Exploring the Roles of Suggestion and Intention in Mindfulness Training Norman A

The Journal of

article Mind Your Expectations: Exploring the Roles of Suggestion and Intention in Mindfulness Training Norman A. Farb, PhD * Mindfulness training (MT) has received increasing recognition for its therapeutic benefits in a variety of clinical contexts. Despite acknowledgement that MT effects are predicated upon the development of both mindful attention and intention, research on MT mechanisms has focused chiefly upon attentional effects. By contrast, hypnosis research has focused explicitly on suggestion techniques for cultivating beneficial therapeutic expectations. Comparing similarities between mindfulness and hypnosis techniques, this paper explores mechanisms of suggestion tacitly employed in mindfulness interventions. Distinctions between mindfulness meditation and hypnotic induction are then used to identify a form of intentionality that is unique to MT, including candidate markers of mindful intention that may help to explain mindfulness’ salutary effects. Finally, the idea of changing intentions during MT is discussed, generating suggestions for how best to monitor the interaction between expectation and attentional practice when studying mindfulness interventions. Studies of intention and expectation in MT could help to determine: i) the degree to which MT benefits are driven by expectation effects rather than changes to attention, ii) how to best motivate the development of mindful attention in therapeutic interventions, and iii) what factors predict the generalization of mindfulness techniques to improve emotion regulation. By acknowledging that suggestion may be important for cultivating mindful intentions, it may be possible to deepen our understanding of how to optimally deliver mindfulness training and improve participant well-being.

Introduction & Schwartz, 2000). Holding right intention, the commitment to ethical and mental self-improve-

Mindfulness training is increasingly recognized ment, is a central tenet of the Buddhist canon mbr.synergiesprairies.ca for its ability to reduce psychological distress (Wallace & Shapiro, 2006). Despite an avoidance across a variety of clinical disorders (Baer, 2003; of attachment to expectation during mindfulness Bohlmeijer, Prenger, Taal, & Cuijpers, 2010; practice, holding intentions for self-improvement Grossman, Niemann, Schmidt, & Walach, 2004). through MT presumably denotes a long-term The meditation technique’s success has been ac- expectation that these practices will be effica- companied by a proliferation of research into MT cious. Indeed, in the first published description mechanisms, exploring the cognitive and neural of Mindfulness Based Stress Reduction (MBSR; bases by which mindfulness improves well-being Kabat-Zinn, 1982), the second key element of the (Holzel et al., 2011; Shapiro, Carlson, Astin, & program is stated as: Freedman, 2006). Several attentional mecha- “Expectation of relief. Meditation was pre- nisms have been proposed for mindfulness’ salu- sented with the suggestion that the techniques are tary effects, such as positive reappraisal (Garland, powerful and that regular practice can bring relief Gaylord, & Fredrickson, 2011), decentering of ex- from pain in many cases. In this way the placebo perience (Fresco, Segal, Buis, & Kennedy, 2007), effect was maximized.” or otherwise “reperceiving” the world (Carmody, By suggesting that participants form inten- * Rotman Research Baer, E, & Olendzki, 2009). And yet, while at- tions for self-improvement, MBSR purposefully Institute tentional accounts of MT have grown in promi- cultivates healing expectations. More recent Brain Health Complex, nence, there are few intentional accounts of mind- MBSR studies have recognized positive expec- 8th Floor fulness mechanisms, i.e., we have little evidence tancy as a potential mechanism of MBSR’s salu- 3560 Bathurst Street- demonstrating how participant intentions for tary effects (Shapiro, Schwartz, & Bonner, 1998), Toronto, Ontario self-improvement support mindfulness’ benefi- one that may even be a requisite component of M6A 2E1 cial effects. the program’s success (Astin, 1997). Despite this Canada Intention is a fundamental principle of both recognition, few empirical studies of MT have email: nfarb@rotman- classic Buddhist meditation and contempo- controlled for the effects of intention and ex- baycrest.on.ca rary MT practices (Kabat-Zinn, 1990; Shapiro pectation, and only one has modeled individual

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differences in intention as part of its experimen- contributions of expectation and attention may tal design (Carmody et al., 2009). Controlling amount to quibbling over semantics rather than Intention for expectancy effects is not a trivial matter: a measuring two distinct influences. An explicit plan for one’s recent study comparing MT to an active control Research is required to determine whether actions group found that group participation in general MT-related modulation of attention and expec- accounted for many of the benefits typically as- tation are empirically separable. However, there cribed to MT (MacCoon et al., 2012). is a theoretical precedent for supporting the dis- Mindfulness’ potential reliance upon expec- tinction between these two constructs (LaBerge, tation effects does not undermine findings that 1995). LaBerge referred to modulation of the at- Expectation MT also generates important and health-relevant tention system as “attentional preparation”, char- An estimation of the likeli- changes to attention, as the research literature acterizing it as “an elevation of activity in the cor- hood of an anticipated event has begun to demonstrate (Jha, Krompinger, & responding perceptual or action brain area that Baime, 2007; Schmertz, Anderson, & Robins, speeds processing of stimuli or actions when the 2009). There is mounting evidence that MT appropriate triggering event occurs” (p.51). This Expectation does more than create positive expectations: description is consistent with MT instructions, An estimation of the likeli- clinical interventions such as Mindfulness-Based which appear to facilitate activation of attentional hood of an anticipated event Cognitive Therapy (MBCT) have outperformed systems for present-moment sensation (Farb et placebo conditions, matching or surpassing the al., 2007). On the other hand, expectations rely efficacy of traditional therapeutic interventions upon more abstract, often verbal representations (Segal et al., 2010; Teasdale et al., 2000). MT has of “an event in terms of its attributes and its spatial also outperformed relaxation training control and temporal characteristics” (LaBerge, p.51), and Placebo groups in several cases, particularly in its abil- thus expectancy does not necessitate attentional A sham medication or pro- ity to reduce ruminative thoughts and behav- preparation. It should be noted however that at- cedure that is described as iors (Alexander, Langer, Newman, Chandler, & tention and expectation are not wholly distinct: being medically efficacious to create an expectation of Davies, 1989; Jain et al., 2007). However, an im- strong expectations for success or benefits from benefit, often used to control portant consideration in the study of any alterna- meditation are likely to be accompanied by in- for the power of expectation tive mental health intervention is whether some tentions to practice, thereby promoting attention to improve subjective well- part of its effects can be attributed more simply preparation. Positive expectations can thus serve being in medical intervention studies to expectancy than that intervention’s purported as a cue for practicing mindful attention, analo- mechanism of action. Indeed, some researchers gous to MT homework instructions to engage in argue that current mindfulness questionnaires daily mindful activities (Kabat-Zinn, 1990). are incomplete in omitting measurements of From this perspective, changes to expectation Mindful intention mindful intentions (Grossman, 2011; Van Dam, are related to but not synonymous with changes mbr.synergiesprairies.ca An explicit plan for one’s Earleywine, & Borders, 2010). By including par- to attention; rather, by providing spatial and tem- actions, without attachment ticipants’ broader intentions and expectations in poral cues for attentional deployment, expecta- or self-critical judgment in future research it may be possible to better char- tions promote practice intentions, an important response to the success or failure of the plan acterize the critical factors underlying efficacious factor in determining whether attentional skills MT interventions, such as how intention serves to learned in a therapeutic context will generalize promote and sustain attentional changes, practice to daily life. Expectation and attention can thus Suggestion compliance and feelings of well-being. work together to promote therapeutic effects. For The invocation of an example, expectations of successfully implement- intention, expectation or Why expectancy theory is ing mindfulness strategies in response to stress perception. needed in MT may help participants to recognize and alter their habitual stress reactions. Conversely, expecta- A practical concern with the study of expectations that mindful attention may be inadequate tions in mindfulness research is whether it will to deal with emotional challenges make it less constructively inform current research and thera- likely that a person will follow through on initial peutic practice. If expectation effects are just an- intentions to practice in chaotic and threatening other facet of attention training, we gain little by contexts. incorporating them in theoretical models. For In the absence of explicit expectations for example, MT could bias attention to focus upon increased awareness of stress reactivity, it seems positive outcomes, and these benign perceptions unlikely that short courses of MT would have the might then promote healthier physiological and ability to implicitly replace longstanding atten- social responses, such as the lowering of blood tional habits in reaction to daily stressors. For ex- pressure, dampening of emotional reactivity, etc. ample, many patients suffering from depression If mindfulness effects can be fully explained by fall into a ruminative style of processing, biasing the attentional habits that these practices engen- attention towards critical self-attributions that re- der, then worrying about distinguishing between inforce depressive affect (Lo, Ho, & Hollon, 2008;

