Practicing Mindfulness Without a Mindfulness Practice:
Ethical Considerations for Teaching Mindfulness Techniques to Psychotherapy Clients

Zac Kramer, MA; Erica Aten, PsyD; and the OPA Ethics Committee

Despite the proliferation of mindfulness techniques in psychotherapy over the last 40 years (Fronsdal, 1998), the unique nature of mindfulness-based interventions has created an uncertain ethical landscape for clinicians. In general, harm to clients occurs inadvertently through lack of knowledge or experience rather than deliberate negligence. This article seeks to synthesize existing empirical and expert guidance on providing mindfulness instruction to clients so that clinicians practicing these interventions can more faithfully uphold relevant ethical principles and standards.

Mindfulness in Psychotherapy

The earliest Western efforts to marry meditation and psychotherapy began in the 1950s as a collaboration between an influential group of psychoanalysts and Japanese Zen teacher Daisetz Teitaro Suzuki, culminating in texts such as Zen Buddhism and Psychoanalysis in 1960 (Harrington & Dunne, 2015). In the decades after, Western mindfulness practitioners such as Jon Kabat-Zinn, Jack Kornfield, and Sharon Salzberg popularized meditation in the West, teaching aspects of Eastern contemplative traditions and attracting scores of people in the Western world to various meditative practices (Fronsdal, 1998). When Jon Kabat-Zinn contacted the University of Massachusetts Medical Center and proposed a secular mindfulness program for patients with chronic medical conditions, the first mindfulness-based intervention (MBI) was born (Fronsdal, 1998). Kabat-Zinn called the program Mindfulness-Based Stress Reduction (MBSR), and nearly every subsequent empirically supported MBI is, to some degree, based on this original protocol (Kabat-Zinn, 2003). Examples of MBSR outgrowths include Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2013), Mindfulness-Based Relapse Prevention (MBRP; Bowen et al., 2009), and Mindful Self-Compassion (MSC;Germer & Neff, 2019). Other evidence-based treatments incorporate mindfulness to a lesser extent, such as Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and certain branches of Cognitive Behavioral Therapy (CBT). Additionally, many psychotherapists teach their clients mindfulness skills and exercises as an ad hoc therapeutic technique. For simplicity, we will refer to all of these interventions as MBIs.

Multiple studies have found that MBIs match the efficacy of other evidence-based treatments (EBTs)––such as traditional CBT, motivational interviewing, and pharmacotherapy––for a variety of clinical presentations. These include generalized anxiety, mood disorders, and refractory depression (Hofmann et al., 2010); schizophrenia, weight/eating concerns, pain conditions, and substance use disorders (Goldberg et al., 2018); and a variety of chronic somatic conditions seen in primary care patients (Demarzo et al., 2015). One meta-analysis found positive associations between trait mindfulness and self-esteem, empathy, cognitive flexibility, expressiveness, and emotional acceptance (Keng et al., 2011). MBIs show similar levels of efficacy when used with children and adolescents (Carsley et al., 2018; Kallapiran et al., 2015; Reangsing et al., 2021).

Competence in the Instruction of Mindfulness

While MBIs have remarkable versatility, mindfulness is sometimes billed as a panacea by both researchers in the scientific literature and mental health professionals writing for popular press (for a summary of this phenomenon in the scientific literature, see Farias & Wikholm, 2016; for popular press examples, see Mukerji, 2021, and Scott, 2022). Clinicians frequently treat mindfulness as a one-size-fits-all solution for their clients, inadvertently ignoring individual differences (Farias & Wikholm, 2016). Concerningly, many clinicians are encouraged to teach mindfulness without adequate training or personal experience (Farias & Wikholm, 2016). These practices come into conflict with Principle A (Beneficence and Nonmaleficence) of the APA Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as the Ethics Code) (APA, 2017).

Clinicians’ lack of knowledge in this area is understandable. It is common for EBT manuals that recommend mindfulness to offer insufficient guidance about: (1) when mindfulness is contraindicated, (2) which mindfulness techniques to use with specific populations (e.g., children, couples), (3) which mindfulness techniques to use for specific conditions (e.g., trauma, chronic pain), and (4) how to help clients advance their mindfulness skills for maximum clinical effectiveness (Pollak et al., 2014). Take, as an example, one of the most rigorous ACT manuals, Learning ACT (Luoma et al., 2007). While this manual specifies when mindfulness is clinically indicated, it provides minimal guidance on when it is contraindicated. Additionally, other than suggesting that ACT therapists strive to be present in session and participate in mindfulness exercises alongside their clients, this manual provides scant direction about how the clinician can cultivate their own present-moment awareness.

