some reading (and writing about) three journal articles that discuss mindfulness and mindfulness-based interventions in psychotherapy.
A RECENT STUDY THAT SUPPORTS THE “MINDFULNESS IN ACTION” MODEL:
Patients Do Better With Psychotherapist Who Practice Zen Meditation, Study Suggests (the impact of the therapist’s meditation practice on the outcome for their patients)
ScienceDaily (Nov. 18, 2007) — An investigation by German researchers headed by Professor Nickel indicates the practicing Zen meditation by psychotherapists matters. All therapists direct their attention in some manner during psychotherapy. A special form of directing attention, ‘mindfulness’, is recommended.
This study aimed to examine whether, and to what extent, promoting mindfulness in psychotherapists in training (PiT) influences the treatment results of their patients. The therapeutic course and treatment results of 124 inpatients, who were treated for 9 weeks by 18 PiTs, were compared.
The PiTs were randomly assigned to 1 of 2 groups: (i) those practicing Zen meditation (MED; n = 9 or (ii) control group, which did not perform meditation (noMED; n = 9). The results of treatment (according to the intent-to-treat principle) were examined using the Session Questionnaire for General and Differen-tial Individual Psychotherapy (STEP), the Questionnaire of Changes in Experience and Behavior (VEV) and the Symptom Checklist (SCL-90-R).Compared to the noMED group (n = 61), the patients of PiTs from the MED group (n = 63) had significantly higher evaluations (according to the intent-to-treat principle) for individual therapy on 2 STEP scales, clarification and problem-solving perspectives.
Their evaluations were also significantly higher for the entire therapeutic result on the VEV. Furthermore, the MED group showed greater symptom reduction than the noMED group on the Global Severity Index and 8 SCL-90-R scales, including Somatization, Insecurity in Social Contact, Obsessiveness, Anxiety, Anger/Hostility, Phobic Anxiety, Paranoid Thinking and Psychoticism.
This study indicates that promoting mindfulness in PiTs could positively influence the therapeutic course and treatment results in their patients.
Journal reference: Grepmair, L. ; Mitterlehner, F. ; Loew, T. ; Bachler, E. ; Rother, W. ; Nickel, M. Promoting Mindfulness in Psychotherapists in Training Influences the Treatment Results of Their Patients: A Randomized, Double-Blind, Controlled Study Psychother Psychosom 2007;76:332-338
Adapted from materials provided by Psychotherapy and Psychosomatics.
READING/REFERENCE LIST FOR MINDFULNESS IN ACTION:
Anderson, D. T. (2005). Empathy, psychotherapy integration, and meditation: A Buddhist contribution to the common factors movement. Journal of Humanistic Psychology, 45, 483-502.
Baer, Ruth A. (2003). Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice. 10(2), 125-143.
Baxter, L.R., et al. (1992). Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Archives of General Psychiatry, 49, 681-689.
Bishop, S.R., Lau, M., Shapiro, S., Carlson, L., Anderson, N.D., Carmody, J., Segal, Z.V., Abbey, S., Speca, M., Velting, D., & Devings, G. (2004). Mindfulness; a proposed operational definition. Clinical Psychology: Science and Practice. 11(3),230-262.
Breslin, F.C., Zack, M., & McMain, S. An information processing analysis of mindfulness: implications for relapse prevention in the treatment of substance abuse. Clinical Psychology: Science and Practice. 9(3), 275-299.
Brown, K.B., & Ryan, R.M. (2004). Perils and promise in defining and measuring mindfulness: observations from experience. Clinical Psychology: Science and Practice. 11(3), 242-254.
Brody, L.R., & Park, S.H. (2004). Narratives, mindfulness, and the implicit audience. Clinical Psychology: Science and Practice, 11(2), 147-154.
Brown, W.B., & Ryan, R.M. (2003). The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology. 84(4), 822-848.
Cahn, B.R. & Polich, J. (2006). Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychological Bulletin, 132(2), 180-211.
Davidson, R.J. et al. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-570.
Ekman, P. et al. (2005). Buddhist and psychological perspectives on emotion and well- being. Current Directions in Psychological Science, 14, 59-63.
Fredrickson, B.L. (2000). Cultivating positive emotions to optimize health and well-being. Prevention and Treatment, 3(0001a), 1-25.
Hayes, A.M. and Feldman, G. (2004). Clarifying the construct of mindfulness in the context of emotion regulation and the process of change in psychotherapy. Clinical Pyschology: Science and Practice, 11, 255-262.
Hayes, S.C. (2002). Acceptance, mindfulness, and science. Clinical Psychology: Science and Practice. 9(1), 101-106.
Hayes, S.C. & Wilson, K.G. (2003). Mindfulness: method and process. Clinical Psychology: Science and Practice. 10(2), 161-165.