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Robinson & Alloy, 2003). If participants can form de Jong, & Braude, 2009), and potentially limits an expectation for success through mindfulness patient autonomy (Kolber, 2009). Encouragingly practice, they may be willing to form explicit in- within the field of placebo research, evidence is tentions to implement their training. When hold- emerging to suggest that explicit deception is not ing an intention to react mindfully in the face of always required to generate expectation-based ef- future stress, mindful responses may be explicitly fects (Kaptchuk et al., 2010; Martin & Katz, 2010), recruited to compete with, and potentially over- indicating that a therapeutic context may yield come ruminative patterns of reactivity (Teasdale, positive outcomes even when its efficacy is explic- Segal, & Williams, 1995). Without explicit in- itly denied. However, as non-deceptive placebo tentions, the instinctual pattern of reactivity to research is very new, it is of limited use in inform- stress is still more likely to be rumination than ing the present discussion. mindfulness. In contrast to placebos, hypnosis has a richly Novel measures of the implicit and explicit documented history of producing clinically sig- application of mindful regulatory strategies will nificant benefits without requiring deception be important for assessing whether mindful strat- (Lynn, Kirsch, Barabasz, Cardena, & Patterson, egies require conscious intentions to be engaged. 2000). Hypnotic suggestion is in some ways a It is still possible that attention training alone is more general form of non-deceptive placebo, af- sufficient for mindful responses to be implicitly firming the principle that powerful expectations cued in the face of stress, although such change can be generated simply by communicating them seems much more likely in the presence of con- to another. Hypnosis has been particularly ef- scious intention to alter response patterns. It fective in the area of pain management (Landolt would seem that there are compelling reasons & Milling, 2011; Vlieger, Menko-Frankenhuis, to believe that expectation and intention have a Wolfkamp, Tromp, & Benninga, 2007), an area role to play in promoting MT’s salutary effects. where mindfulness-based interventions have also Yet even if one accepts that expectancy should be shown particular promise (Chiesa & Serretti, 2011; studied, a new challenge emerges: how does one Kabat-Zinn, Lipworth, & Burney, 1985). Indeed, best operationalize intention and expectation and one of the few comparison studies between hyp- include them in intervention models? nosis and meditation found that the techniques were equally effective in reducing clinical anxiety Hypnosis as a resource for (Benson et al., 1978). understanding expectation in Like placebos, hypnosis-based therapeutic mindfulness interventions rely explicitly on the cultivation of positive suggestion to effect psychological change To begin to understand how intentions and ex- (Erickson & Rossi, 1976; Heap, 1996), modulating mbr.synergiesprairies.ca pectations shape mindfulness effects, it may be expectations at deeply-engrained levels of per- helpful to compare the structure of MT to well- ceptual awareness (Ploghaus, Becerra, Borras, & researched interventions in which health-pro- Borsook, 2003). Hypnosis research is therefore moting expectations are purposefully cultivated. well-suited to inform our understanding of the While the creation of expectation is not syn- conditions that foster expectancy. By reviewing onymous with the creation of intention, positive the mechanisms of hypnotic induction, it may be expectations may serve as a helpful precursor to possible to identify suggestive practices in MT practice intentions, and thus are instrumental to that generate participant expectations. The iden- an intervention’s success. The creation of expecta- tification of these suggestions may help to opera- tions is a major focus of both hypnosis (Erickson tionalize factors of intention and expectation in & Rossi, 1976) and placebo research (Stewart- mindfulness research. Williams & Podd, 2004), which convincingly il- lustrate that when a person acts with the expec- Suggestion techniques com- tation of a therapeutic effect, these expectations mon to MT and hypnosis can powerfully modulate attention, behavior, and well-being. For most people, mindful and hypnotic states There are numerous accounts of placebo ef- both represent departures from one’s habitual fects improving subjective well-being (Price, mode of experiencing reality. During the in- Finniss, & Benedetti, 2008) that could serve as a duction of these states, participants take on the model for expectation effects in MT. However, expectation of altered perception or mental ca- unlike MT, the placebo effect generally requires a pacity. Whether or not such expectations mani- level of deception that has raised ethical concerns fest in a qualitatively distinct form of awareness (Miller, Wendler, & Swartzman, 2005; Raz, Harris, depends upon the person: hypnotizability varies