This lack of concrete guidance, including in highly regarded treatment manuals, creates a challenge for clinicians seeking to uphold Standard 2.01 (Boundaries of Competence) of the Ethics Code, which states:

(a) Psychologists provide services… in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience. …

(c) Psychologists planning to provide services… involving… techniques… new to them undertake relevant education, training, supervised experience, consultation, or study.

Given limited empirical research on what constitutes “competent” mindfulness instruction, clinicians may struggle to acquire relevant education and training about MBIs (Crane et al., 2010). Ethics Code Standard 2.01(e) stipulates that: “In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients… from harm” (APA, 2017).

But what would be considered “reasonable steps” in these circumstances? Let’s first consider how clinicians might practice nonmaleficence before moving on to beneficence.

Nonmaleficence

Ethics Code Standard 3.04 (Avoiding Harm) requires clinicians to “take reasonable steps to avoid harming their clients.” At the most basic level, protecting clients from harm requires accounting for risks and contraindications associated with a given intervention. While mindfulness largely appears to be safe, the literature suggests that it may have some limited adverse effects. According to Van Dam et al. (2018), around 20 published case reports and observational studies have documented mindfulness-induced psychosis, mania, dissociation, severe anxiety, and intrusive trauma memories. One source also lists increased likelihood of depression and suicidal thoughts, and perhaps accordingly, high suicide risk is contraindicated by the MBSR and MBCT manuals (Crane & Kuyken, 2012). Out of an abundance of caution, screening for psychosis, suicidality, trauma symptomatology, and other psychiatric conditions should be standard when practicing MBIs.

Moreover, understanding and communicating these risks to clients is a vital part of informed consent. Standard 10.01 (Informed Consent) also stipulates that, when using interventions “for which generally recognized techniques and procedures have not been established,” psychologists should inform clients about the “developing nature of the treatment” as well as the “potential risks involved” (APA, 2017).

Beneficence

In the absence of research-based standards for MBI training and delivery, it is reasonable for clinicians aspiring toward beneficence to defer to the recommendations provided by the creators of “gold-standard” MBIs, prominent researchers in the mindfulness literature, and veteran MBI instructors. The consensus among these groups is that effective mindfulness programming entails several important considerations, the complexity of which may surprise many clinicians who currently teach mindfulness to their clients (Pollak et al., 2014). These considerations include technique (e.g., body scan, walking meditation); choice of mindfulness “object” (e.g., an internal object like one’s own breath vs. an external object like sounds); clinical presentation (e.g., “urge surfing” for substance use disorder); and which skills to emphasize (e.g., concentration training to support “stepping back” vs. open monitoring to support “leaning in”) (Pollak et al., 2014). One of the most important of these considerations is deciding whether to help clients turn toward “safety” (e.g., reduced physiological arousal) or “sharp points” (e.g., inner conflicts and disavowed emotions) (Pollak et al., 2014). Clients with low distress tolerance or who are easily overwhelmed by intrusive thoughts are best encouraged toward safety, while clients seeking greater integration of disavowed emotions may wish to turn toward sharp points (Pollak et al., 2014). Clinicians referring a client to mindfulness/meditation smartphone applications (such as Headspace or Calm) should provide psychoeducation on which technique(s), mindfulness object(s), and skill(s) would be best suited to the client’s clinical presentation and treatment goals. Clinicians who use a one-size-fits-all approach may be frustrated when their clients do not benefit from mindfulness, or worse, deteriorate.

Practicing Mindfulness without a Mindfulness Practice

Should clinicians delivering MBIs have personal experience practicing mindfulness or meditation? Clinicians providing mindfulness instruction to clients can be excused from overlooking a possible need for direct practice. After all, in many cognitive-behavioral approaches, there is a strong emphasis on clinicians developing skills and expertise but less emphasis on clinicians’ experiential use of the concepts they teach clients (Shafran et al., 2009). Additionally, there is little in the way of empirical research that evaluates whether mindfulness instructors’ personal use of mindfulness impacts client outcomes. Even Marsha Linehan (the creator of DBT), who was herself a Zen student, does little in the principal DBT manual to encourage clinicians’ direct experience with mindfulness despite it being a central pillar of the DBT protocol (Linehan, 2018).