Kabat-Zinn, Jon (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8, 73-83.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology, Science and Practice, 10, 144-156.
Kitzman, H., & Guyotte, S. (2006). Enhancing health and emotion: mindfulness as a missing link between cognitive therapy and positive psychology. Journal of Cognitive Psychotherapy: An International Quarterly. 20(2), 123-134.
Lau, M.A., & McMain, S.F. (2005). Integrating mindfulness meditation with cognitive and behavioral therapies: the challenge of combining acceptance and change based strategies. The Canadian Journal of Psychiatry. 50(13), 863-869.
Lazar, S.W., Kerr, C.E., Wasserman, R.H., Gray, J.R., Greve, D.N., Treadway, M. T., McGarvey, M., Quinn, B.T., Dusek, J.A., Benson, H., Rauch, S.L., Moore, C.I., Fishchl, B. Meditation experience is associated with increased cortical thickness. NeuroReport, 16(17), 1893-1897.
Marra, T. (2006). Dialectical Behavior therapy in private practice. Psychiatric Rehabilitation Journal. 29(4), 324-325.
Martin, J.R. (1997). Mindfulness: a proposed common factor. Journal of Psychotherapy Integration. 7(4), 291-312.
Martin, J.R. (2002). The common factor of mindfulness-an expanding discourse: comment on Horowitz. Journal of Psychotherapy Integration. 12(2), 115-142.
Miller, W.R. & Thorensen, C.E. (2003). Spirituality, religion, and health. American Psychologist, 58(1), 24-35.
Motivala, S.J., et al. (2006). Tai Chi Chih acutely decreases sympathetic nervous system activity in older adults. Journal of Gerontology, 61, 1177-1180.
Proulx, K. (2003). Integrating mindfulness-based stress reduction. Holistic Nursing Practice, 17(4), 201-208.
Roemer, L. and Orsillo, S.M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54-68.
Roemer, L. & Orsillo, S.M. (2003). Mindfulness: a promising intervention strategy in need of further study. Clinical Psychology: Science and Practice. 10(2), 172-178.
Saxena, S., Brody, A.L, Schwartz, J.M., & Baxter, L.R. ( 1998). Neuroimaging and frontal-subcortical circuitry in obsessive-compulsive disorder. British Journal of Psychiatry, 35, 26-37.
Scherer-Dickson, N. (2004). Current developments of metacognitive concepts and their clinical implications: mindfulness-based cognitive therapy for depression. Counseling Psychology Quarterly. 17(2), 223-234.
Schwartz, J.M. (1998). Neuroanatomical aspects of cognitive-behavioral therapy response in obsessive-compulsive disorder. British Journal of Psychiatry, 35, 38- 44
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Seligman, M.E.P., & Csikszentmihalyi, M. (2000). Positive psychology. American Psychologist, 55(1), 5-14.
Seligman, M.E.P., Steen, T.A., Park, N., & Peterson, C. (2005). Positive psychology progress. American Psychologist, 60(5), 410-421.
Shapiro, S.L., Astin, J.A., Bishop, S.R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: results from a randomized trial. International Journal of Stress Management. 12(2), 164-176.
Shapiro, S.L., Carlson, L.E., Astin, J.A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62(3), 373-386.
Siegel, D.J. (2006). An interpersonal neurobiology approach to psychotherapy. Psychiatric Annals, 36, pp. 248-256.
Singh, N.N. et al. (2007). Adolescents with conduct disorder can be mindful of their aggressive behavior. Journal of Emotional and Behavioral Disorders, 15, 56-63.
Teasdale, J.D. et al. (2001). How does cognitive therapy prevent relapse in residual depression? Evidence from a controlled trial. Journal of Consulting and Clinical Psychology, 69, 347-357.
Teasdale, J.D., Moore, R.G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z.V. (2002). Metacognitive awareness and prevention of relapse in depression: empirical evidence. Journal of Consulting and Clinical Psychology, 70(2), 275-287.
Teasdale, J.D. et al. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70, 275-287.
Tull, M.T. et al. (2004). The role of experiental avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety, and somatization. Journal of Nervous and Mental Disease, 192, 754-761.
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Wachholtz, A.B., & Pargament, K.I. (2005). Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. Journal of Behavioral Medicine, 28(4), 369-384.
Wallace, B.A. and Shapiro, S.L. (2006). Mental balance and well-being. American Psychologist, 61, 690-701.
Walsh, R. and Shapiro, S.L. (2006). The meeting of meditative disciplines and Western psychology: A mutually enriching dialogue. American Psychologist, 61, 227-239.
Williams, J. M., Duggan, D., Crane, C., & Fennell, M. (2006). Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. Journal of Clinical Psychology. 62(2), 201-210.
Witkiewitz, K., Marlatt, G.A., and Walker, D. (2005). Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy, 19, 211-228.