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widely by individual, environmental context and conclusion of a hypnotic session may also include experience with hypnotic induction (Deckert & post-hypnotic suggestions that will come into ef- West, 1963; Diamond, 1974; Spiegel & Greenleaf, fect during the participant’s daily life. 1992). Similarly, trait measures of mindfulness at As articulated in recent theoretical research least subjectively characterize the extent to which (Lynn, Surya Das, Hallquist, & Williams, 2006; an individual is able to enter and sustain mindful Yapko, 2011), some of the procedures employed attention, an ability that also appears to increase in introductory guided mindfulness meditations with practice (Baer et al., 2008; Lau et al., 2006; bear considerable structural similarity to sugges- Walach, Buchheld, Buttenmuller, Kleinknecht, tion during hypnotic induction*. Mindfulness & Schmidt, 2006). Understanding how expecta- meditation teachers will also attempt to secure tions for the hypnotic state are created may there- trust of participants by discussing the virtues of fore also aid in understanding whether such tech- the meditative practice. The meditation state niques are at play in mindfulness. is often formally demarcated by suggestions to Several structural similarities are apparent adjust posture, close one’s eyes, and sometimes between hypnotic induction and guided mindful- to listen to the sound of a bell or chime. Like ness meditation. Both the hypnotic and mindful hypnotists, mindfulness teachers often orient states are associated with the ability to attend with- participants to naturally-occurring events, es- out distraction (Brown, Forte, Rich, & Epstein, pecially those that occur within the body such 1983; Kumar & Pekala, 1988). The induction of as the breath or physical sensations. Sometimes these altered states can occur rapidly, over the dissociative suggestions to let go of conceptual course of minutes, and is generally accomplished thoughts will also be present, or suggestions to through the guidance of an experienced instruc- focus entirely upon physical sensation. Similar to tor. In hypnosis, the participant focuses attention building a response set in hypnosis, mindfulness to the scope and focus proposed by the hypno- teachers discuss the management of distraction, tist (Jamieson & Sheehan, 2006), accompanied i.e., the failure of directed attention, and suggest by explicit suggestions towards attentional ab- a nonjudgmental reallocation of attention back to sorption (Rainville & Price, 2003). The resulting present moment sensations. It could be argued focused attentional state renders the participant that in urging participants to be kind or nonjudg- more amenable to suggestion, reducing compet- mental when attention wanders, therapeutic sug- ing input from extraneous stimuli or spontaneous gestions are being made. Similarly, post-medita- thoughts (Oakley & Halligan, 2009, 2010). tion suggestions may also occur, as teachers often Several standard practices are employed to suggest that participants allow feelings of mindful *It should be noted that accomplish hypnotic induction, which may serve attention to extend into their daily lives. while instructor-guided as candidate factors for cultivating participant ex- Substantial overlap exists between hypnotic mbr.synergiesprairies.ca meditation is an impor- pectancy (Barber & De Moor, 1972): the situation and guided mindfulness meditation induction tant element of introductory mindfulness training is defined as hypnosis, priming participant ex- techniques. The contribution of each of these courses such as MBCT pectations for altered perception or control. The techniques to salutary effects in mindfulness is and MBSR, such guidance hypnotist attempts to address participant fears unknown, and ripe for experimental manipula- during meditation is not and preconceptions, and then secure participant tion and investigation. However, in the process universal to all contemplative practices. Japanese Zen co-operation in the enterprise, establishing a of attempting to experimentally manipulate sug- meditation for instance is willingness to follow suggestion. Participants are gestion in MT, researchers must be careful not to accompanied by a minimum asked to close their eyes, removing visual stimu- violate the core values of mindfulness interven- of instructor suggestion or lation as a competing source of sensory stimula- tions or to remove suggestions that are founda- guided direction of attention (Austin, 1998). On the other tion and tacitly indicating participants’ trust in tions of attention training. Table 1 summarizes hand, such Zen practices the procedure. The induction then often begins the hypnotic induction techniques found in a still place large importance by suggesting naturally-occurring events, such as typical guided mindfulness meditation, and pres- on holding a strong long- noticing one’s breathing or the sound of the hyp- ents hypotheses as to whether these techniques term intention to practice, and so some suggestion may notist’s voice. Since these phenomena are easily may be manipulated without compromising at- arise in cultivating these in- attended to, it allows for the participant to ha- tention training. Some techniques, such as sug- tentions. Given the variation bituate to the act of following the hypnotic suggesting nonjudgmental and present moment in contemplative traditions gestion. The hypnotist also provides guidance for awareness seem to be integral to mindful atten- and practices, it is important to consider the specific what to do when the direction of attention fails, tion; other techniques, such as talking in a soft training practices idiosyn- attempting to ensure that it is always possible for and slow voice, may be an affectation that is not cratic to a given tradition, the participant to comply with initial suggestions, required for successful training. However, many and bear in mind that the and strengthening the pattern of participant ac- elements of suggestion in MT fall into a third cat- present discussion focuses only on these standardized ceptance. After establishing a response set with egory, where it is difficult to determine whether introductory mindfulness the participant (Kirsch, 2000), the hypnotist the suggestion is required. For instance, mindful- courses. may begin to make therapeutic suggestions. The ness instructors often suggest examples of specific

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Suggestion Technique Description Necessary for Attentional Aspects of MT? Defining the situation: - suggesting an intention to be Yes mindful - providing a historical context for No the practices Securing cooperation: - asking participants to assume a No meditation posture - asking participants to close their No eyes Suggesting an altered - present moment focus Yes state: - nonjudgmental awareness Yes - suggesting that participants relax, No or ‘let go’ of their experience Maximizing suggestion - speaking in an atypically slow and No phrasing: distinct voice, using long periods of silence between repeated suggestions Coupling suggestions - initial suggestion to focus on body Yes with naturally occurring awareness events: - supplying examples of bodily No sensation Preventing or re- - initially discussing mind- Yes interpreting failure of wandering and painful sensation suggestions: and how to respond - suggesting that mind wandering may have occurred and inviting Unknown redirection of attention - anticipating postural pain during meditation and providing options for how to respond Unknown Stimulating long term / - formal meditation practice Yes mbr.synergiesprairies.ca goal-directed - homework to apply mindfulness Yes imagination into daily living - suggesting how reactivity might No change using mindfulness - promise of long term benefits No

