CORRECTED APRIL 24, 2010; SEE LAST PAGE Psychotherapy Theory, Research, Practice, Training © 2010 American Psychological Association 2010, Vol. 47, No. 1, 83–97 0033-3204/10/$12.00 DOI: 10.1037/a0018842 PSYCHOTHERAPIST MINDFULNESS AND THE PSYCHOTHERAPY PROCESS NOAH G. BRUCE, RACHEL MANBER, SHAUNA L. SHAPIRO, AND MICHAEL J. CONSTANTINO Oakland Psychiatry and Behavioral Medicine, Oakland Medical Center, Oakland, California A psychotherapist’s ability to relate to therapists to develop quality relationships with his or her patients is essential for de- patients (e.g., Castonguay, Constantino, & Holt- creasing patient suffering and promot- forth, 2006). Instead, psychotherapy researchers have directed most of their energies toward dis- ing patient growth. However, the psy- cerning which psychotherapeutic techniques are chotherapy field has identified few most effective for alleviating specific symptoms effective means for training psychother- (e.g., Lambert & Ogles, 2004; Roth & Fonagy, apists in this ability. In this conceptual 2005). As we address this imbalance, the goal of article, we propose that mindfulness the present conceptual article is to promote a practice may be a means for training dialogue about the role that a psychotherapist’s mindfulness plays in the psychotherapy process, psychotherapists to better relate to their specifically in the development of the patients. We posit that mindfulness is a psychotherapist–patient relationship. We propose means of self-attunement that increases that a psychotherapist’s ability to be mindful one’s ability to attune to others (in this (psychotherapist mindfulness) positively impacts case, patients) and that this interper- his or her ability to relate to patients. We posit sonal attunement ultimately helps pa- that mindfulness may be a method for developing and optimizing clinically beneficial relational tients achieve greater self-attunement qualities in a psychotherapist such as empathy, that, in turn, fosters decreased symptom openness, acceptance, and compassion. Although severity, greater well-being, and better this hypothesis has yet to be substantiated empir- interpersonal relationships. ically, we believe that the evidence, both empir- ical and theoretical, suggests a link between mindfulness and relational capacity. Our discus- Keywords: mindfulness, attunement, sion draws primarily from psychotherapy re- meditation, empathy, clinical training, search, theoretical work in the field of attach- therapeutic relationship ment, and empirical, theoretical, and Buddhist studies of mindfulness. Mindfulness has been proposed as a form of Research consistently shows that effective psy- self-attunement that increases one’s capacity to chotherapists are best distinguished in terms of attune with others (Siegel, 2007). We believe that effectiveness by their ability to relate to their the ability to attune with others can be learned, patients (Lambert & Barley, 2001; Lambert & and that this ability is at the heart of a healing, Okishi, 1997). However, there has been limited empathic relationship. We propose that through empirical focus on methods of training psycho- mindfulness practice, a psychotherapist comes to increasingly know and befriend himself or her- self, fostering his or her ability to know and Noah G. Bruce, Rachel Manber, Shauna L. Shapiro, and befriend the patient. We further believe that the Michael J. Constantino, Oakland Psychiatry and Behavioral Medicine, Oakland Medical Center, Oakland, California. psychotherapist’s ability to form an attuned, em- Correspondence regarding this article should be addressed pathic relationship with the patient can lead to to Noah G. Bruce, Oakland Psychiatry and Behavioral Med- improvement in the patient’s ability to self- icine, Oakland Medical Center, 3900 Broadway, Oakland, CA attune, and that this ability can, in turn, diminish 94611. E-mail: [email protected] suffering, promote greater well-being, and in- 83 Bruce, Manber, Shapiro, and Constantino crease the patient’s ability to form and maintain (a) the psychotherapist’s own body and mind, (b) interpersonal relationships. Ultimately, we posit the patient, and (c) the relationship as it plays out that a greater focus on the impact of psychother- moment by moment between psychotherapist and apists’ mindfulness may contribute to the field’s patient. This process is akin to Sullivan’s (1953) understanding of ways in which psychotherapists notion of the psychotherapist as a participant- can be trained to foster positive relational expe- observer of self, other, and process. riences in psychotherapy. The second element is attitudinal. Although the ability to pay attention is essential to mindful- Mindfulness ness, the experience of mindfulness is more than “bare awareness” (S. L. Shapiro