However, a foundational prescription in MBSR and MBCT (two of the gold-standard MBIs) is that mindfulness instructors should have their own dedicated mindfulness practice (Segal et al., 2013). This message is echoed frequently by other instructional texts on teaching mindfulness to clients (Pollak et al., 2014). The creators of these gold-standard MBIs warn sternly against situations in which therapists with little mindfulness experience feel they can teach an MBI once they have studied the associated manual (Kabat-Zinn, 2003; Segal et al., 2013). The creators of MBSR, for example, recommend that instructors have: (1) an ongoing personal practice, (2) basic teacher training (e.g., learning protocol and underlying psychological theory), and (3) advanced mindfulness training (e.g., attending meditation retreats, receiving supervision from a mindfulness teacher, learning Buddhist underpinnings of secular mindfulness practices) (Crane et al., 2010).

Clinicians may be surprised by the rigor of these recommendations, but there are at least three compelling reasons why MBI practitioners might benefit from personal practice. First, one of the most clinically relevant uses of mindfulness is to help clients relate differently to negative affect. Mindfulness students learn better when the instructor is able to model mindfulness in their own approach to problems that arise in session (Crane et al., 2010). As Crane et al. (2010) explained, “Learning is communicated in the class through the teacher’s direct personal experience of ‘being,’ and … this experience is gained through mindfulness practice” (p. 78). Second, a personal mindfulness practice facilitates the hands-on experience needed to understand and address client difficulties (Pollak et al., 2014). This is akin to therapists receiving their own therapy to get an “inside view” of the client experience. The creators of MBCT are explicit that their respect for clients using mindfulness increased dramatically after beginning their own mindfulness practices (Segal et al., 2013). The same authors also emphasize that personal practice facilitates more effective pacing of mindfulness skill building and better troubleshooting of issues that commonly arise for clients (Segal et al., 2013). Third, without a mindfulness practice, mindfulness instructors may be at higher risk of colluding with their clients’ emotional avoidance. Segal et al. (2013) stated that, “If a therapist is afraid of powerful affects, [they] may nudge patients toward safety to avoid [their] own discomfort,” and similarly, “If a therapist is insecure about [their] therapeutic talents and feels a need to show progress, [they] may nudge patients prematurely toward the sharp points” (p. 24). In other words, if mindfulness instructors can learn to work skillfully with their own powerful emotions and insecurities, they can minimize iatrogenic effects when delivering MBIs (Segal et al., 2013). Thus, in the opinion of the creators of gold-standard MBIs––who are also often veteran mindfulness researchers, instructors, and practitioners––having a personal mindfulness practice is necessary to uphold the ethical principles/standards of beneficence, nonmaleficence, and competence when delivering MBIs.

Conclusion

Clinicians using MBIs should keep in mind that these interventions, like any others, come with a unique set of risks and benefits. In the absence of empirical guidance for MBI training and delivery, the use of mindfulness in psychotherapy can rightly be considered an emerging treatment, and thus many of our best practices for delivering MBIs are derived from the experience of veteran mindfulness instructors, researchers, and practitioners. To uphold Ethics Code principles/standards of beneficence, nonmaleficence, competence, avoidance of harm, and informed consent, these experts recommend that clinicians delivering MBIs should:

1. Assess clients for psychosis, suicidality, trauma symptomatology, and other psychiatric conditions, and consider the appropriateness of MBIs if these conditions are present (or make appropriate adjustments)
2. Inform clients about the developing nature of MBIs as well as possible risks (e.g., worsening of negative affect, intrusive memories, etc.)
3. Obtain relevant education and seek supervised training from an experienced MBI practitioner
4. Take into account expert guidance on which technique(s), mindfulness object(s), and skill(s) would be best suited to a client’s clinical presentation and treatment goals. Clinicians should provide clients with psychoeducation about these factors, especially when recommending outside mindfulness resources, such as smartphone applications.
5. Develop a personal mindfulness practice (e.g., meditation), ideally under the guidance of an experienced mindfulness teacher. Clinicians are also encouraged to seek mindfulness teacher training.

We encourage further reading into clinical and ethical factors not fully addressed here. For more guidance on clinicians developing their own mindfulness practices and best practices for using mindfulness techniques with clients, please see:

Ivtzan, I. (Ed.). (2019). Handbook of mindfulness-based programmes: Mindfulness interventions from education to health and therapy. Routledge. ISBN: 9781138240940.