Table 1. A summary of suggestion techniques used in MT and their hypothesized necessity for attentional training. Note: these techniques are adapted from Barber & Moore’s (1972) theory of hypnotic induction. Whether these techniques are necessary components for MT attentional training is a matter of conjecture, and as such are subject to debate and revision. body sensations or potential distractions; these When researching expectancy mechanisms suggestions may be helpful or even necessary for in MT, this admittedly non-exhaustive list dem- scaffolding participant ability to eventually notice onstrates a variety of candidate elements that such aspects of experience autonomously. On the may be experimentally manipulated. Researchers other hand, suggesting potential experiences to have great latitude in potential approaches to this participants can create an expectation for those investigation: one may strip away any hint of sug- experiences, and spur evaluations as to one’s abil- gestion to isolate attention training effects; ality to notice these experiences rather than main- ternatively, one may conservatively manipulate taining mindful curiosity. Thus, while suggested only the most obvious cases of suggestion to safe- experiences may be helpful instruction aids for guard the intervention’s validity. When working mindfully noticing and responding to distraction, with clinical populations, where maintaining a they may not be strictly necessary for the culti- standard of care is an important ethical consid- vation of mindful attention. Investigating the eration, a conservative approach may be more necessity of suggestion techniques in this third appropriate, whereas in less vulnerable samples category may help researchers to more finely dis- more radical variants of MT may be employed. criminate between conventional and necessary Given the potential for reshaping MT inter- components of MT. ventions, it will be important to monitor whether

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Overall Efficacy Overall Efficacy to suggest specific outcomes rather than only

Maintained Changes structuring the perceptual experience during the intervention. Thus while suggestion in MT may be impor- Attention Effects Relevant for Expectancy Irrelevant tant for directing attention to particular aspects Maintained Effects in MT of experience, the interpretation of these experi-

ences is left undefined and open to participants

Relevant for Attention Attention Effects Relevant for Attention reflection. While there is a suggestion of long Effects Unrelated to Well- Change Effects in MT term benefits in MT, there is a purposeful avoid- Being ance of creating expectations for immediate relief. Participants are encouraged to think about Table 2. Interpretation of effects from manipulating candidate elements of suggestion in MT incorporating long-term lasting changes to their the manipulation of these suggestion elements af- perceptual habits and patterns of reaction, with fects: i) the overall efficacy of the MT intervention expectations for increased well-being or relief on participant well-being, and ii) changes in at- from stress being contingent upon these gradu- tention related to MT. Four potential outcomes of al changes. Of course, just because instructors such manipulation seem possible as summarized preach a lack of short term expectation does not in Table 2. If overall intervention efficacy is un- mean that participants will abide by this request. altered, then the suggestion is either wholly irrel- It is a common occurrence for a participant to laud evant or is influencing some aspect of attentional the feeling of relaxation or bliss that may be en- training that is immaterial to MT effects on well- countered during a meditative practice. Indeed, being. However, if overall intervention efficacy is participants often pick favorite practices over an altered, then the suggestion is either a component 8 week course, and their reasons for choosing one of MT expectation effects (in the case that atten- practice over another may have a lot to do with tion changes are unaltered), or the suggestion is the satisfaction of short term expectations of re- foundational for attention effects driving MT in- lief or positive affect. Whether such expectations tervention efficacy. Partial mediation outcomes are ultimately unsatisfying when compared to a are also possible, in which attention effects are participant who eschews such expectations is an slightly altered, but overall intervention efficacy is altered to a larger degree, effects which can be calculated with mediation models. Regardless of outcome, manipulating elements of suggestion in

MT may both powerfully identify that element’s mbr.synergiesprairies.ca relevance to MT efficacy, and, if attention changes are also measured, serve to characterize the extent to which the suggestion element is associated with cultivating mindful attention.

Suggestion techniques specific to MT

Guided mindfulness meditation and hypnotic induction techniques appear to share many features of suggestion that may promote their therapeutic efficacy. However, the common use of suggestion in hypnotic and mindfulness inductions does not imply identical mechanisms of action. For example, while perceptual suggestions may occur in both MT and hypnosis, a mindfulness instructor would generally not suggest specific outcomes of a meditation, such as feeling less anxious or de- pressed. In hypnosis however, specific immediate outcomes are commonly suggested, such as the Figure 1. Hypothesized distinctions marking the cultiva- well-known example of suggesting a participant’s tion of mindful intentions, relative to intentionality associated arm has become too heavy to lift (Shor & Orne, with instructor-led interventions. This model assumes that 1962; Weitzenhoffer & Hilgard, 1962). The heavy participants new to MT would likely approach guided meditation as though it were a hypnotic induction; over time, the arm suggestion is somewhat trivial as an exam- internalization of intentions distinctive to mindfulness may ple of hypnotherapy, but highlights a willingness be observed.

