Data reported below are from qualitative interviews and support group session notes unless otherwise noted.
Elements of the Skills-based Training
Therapists identified several factors that increased their receptivity to the training. For some, the diversity of the teaching staff had a positive impact. “As a woman of color,” one clinician said, “I was glad that there was a person of color presenting, that it wasn’t just two white men”.
Affirmation from the clinic’s administrative staff also fostered receptivity. The medical director supported the program’s development and participated in the training. His presence was noted by some participants as supporting their desire to further develop their clinical skills. “It is important that leadership was involved to sponsor and validate [the training]… and he wants the center to value mindfulness.”
Experiential aspects of the training, including the meditation scripts and the dyad and triad role-play exercises, fostered skill development. Participants responded favorably to the blending of instruction, practice, discussion and exercises and to the interactive nature of the training. One therapist stated, “I definitely thought the experiential pieces [that] we were getting to do were really helpful. When I was on the receiving end of getting a training – that helps solidify and give the recipient a hands-on experience.”
Participants described the program scripts and recorded meditations as beneficial, tangible, and relevant to their clinical work. “I liked the resources; how accessible they were ….so we could look it over, and practice leading a partner into a meditation.”
A number of participants noted that their learning was enhanced by the case presentation of a woman who benefitted over several sessions from mindfulness practices adapted to her treatment for depression and pain. A number of participants commented on the breadth of practices and expressed an appreciation for the instructors’ willingness to provide therapeutic and theoretical context for the curriculum. They felt the curriculum explained the scope and application of mindfulness practices as well as the integration of mindfulness with other therapeutic modalities, such as DBT and trauma-focused CBT.
In the evaluation form administered at the end of the last training session, participants commented favorably on the clarity of the instruction, the accepting and encouraging atmosphere, and the use of guided meditations. Several wanted further sessions and ongoing reinforcement of the material as well as continued access to the meditations and resources on the course webpage.
Building Therapists’ Personal Practice
Therapists spontaneously commented on their personal benefit from learning about and practicing mindfulness. One therapist said, “I do [mindfulness] sporadically when my stress levels become really high.. . when I need to ground.” Some perceived how the benefits of mindfulness spilled over from therapist to patient; for instance, one therapist commented, “I think mindfulness is an incredible tool to be able to model for somebody else how to stay present and navigate difficult moments.” One of the perceived personal benefits was to enhance their skill as a clinician: “I think mindfulness makes a person a better clinician in that you’re more sensitive, more compassionate, with yourself and with another person, more aware of what is happening in the moment. Being a clinician is really hard, we all struggle in the moment with all kinds of difficulties, our own challenges when we’re engaging with a patient.”
Clinicians who reported having a personal mindfulness practice said their experience prepared them to introduce mindfulness to their clients. They felt that on-going practice would make them more effective in guiding clients during sessions. One clinician commented, “There are a couple of reasons why personal practice is important…if you don’t practice yourself, it’s hard to tell other people to practice and how to problem-solve.” A second clinician emphasized how ongoing practice boosts confidence. She said, “Individually, it gives me more confidence if I’m practicing regularly the mindfulness strategies that we learned.”
In the six-month follow-up survey that was sent to therapists who completed the training, 11 responded, and 9 stated that the training workshops had influenced their practice. Compared to the pre-training survey, the six-month post-training survey revealed a moderate increase in the number of therapists who practiced meditation on their own and in their practice with clients. (Table 3).
Integrating Mindfulness into Clinical Practice
In the post-training interviews, clinicians remarked on several challenges they faced integrating mindfulness practices into their clinical work. Some bilingual participants commented on the lack of scripts in languages other than English. They felt the availability of scripts in Spanish and Chinese, the predominant languages of their clients, would facilitate implementation. A number of therapists felt client receptivity was possible if the introduction to mindfulness was culturally sensitive. One therapist’s strategy was to avoid the word “mindfulness” and refer to the practices as “tools” that could be used to address a specific issue, for instance, improving one’s relationship with a spouse. One therapist who worked with adolescents stated, “Helping them understand what it is, and doing it again and again, it’s a slow process. I have never had a kid that didn’t benefit from it.”
Clinicians questioned the acceptability and practicality of integrating mindfulness into the clinic setting. Some said mindfulness for clients facing ongoing psychosocial crises, trauma, and severe mental illnesses seemed inappropriate. In the follow-up survey, six therapists of 11 identified that some clients were not interested in mindfulness, and two that mindfulness practice may not be appropriate for some clients. “My clients don’t really want to focus on mindfulness if they have so many things they want to tell me… With our particular clients, sometimes you’re able to use mindfulness, but sometimes you have to address crises…. If they’re in crisis, you have to focus on problem-solving.… With mindfulness and meditation,. .. we’re asking them to practice awareness and attention regulation skills that are somewhat challenging to do.”
In both the interviews and the six-month follow-up survey, time constraints were mentioned as a major impediment for integrating mindfulness into practice. Clinicians commented that that their large caseloads and the abbreviated length of the typical psychotherapy session (30 minutes) did not allow sufficient time with each client to teach mindfulness effectively. In the follow-up survey, 9 of 11 (82%) participants stated that insufficient time was the biggest obstacle to incorporating mindfulness into their practice.
Therapists’ lack of confidence in their own practice was a barrier to implementation with clients. In the follow-up survey, five of 11 believed they lacked confidence to do the practice on their own or with clients, three therapists identified their lack of a personal practice as a challenge to bringing mindfulness into sessions, and three did not feel comfortable leading mindfulness practices with clients. Therapists who practiced on their own and introduced mindfulness into clinical sessions, however, reported benefits.
In the six-month follow-up survey, nine of 11 respondents indicated that they were using mindfulness in sessions. Before the training, 29% reported that had occasionally or frequently used mindfulness with clients; after the training 64% of the respondents said they did (Table 3).
Therapists were selective about which patients they chose for mindfulness practice. “I’ve been incorporating a lot of the scripted meditations. I’m using it with a handful of patients. Meditating with the breath, body scan, body sensations.. . I’ve been working with thoughts, with patients who are anxious about pain.”
In the six-month follow-up survey, therapists reported using mindfulness most often with anxious clients or those with a history of trauma (Fig. 1: Client Issues for Which Mindfulness Was Perceived by Therapists to Be Most Helpful).
In the interviews, therapists stated that the busyness of the clinic and the diversity of the clients were obstacles but that the support group assisted integration. One therapist stated, “There are so many nuances to teaching mindfulness and bringing it into a clinical setting that it would take more…. It’s a life approach really.”
Integration and acceptability of meditation with clients were also explored in the support group. Seven therapists attended the support group regularly. Some reported obstacles when working with Hispanic clients who viewed meditation and mindfulness as counter to the Christian faith. Therapists working with people of color, both adults and teens, noted that mindfulness and meditation were sometimes seen as practices of privileged white people that had no relevance to them. Clinicians noted that support group sessions — which encompassed group practice, discussion, case presentations, and information about trauma-sensitive mindfulness  — helped them to continue practicing and learn more about the applications of mindfulness. All seven respondents who attended the support group found the sessions provided opportunities to share experiences and supported their own practices. Of those who hadn’t attended these sessions, most stated in the six-month online survey that they didn’t have time in their busy schedules; one stated that the meeting time was not convenient, and one was not implementing mindfulness interventions.