Pollak, S. M., Pedulla, T., & Siegel, R. D. (2014). Sitting together: Essential skills for mindfulness-based psychotherapy. Guilford Press. ISBN: 9781462513987

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press. ISBN: 9781462507504.

References

American Psychological Association [APA]. (2017). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code/

Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., Clifasefi, S., Garner, M., Douglass, A., Larimer, M. E., & Marlatt, A. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295–305. https://doi.org/10.1080/08897070903250084

Carsley, D., Khoury, B., & Heath, N. L. (2018). Effectiveness of mindfulness interventions for mental health in schools: A comprehensive meta-analysis. Mindfulness, 9, 693-707.

Crane, R. S., & Kuyken, W. (2012). The implementation of mindfulness-based cognitive therapy: Learning from the UK health service experience. Mindfulness, 4, 246–254. doi:10.1007/s12671- 012-0121-6

Crane, R. S., Kuyken, W., Hastings, R. P., Rothwell, N., & Williams, J. M. G. (2010). Training teachers to deliver mindfulness-based interventions: Learning from the UK experience. Mindfulness, 1, 74-86.

Demarzo, M. M., Montero-Marin, J., Cuijpers, P., Zabaleta-del-Olmo, E., Mahtani, K. R., Vellinga, A., Vicens, C., López-del-Hoyo, Y., & García-Campayo, J. (2015). The efficacy of mindfulness- based interventions in primary care: A meta-analytic review. Annals of Family Medicine, 13(6), 573–582. https://doi.org/10.1370/afm.1863

Farias, M., & Wikholm, C. (2016). Has the science of mindfulness lost its mind? BJPsych Bulletin, 40(6), 329-332. doi:10.1192/pb.bp.116.053686

Fronsdal, G. (1998). Insight meditation in the United States: Life, liberty, and the pursuit of happiness. In C. S. Prebish, & K. K. Tanaka (Eds.), The faces of Buddhism in America (pp. 163-182). University of California Press.

Germer, C., & Neff, K. D. (2019). Mindful self-compassion (MSC). In I. Itvzan (Ed.), The handbook of mindfulness-based programs: Every established intervention, from medicine to education (pp. 357-367). Routledge.

Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52-60.

Harrington, A., & Dunne, J. D. (2015). When mindfulness is therapy: Ethical qualms, historical perspectives. The American Psychologist, 70(7), 621-631.

Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169–183. https://doi.org/10.1037/a0018555

Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8(2), 73-82.

Kallapiran, K., Koo, S., Kirubakaran, R., & Hancock, K. (2015). Effectiveness of mindfulness in improving mental health symptoms of children and adolescents: A meta‐analysis. Child and Adolescent Mental Health, 20(4), 182-194.

Keng, S. L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6), 1041–1056. https://doi.org/10.1016/j.cpr.2011.04.006

Linehan, M. M. (2018). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance & commitment therapy skills-training manual for therapists. New Harbinger Publications.

Mukerji, I. (2021, May 17). Here’s everything you should know about mindfulness and how to practice it. HealthShots. Retrieved May 7, 2023, from https://www.healthshots.com/mind/happiness-hacks/ heres-everything-you-should-know-about-mindfulness-and-how-to-practice-it/

Pollak, S. M., Pedulla, T., & Siegel, R. D. (2014). Sitting together: Essential skills for mindfulness-based psychotherapy. Guilford Press.

Reangsing, C., Punsuwun, S., & Schneider, J. K. (2021). Effects of mindfulness interventions on depressive symptoms in adolescents: A meta-analysis. International Journal of Nursing Studies, 115, Article 103848. https://doi.org/10.1016/j.ijnurstu.2020.103848

Scott, E. (2022, September 19). How to Become More Mindful in Your Everyday Life. Verywell Mind. https://www.verywellmind.com/mindfulness-exercises- for-everyday-life-3145187

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). Guilford Press.

Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., Freeston, M., Garety, P. A., Hollon, S. D., Ost, L. G., Salkovskis, P. M., Williams, J. M., & Wilson, G. T. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47(11), 902–909. https://doi.org/10.1016/j.brat.2009.07.003

Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C. D., Olendzki, A., Meissner, T., Lazar, S. W., Kerr, C. E., Gorchov, J., Fox, K. C. R., Field, B. A., Britton, W. B., Brefczynski-Lewis, J. A., & Meyer, D. E. (2018). Mind the hype: A critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspectives on Psychological Science: a Journal of the Association for Psychological Science, 13(1), 36 61. https://doi.org/10.1177/1745691617709589