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empirical question, one that requires longitudinal benefit from mindfulness much as high suggest- documentation of participant expectations, in- ible people show the biggest response to hypno- tentions and well-being. sis. Looking realistically at MT as one of many So, while the structure of suggestion appears possible therapeutic interventions rather than similar between mindfulness and hypnosis, MT some sort of panacea, it will be important to char- may employ suggestion to a different end. When acterize who is likely to benefit most from MT in- evaluating participant intentions during mindful- terventions to efficiently allocate therapeutic re- ness interventions, it may be possible to evaluate sources. A second possibility is that mindfulness whether participants endorse more mindful in- course participants do not start off as being par- tentions for mindful practice compared to inten- ticularly mindful, but begin to internalize course tions found in hypnotherapy or other interven- concepts and values, adopting traits that reinforce tions promising more immediate effects. Even being mindful on a daily basis. Regardless of the if participants beginning MT show a pattern of rigidity of mindfulness traits, the measurement of expectations more reminiscent of hypnosis than these traits throughout MT participation may be mindfulness, intentions and the quality of ex- a good indicator of participant readiness to incor- pectations held for mindfulness practice may porate mindful regulatory strategies and perceive shift over the course of training. Monitoring this value in the intervention. transition may serve as a sensitive index of the internalization of mindfulness values. Proposed Cultivation of an internal locus of below are several suggestions that may be specific control. to MT (also summarized in Figure 1): While it is documented that a hypnotized par- Endorsement of mindfulness traits. ticipant must work hard to realize the hypnotist’s suggestion (Hilgard, 1977), the locus of control Hypnosis and mindfulness research literatures for the modulations in attention and/or percep- both acknowledge large individual differences in tion is generally external in hypnosis and inter- responsiveness to their practices. Trait suggest- nal in mindfulness. Both practices begin with an ibility may be used to predict a person’s response external locus of control in which participants to suggestions regardless of whether or not they direct attention according to their instructors’ are in a hypnotized state (Braffman & Kirsch, 1999; directions, but mindfulness moves quickly into Kirsch & Braffman, 2001), whereas trait mindful- promoting independent practice in which atten- ness may in turn predict responsiveness to MT tion is self-guided. Therapeutic hypnosis may and the specific attention tasks therein (Creswell, also move towards allowing patients to partici- Way, Eisenberger, & Lieberman, 2007; Shapiro, pate in self-hypnosis practices, but this progres- mbr.synergiesprairies.ca Brown, Thoresen, & Plante, 2010). However, sion is not an integral component of the process. whether or not a person meditates and their facil- Thus different sorts of individuals may benefit ity therein does not seem to be related to hypnotic from the two practices depending upon their susceptibility (Murphy, Donovan, & Taylor, 1997; desire for independence or desire for care from Rivers & Spanos, 1981; Spanos, Gottlieb, & Rivers, another, or from their facility with the control de- 1980), suggesting that individuals participating in mands of the practices themselves. For example, MT may respond differently to suggestion than a person with strong issues with authority may highly hypnotizable participants. As research on not be ideally suited to follow guided hypnosis, suggestibility and meditation practice preceded whereas a person who finds self-monitoring to be the popularization of trait mindfulness measures, too difficult or stressful may benefit more from a the relationship between this new generation of guided approach. trait measures and suggestibility is still unclear. The intention to foster an internal locus of However, the traits of mindfulness and suggest- control in MT may be one reason that facility ibility may represent distinct dimensions of at- with mindfulness does not appear to be related tentional expectations that attract distinct types to suggestibility. This hypothesis could be em- of participants. pirically tested by borrowing from the rich social The association between trait mindfulness psychology literature on internal and external lo- and hypnotic suggestibility could be formally cus of control (Rotter, 1990). For example, one investigated by assessing both of these traits in measurable proxy for the adoption of mindful participants from each practice. It is important intentions may be participant willingness to as- for our understanding of mindfulness training to cribe personal responsibility for their reactions account for the possibility of self-selection, that to stressful events (Gaylord et al., 2009; Lakey, highly mindful participants are the ones who Kernis, Heppner, & Lance, 2008)

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Attending mindfully rather than practices, such as breath monitoring and targeted engaging in absorption. body scanning, before moving onto more diffuse attentional practices such as mindful attention. To describe the special quality of attention that From an intentional angle, it would be interest- allows for hypnotic trance states, the term absorp- ing to evaluate how participants understand the tion was coined, describing such intense focal at- intention to deploy mindful attention during tention that the distinction between the self and formal practices and during daily life, evaluating object becomes lost, altering one’s self-concept. whether these intentions become less synony- Psychometric measurement of trait absorp- mous with absorption and align more with dif- tion are correlated with hypnotic susceptibility fuse or open awareness. (Tellegan & Atkinson, 1974). Since mindful and hypnotic states both involve continuous atten- Increased decentering and reduced tion and resistance to momentary distractions, dissociation. it might be argued that both states are character- ized by high levels of absorption. Additionally, it The term dissociation refers to a partial division is true that some concentrative meditation prac- of consciousness into two or more parts, and is tices involve intense focal attention on a particu- used in broader psychiatric research to describe lar object with the intent of dissolving self/object a range of disorders that involve a partitioning boundaries (Lutz, Slagter, Dunne, & Davidson, of consciousness from awareness, such as dis- 2008), a description that is highly congruent with sociative identity disorder or dissociative am- absorption. nesia (Kirsch & Lynn, 1998). However, within However, a major point of distinction be- the realm of hypnosis, constructive cases of dis- tween mindfulness and hypnotic absorption sociation are also regularly suggested, such as is that mindful attention involves more than suspending consciousness of negative emotions the non-distracted observation of experience. when discussing a traumatic event. The argu- Several psychometric investigation exploring ment has been made that both mindfulness and self-reported mindfulness have found moder- hypnosis are dissociated states (Yapko, 2011); af- ate relationships between the absorption and the ter all, in therapeutic contexts such as chronic tendency to mindfully observe one’s experience pain, both hypnosis (Dillworth & Jensen, 2010) (Baer, Smith, & Allen, 2004; Lau et al., 2006), but and mindfulness (Morone, Greco, & Weiner, only a weak relationship with decentering, and no 2008; Rosenzweig et al., 2010) reduce subjective relationship with the tendencies to describe one’s reports of distress, suggesting that the meditator experience act with awareness or nonjudgmental- and hypnotized person alike are dissociated from

ly accept experience (Baer et al., 2004). Using a their pain. However, the purported mechanisms mbr.synergiesprairies.ca single factor scale for mindfulness (Walach et al., by which hypnosis and MT purport to improve 2006), absorption and mindfulness were nega- well-being in chronic pain are very different. tively correlated, recapitulating the idea that high While hypnosis attempts to limit pain perception, levels of absorption do not support mindful atten- either by transforming sensation or reducing at- tion. Furthermore, in a comparison of mindful- tention to sensory experience, MT does not seem ness and concentrative meditators, both groups to reduce pain sensation but instead limits the were found to be superior to controls in terms automatic recruitment of self-referential second- Diffuse attention of sustained attention capacity, but mindfulness ary appraisals about pain, such as one’s sense of An open and inclusive meditators showed an additional advantage for suffering or self-limitation. form of attention that allow responding to unexpected stimuli, indicating en- By bringing pain more focally into awareness for unbiased awareness hanced sustained attention but less absorption rather than attempting to alter its sensory charac- of thoughts, feelings, and sensations as they occur in with the task set (Valentine & Sweet, 1999). Thus, teristics, MT seeks to change the attribution that the present moment. Unlike absorption may be a property of both hypnotic pain needs to be a major determinant of well- focused attention, diffuse and concentrative meditation states, but less so of being. Mindfulness therefore tends not to pro- attention seeks to avoid mindfulness states, in which diffuse rather than mote dissociation so much as decentering, which attachment to any one particular experience, instead focal attention is deployed. It may be that in the connotes a viewing of experience as transitory allowing for awareness of absence of such absorption, and particularly ab- rather than as self referential truth. Decentering diverse experience arising sorption with the instructor’s suggestions, the ef- appears to be an important factor in predicting and passing from awareness. fects of suggestion are greatly diminished. MT’s prophylactic effects (Carmody et al., 2009; Dissociation In tracking the progression of participants Feldman, Greeson, & Senville, 2010; Fresco, Segal A splitting off of a group of through an MT intervention, it may be useful to et al., 2007). The absence of suggestion to alter mental processes from the consider how intentions towards practice change sensory experience may be a further reason that main body of consciousness, as a function of the transition between concentra- feelings of dissociation are not commonly docu- allowing for an altered or absent perception of events tive and mindful practices. For example, MBSR mented in mindfulness. By acknowledging nega- or capacities. interventions incorporate both concentrative tive experience, but shifting any given experience