et al., 2006). Mindfulness refers to a psychological process, Mindful awareness is infused with attitudes of a type of meditation practice, and a theoretical curiosity, openness, and acceptance (Lau et al., concept (Brown, Ryan, & Cresswell, 2007; 2006). Siegel (2007) used the acronym COAL to Germer, 2005). The concept and practice of refer to a similar list of qualities: curiosity, open- mindfulness are rooted in Buddhism; however, ness, acceptance, and love. These attitudes may the psychological process is universally applica- be considered the “heart” aspects of the practice, ble, and not exclusive to any one culture or reli- and they differentiate mindfulness from solely gion. Just as the mind can be sleepy, daydream- cognitive pursuits (W. D. Morgan & Morgan, ing, concentrated, emotional, or scattered, the 2005; S. L. Shapiro & Schwartz, 2000). In fact, mind can also be mindful. Mindfulness medita- the Asian character for “mindfulness” is com- tion helps practitioners cultivate this quality of posed of two interactive figures: one mind and consciousness, dwelling in it more frequently and the other heart (Santorelli, 1999). Rinpoche for longer periods (Kabat-Zinn, 2003; S. L. Sha- (1993), writing from the perspective of a vener- piro, Astin, Carlson, & Freedman, 2006). ated Tibetan Buddhist monk, put it this way: Western science has had a difficult time agree- “[mindfulness has] the flavor of boundless ing on a definition of mindfulness (Hayes & space, so warm and cozy that you feel envel- Shenk, 2004). As Gunaratana (2002, p. 137) oped and protected by it, as if by a blanket of noted, “You can play with word symbols all day sunshine” (p. 61). long and you will never pin it down completely.” For the psychotherapist, this element of mind- However, it is important to have an operational fulness may involve the intention to relate to definition for the purposes of academic explora- whatever arises in the psychotherapy process tion. An oft-cited definition in the literature is, with an attitude of COAL. We suggest that Sie- “The awareness that emerges through paying at- gel’s acronym COAL is actually hierarchical in tention on purpose, in the present moment, and that it is likely easiest to relate with curiosity to a nonjudgmentally to the unfolding of experience patient, and likely most challenging to actually moment to moment” (Kabat-Zinn, 2003, p. 145). love a patient, particularly a difficult patient. This This definition can be broken down into three core is not an easy task, for what arises in psychother- mindfulness elements: (a) attention, (b) attitude, and apy is sometimes unpleasant. The mindful psy- (c) intention (S. L. Shapiro et al., 2006). chotherapist would intend to greet with COAL The first element is the ability to keep one’s not only the likable aspects of the patient’s per- attention in the present moment. This ability re- sonality, but also the patient’s darker feelings of quires suspension of all manner of interpreting anger, jealousy, loss, hate, and pain. We suggest experience and simply attending to the experi- that it is the patient’s ability to be increasingly ence itself (S. L. Shapiro et al., 2006). The op- vulnerable and the psychotherapist’s ability to posite of such attention is being lost in thought or connect with this vulnerability that allows the being on autopilot. In mindfulness meditation, psychotherapist to relate to the patient’s difficult the practitioner trains in catching oneself when feelings with a deepening progression from curi- one’s mind drifts from the present moment and osity to openness, acceptance, and ultimately, returning the attention gently to the here and now. love. He or she would also intend to relate with Over time, the practitioner’s ability to attend to COAL to his or her own thoughts, emotions, and the present without drifting is increased. In psy- sensations, including feelings of boredom, fear, chotherapy, this ability can mean being aware, in and frustration. Finally, he or she would intend to the present moment, of three objects of attention: approach the therapeutic relationship with 84 Psychotherapist Mindfulness and Psychotherapy COAL, in whatever stage the relationship is in, ilar process of bidirectional communication in a be it healthy and productive or stormy and stuck. videotaped psychotherapy case study. She de- The third element of mindfulness is intention, scribed in detail how she as the psychotherapist which directly affects mindfulness practice. Indi- communicates her understanding of her patient’s viduals practice mindfulness with different inten- feelings state through facial expression, body tions and, according to a study by D. H. Shapiro posture, and speech including tone, cadence, and (1992), meditators tend to realize