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away from the “centre” of one’s interpretive con- ordinarily dressed and unaccredited teacher may text, there is room for a more balanced percep- promote less authority than a venerable and elab- tion of experience that is not dominated by one orately garbed teacher who is introduced with Decentering particular sensation or mental event. In this way, many testimonials and accolades. Altering the The ability to view one’s decentering may allow participants to feel an in- mystique and prestige of the teacher may power- thoughts, feelings and physical sensations as momentary creased sense of balance or integration (Wallace fully impact participant expectations for an inter- and transitory experiences & Shapiro, 2006), but without dissociation from vention and thereby also modulate its perceived rather than self-diagnostic the awareness of sensation itself. efficacy and impact on well-being. By increas- events or “Truths” about To gauge the intentionality around viewing ing the perceived authority of the mindfulness the self. experience, it may be useful to assess how par- instructor, participants may have greater expec- ticipants characterize perceived regulatory ben- tations of course efficacy, but also show fewer efits of MT. Specifically, participant approaches intentions for autonomy as they rely upon the to engagement with negative experience may be teacher’s expertise to the detriment of their own evaluated, distinguishing between terms such as experiences. Manipulating instructor authority avoiding, controlling or suppressing negative expe- may therefore have the curious effect of increas- rience as conventional regulatory strategies, and ing perceived benefits of training while reducing approaching, exploring or opening to experience as intentions for future self-directed practice. the intention for a mindful response. Decentering Aside from manipulating instructor au- may be specifically assessed using measures such thority, it will be important to measure the de- as the Experiences Questionnaire (Fresco et al., gree to which MT participants begin to engage 2007) or Toronto Mindfulness Scale (Lau et al., in autonomous practice by the end of a course. 2006), which contain measures of a person’s ten- Through exit interview, one can measure whether dency to assign self-relevance to thoughts and participants still rely primarily on guided medi- experiences. tation audio recordings and group sessions, or whether they have begun to practice without the Cultivation of autonomous practice. benefit of these instructions and the suggestive support that they provide. The practices taught Expectancy and response set theories of hypnosis in MT may also influence the cultivation of au- (Kirsch, 2001; Lynn & Sherman, 2000) emphasize tonomy — for instance, in MBCT participants are the importance of culturally derived social con- taught a “3 minute breathing space” that can be text in enhancing the power of suggestion, rather practiced without guidance throughout the day. than requiring that hypnosis be considered a spe- In this way, the suggestion of developing au- cial and unique state of consciousness. Within tonomy is introduced more gradually than when this social domain, a critical difference between asking participants to switch from a 40-minute mbr.synergiesprairies.ca the hypnotist and meditation instructor becomes guided meditation to a comparable self-directed apparent: participants of a mindfulness induction meditation. Whether offering shorter autono- are not explicitly instructed to enter a hypnotic mous meditations acts to improve participant au- state or trance, nor is there a parallel cultural ex- tonomy more broadly is an outstanding empirical pectation of such effects as there is in hypnosis. question. Furthermore, the mindfulness induction suggests that participants view their experiences with cu- Measuring intentions and riosity and openness, but does not suggest what expectations in mindfulness those experiences should feel like. By contrast, interventions hypnotic induction contains explicit instructions on how to feel, with regard to feeling sleepy, The similarities between mindfulness and hyp- heaviness in the body, changes in motor control notic inductions present opportunities for ma- or willpower, etc. The gradually increased asser- nipulating suggestion within MT interventions, tion of authority by the hypnotist over the partici- and the distinctions between the two practices pant’s internal experiences may be a critical facet have also generated a series of testable questions. of hypnotic induction, one that seems to build a Further opportunities for modeling intention much stronger response set then asking partici- and expectation in MT are available when one pants to maintain attention and avoid judgmental considers how best to measure the effects of ma- thoughts on their experiences. nipulated suggestions over the course of a mind- It may be difficult to experiment with the so- fulness intervention. In hypnosis research, the ciocultural background surrounding meditation effectiveness of hypnotic induction is often oper- teachers, although one could imagine an experi- ationalized as the efficacy of suggestion on shap- ment that manipulates the perceived venerabil- ing behaviour (Raz, 2007); indeed, it is theorized ity and authority of the instructor. A younger, that a central feature of hypnosis is the tendency

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to respond to suggestion, an explicitly expected Endorsement of the Intervention. response (Lynn, 1997). Therapeutic hypnotism tends to focus on tackling specific issues, such One of the best studied effects of expectation on as weight loss (Stanton, 1975), pain management therapeutic intervention centers on participant (Chaves, 1994), mood problems (Yapko, 2001), or expectations of therapeutic benefit (Benedetti, altering features of perception (Spiegel, Bierre, & 2008; Price et al., 2008). Participant expecta- Rootenberg, 1989). In all of these domains, reso- tions may vary during the course of an interven- lution of these issues can be measured as direct re- tion (Stone, Kerr, Jacobson, Conboy, & Kaptchuk, sponses to targeted hypnotic suggestions, provid- 2005), suggesting that it is important to follow ing a rich opportunity for empirical observation. up on intervention endorsement at multiple time In mindfulness however, suggestions with points to accurately model the effect of such ex- specific behavioral or affective expectations are pectations on MT outcomes. Such expectations rare; the act of being mindful is primarily a senso- can be simple to assess; acupuncture researchers ry and attentional one, without a predictable be- asked participants how effective they believed the havioral outcome (Davidson & Goleman, 1977). intervention to be, and followed up on this as- Mindfulness inductions explicitly avoid target- sessment with a mid-intervention confidence rat- ing a particular problem. Instead mindfulness ing (Linde et al., 2007), demonstrating a strong encourages participants to approach experience effect of intervention endorsement on the odds of from a less egocentric, goal-less state (Gilpin, responding to treatment. 2008; Rosch, 1997). By promoting open awareness, a diffuse allocation of attention to any and Holding Intentions vs. Expectations. all experiences, mindfulness attempts to avoid the goal-orientation of hypnosis or of concentrative In determining whether a participant is attempt- meditative practices (Lutz et al., 2008). In doing ing to internalize the intentionality prescribed in so, MT may also invalidate reliance upon discrete MT, it is important to distinguish between par- behavioral responses as evidence of suggestion. ticipant intentions for present moment awareness Without concrete behaviors to measure in and expectations for awareness. Mindfulness mindfulness training, how can a science of sug- training may still contain explicit suggestions in gestion proceed? What’s more, how can a thera- terms of the intended contents of awareness, with- peutic intervention hope to succeed without in- out dwelling on the outcomes of these intentions tended beneficial results, i.e. expected outcomes? as successful or failed goal states. Participants If the idea of mindfulness as an aimless therapeu- are counseled that when they mind-wander, de- tic process seems unfair, then perhaps we might spite their best intentions to focus on present consider whether mindfulness training is truly moment sensation, to simply make that aware- mbr.synergiesprairies.ca goal-less in its application, despite its core values ness of mind wandering their present moment of nonjudgment and acceptance. Several oppor- experience. Suggestions to bring equanimity to tunities for understanding the role of suggestion momentary experience may indeed be seen as an and goals are apparent when considering the na- example of setting expectations for experience in ture of suggestion and the composition of mind- mindfulness, but it is the paradoxical expectation fulness interventions. Within each of these inter- of perception free from expectation that is being vention elements, the application of the unique entertained (Epstein, 1999). mindfulness techniques outlined above may be In this context, it may be useful to formally evaluated (summarized in Figure 2): distinguish between attachment to intentions and expectations. An expectation has a success or failure attached to it depending upon whether that expectation is realized. If I have a goal of losing 5 pounds in the next week, my bathroom scale can verify whether or not this goal has been successfully attained, validating or invalidating my expectation. An intention, on the other hand, is either held or not, but is not contingent upon external outcomes. My weight change over the week does not impact whether or not I held the intention to lose weight. If I am attached only to my intention to hold weight, but freely dis- card my expectations when they are proven false, then my intention becomes stronger, unmoved Figure 2. Candidate measurements of intention within the framework of an MT intervention.

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by external outcomes. This shift in one’s inten- endpoint to a therapeutic intervention, mindful- tions from living in a world where satisfaction is ness focuses on engaging participants in the ac- dictated by outcomes to one where satisfaction is tive process of identifying what is already work- driven by intentions is a critical milestone in the ing in their lives. To the extent that participants MT process. begin to internalize this process through practice, By focusing on the distinction between a fixation on long term outcomes becomes less whether a participant is focused upon holding important than an ability to appreciate positive right intentions instead of expected outcomes, it aspects of the present moment. Critically, such a may be possible to more finely classify whether shift in goal focus can occur even in the cases of participants are maintaining mindful intentions chronic conditions whose presenting symptoms or more conventional, expectation-laden strate- may not be cured by mindfulness interventions. gies. To this end, it may be helpful to measure By changing the fixation on a curative goal, par- participant descriptions of their own intentions, ticipants can remodel the criteria for their own particularly in their approach to meditation prac- happiness to become independent of that chronic tice, and more broadly in their intentions for the condition. intervention. The impact of a teacher’s sugges- Examining participant’s criteria for well-be- tions in fostering intentions of equanimity and ing provides another index of the effects of sug- present-moment focus in participants may be an gestion in mindfulness: how participants intend important first step in operationalizing the effects to view their own well-being. Do participants of suggestion in MT. still expect to feel better one day in the future, or are they focused on noticing positive aspects of Criteria for Well-being. their lives in the present? This second point is in some ways a generalization of the first, moving We have already discussed the idea that MT does from intentions within the context of medita- not condemn broad expectations, as one’s expec- tion practice, to examine a person’s intentions for tation for benefit is supportive of intentions to evaluating his or her state of well-being. practice and integrative mindfulness techniques. Rather, it is an attachment to short-term expec- Practice compliance. tations that is discouraged. While the expectation for experiences such as the relief of suffer- The performance of daily formal meditation is ing may be appropriate in contexts of hypnosis or an integral aspect of mindfulness interventions. conventional medical intervention, allowing such While expectations for the specific experiences expectations to dictate one’s sense of well-being is encountered during formal meditation are dis- antithetical to the practice of mindful attention. couraged, the performance of meditation itself mbr.synergiesprairies.ca However, the elimination of short-term ex- is strongly advocated; difficulties in homework pectations may be particularly problematic when compliance are a frequent topic of discussion in thinking about MT in a therapeutic context. MT group sessions (Kabat-Zinn, 1982), aimed at Spiritual devotees of meditation may seek com- improving rates of practice compliance. plete liberation from worldly attachment (Burton, Despite the theoretical importance of prac- 2004), and increases in spirituality following tice for promoting changes in mindful attention, training correlate with mindfulness’ salutary ef- a recent review found mixed evidence relating fects (Carmody, Reed, Kristeller, & Merriam, practice compliance to positive intervention out- 2008). Unlike those pursuing a spiritual path, the comes (Vettese, Toneatto, Stea, Nguyen, & Wang, average secular MT participant at a medical clinic 2009). While the importance of practice for MT most likely takes on meditation practice with the effects is itself an empirical question, practice in- expectation of relief from clinically high levels tentions and subsequent compliance present an of suffering rather than some sort of metaphysi- additional opportunity to examine the effects of cal liberation. In this situation, it is likely that intention in MT. the meditator has immediate goals of symptom Intention to practice at different time points improvement; presumably clinical mindfulness of a course may reflect participant endorsement instructors are also motivated to teach mindful- of the mindfulness intervention as potentially ness with the goal of reducing suffering in mind promoting health benefits. Additionally, prac- (Schmidt, 2004). tice intentions may not be equivalent to par- Perhaps no self-improvement project is truly ticipant expectations for practice (Warshaw & free of future aspirations. However, one can con- Davis, 1985), with expectations providing a bet- sider MT as the modeling of a new process by ter indicator of actual practice compliance, given which to seek such self-improvement. Rather a potential disparity between participant atti- than worrying about when one will be cured as an tudes and their perceived self-efficacy. Changes

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in the disparity between practice intention and expectations for residual benefits from the course expectation throughout the intervention period may still be a powerful predictor of longitudinal are another rich source of information for how well-being. Obtaining specific estimates from the the intervention shapes participant beliefs about participant about how long they expect to benefit their own ability to engage in health promotion. from the training would provide a useful index of Critically, mindfulness itself may help to bridge such expectation effects, particularly if such data the gap between intention and practice compli- were compared between participants who main- ance: in a recent study researchers observed that tain a formal meditation practice and those who trait mindfulness was a powerful mediator of the do not. relationship between intentions and behavior A second issue in measuring long-term ex- (Chatzisarantis & Hagger, 2007). pectancy effects of MT rests on how automatic Suggestion of practice compliance in MT may the mindful state is expected to become with therefore operate at multiple levels: it may first time. Anecdotally, participants in mindfulness create intentions to practice, but also reinforce courses often emerge from introductory medi- existing intentions as greater levels of subjective tations in a somewhat trancelike state, and after mindfulness are engendered. Increased self-effi- longer meditation sessions are cautioned to care- cacy could in turn promote positive self-evalua- fully integrate themselves back into the world. tions at the end of the intervention, and predict However, with greater levels of practice, the dis- longitudinal benefits through an upward spiral tinction between the meditation state and daily of practice compliance leading to positive reap- life becomes less apparent. This observation is praisal of self-efficacy (Garland et al., 2010). On supported by an intriguing neuroimaging study the other hand, continued suggestions to practice of the meditative state against a range of practice when efforts to practice have been largely unsuc- experience (Brefczynski-Lewis, Lutz, Schaefer, cessful may feed into negative self-evaluations Levinson, & Davidson, 2007). Relatively novice and feelings of failure, undermining other sugges- meditators demonstrated pervasive neural acti- tions to remain expectation-free in one’s practice. vation relative to controls when entering a medi- To formally test for the relationship between tative state, engaging in an effortful and resource intention and expectation on practice compliance, intensive process that likely was accompanied monitoring of both intentions to practice and by an altered state of awareness. However, ad- compliance could be performed on a weekly ba- vanced meditators showed little neural change sis. Additionally, to powerfully examine the role during meditation, suggesting that little distinc- of suggestion in promoting practice intentions, as tion between the meditative and baseline state well as in promoting positive and negative cycles after so many years of practice. Measurement of of compliance and enjoyment, the requirement how habitual present-moment awareness has be- mbr.synergiesprairies.ca to practice could be experimentally manipulated, come after longer periods of meditation practice including a partial or even no practice condition may be a tricky empirical issue, but measuring in an otherwise standard mindfulness course the perception and expectations around specific (Vettese et al., 2009). A more nuanced approach practice targets such as body awareness may be would manipulate practice suggestions as a func- a more tractable initial research question. Of tion of compliance and participants’ reasons for particular interest would be a person’s practice non-compliance, modulating when practice intentions and expectations for the development suggestions are used to determine their optimal of body awareness at the completion of a course, implementation. and whether such expectations predict subjective and objective improvements in body awareness Longitudinal Change in Intentional- during longitudinal follow up. ity. Concluding remarks Finally, it will be important to examine whether mindfulness fosters lasting changes in intention Intention and expectation are under-investigated that linger beyond the culmination of the thera- but potentially important contributors to the ef- peutic intervention. It is important to acknowl- ficacy of mindfulness based interventions. To be- edge that the long term design of mindfulness gin to investigate intentionality in MT, research- training is to encourage participants to incorpo- ers must begin to operationalize measures of rate mindful attention into daily life (Kabat-Zinn, instructor suggestion, participants’ expectations 1982), to integrate mindfulness into their baseline for benefit and compliance, and their intentions modes of attention. Even if intentions to continue to apply mindfulness techniques. Two potential formal mindfulness practices abate following the study strategies include prospective and retro- conclusion of an MT intervention, a participant’s spective interviewing of intervention participants,

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examining their intentions and expectations to however, if suggestion-based expectancy effects employ mindful attention, and exploring whether are formally modeled, this knowledge may help such strategies were actually employed after a gauge participant insight, i.e., changes in inten- stressful event. Longitudinal measures of how tion and expectation that cannot be explained participant’s intentions at the end of an interven- by suggestion effects alone. For example, in an tion predict well-being may also be useful mea- experiment where suggestion is manipulated sures of suggestion-based efficacy. between two groups of participants, researchers Complementing the observational measures could measure the degree to which changes in described above, some of the basic components of well-being are not accounted for by the manipula- induction common to both mindfulness and hyp- tion of suggestion. These residual improvements nosis may be manipulated. It seems unrealistic to in well-being may also be correlated with partici- manipulate each of these elements of suggestion pant’s subjective accounts of insight, and serve as in the context of separate 8-week MBSR interven- an expectancy-controlled measure of intentional tions; however, performing comparisons between changes driven by contemplative practice rather a standard MBSR course, which contains many than suggestion. if not all of these suggestions, against one that In many mindfulness intervention contexts, is stripped of expectation-generating induction the notion of suggesting contents of awareness to techniques may create powerful differences in ef- participants has been a taboo. However, perhaps ficacy. Perhaps more tractably, it may be possible it is time to seriously examine the inconsistencies to examine the effects of single-visit mindfulness between descriptions of MT and its application, inductions while manipulating one or more of particularly given the many similarities in sug- these techniques. gestion techniques found between the mindful- A caveat in this enterprise is recognizing that ness and hypnosis induction. By acknowledging not all changes in participant intentions may come the multifaceted nature of mindfulness interven- from suggestions; MT is designed to foster insight tions, the use of suggestion may motivate par- into one’s experiences, leading participants to ticipant practice completion and compliment generate their own new interpretations and per- attentional training, helping to reduce partici- spectives on emotional reactivity and personal re- pant suffering without violating the basic mind- sponsibility. Thus while the experimental manip- fulness tenets of present moment awareness and ulation of suggestion may be an effective means nonjudgment. Perhaps it is time to let go of pre- for measuring the manipulation of expectation conceptions of some idealized, expectation-free effects, observational research designs may have mindfulness intervention, and start approaching difficulty in distinguishing between the sources the ancient tradition of mindfulness training with of change in participant expectancy. Hopefully a newfound sense of curiosity. mbr.synergiesprairies.ca

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