“Mindfulness-based stress reduction (MBSR) is more than just a

protocol, and this book is more than just a manual. It is a clear,

cogent, and comprehensive guide to the teaching of mindfulness that
is borne of the collective wisdom and experience of two remarkably
gifted teachers and trainers. This book is a detailed reference and
companion guide to teaching this transformational program that
acknowledges the primary role of the embodiment of the teacher. I
highly recommend this book to teachers of MBSR at every level of
experience. You’ll be glad you have it.”
—Steven D. Hickman, PsyD, executive director at the Center
for Mindful Self-Compassion, founding director of the UC
San Diego Center for Mindfulness, and associate clinical
professor at the UC San Diego School of Medicine

“What a wonderful offering on the art and science of MBSR and its
implementation with an emphasis on trauma sensitivity, inclusivity,
and diversity in serving all who live with stress, pain, or illness.”
—Bob Stahl, PhD, senior MBSR teacher at the Mindfulness
Center at Brown University, and coauthor of A Mindfulness-
Based Stress Reduction Workbook, Living with Your Heart
Wide Open, Calming the Rush of Panic, and MBSR Every
Day

“This book goes to the heart of MBSR. It will prove to be an

invaluable companion for MBSR teachers worldwide. The essence
and spirit of the MBSR curriculum shines through, along with clear,
practical, and down-to-earth guidance on form and structure. The
writing honors the established integrity of the MBSR program, and
simultaneously clearly communicates the relevance and contribution
the program makes to this moment in history. A timely and welcome
contribution to our field.”
—Rebecca Crane, PhD, director of the Centre for Mindfulness
Research and Practice at Bangor University in the UK, and
author of Mindfulness-Based Cognitive Therapy
“This wonderful book skillfully balances the practical of what,
where, and who we teach with the conceptual/experiential of why
and how. Importantly, it explores key issues in our field, including
curriculum drift and dilution, certification, diversity, and online
delivery among others. It is suitable for both new teachers-in-
training, as well as the continuing education and development of
established teachers of MBSR and other mindfulness programs. A
huge contribution!”
—Evan J. Collins MD, FRPCPC, assistant professor in the
department of psychiatry at the University of Toronto, and
coauthor of Mindfulness-Based Cognitive Therapy

“There is so much wisdom and skill here. It should be required

reading for MBSR teacher training, and even experienced
mindfulness instructors stand much to gain. From their personal
experience of practice and ‘teaching from the practice,’ these highly
skilled trainers weave together valuable insights of embodiment and
inquiry, and provide the most thorough discussion of the pedagogy
of teaching mindfulness-based practices to be found anywhere.”
—Carl Fulwiler, MD, PhD, director of the MBCT training
program at Cambridge Health Alliance

“In the four decades since MBSR was founded, teachers have
developed a great deal of wisdom and practical knowledge about
how to make it work most effectively for participants. Woods and
Rockman are two of the very best. They offer both deep insight and
fingertip feel for how to engage participants of all kinds in MBSR as
a living, breathing curriculum—not a static checklist of to-dos. They
understand how to be both very faithful to the pillars of this
groundbreaking program, and responsive to the needs of those who
come to it at critical junctures in their lives. It also provides a
treasure trove of resources for MBSR trainers.”
—Barry Boyce, founding editor of Mindful magazine and
www.mindful.org
“As one of the very first MBSR teachers with Jon Kabat-Zinn, I’m
thrilled to recommend this excellent book. Stunningly thorough and
full of integrity, it is a godsend for anyone aspiring to teach MBSR
and mindfulness-based programs. Based on their decades of
experience, the authors’ unstinting generosity in offering detailed
instructions to prospective teachers embodies the heart of what they
are teaching. May the clarity, honesty, and power of their guidance
on diversity and cultural relevance inspire everyone in the field!”
—Trudy Goodman, PhD, founding teacher at InsightLA,
cofounder of the Institute for Meditation and Psychotherapy,
and the fourth person trained to teach MBSR with Jon Kabat-
Zinn

“This wonderful book provides a trustworthy resource for anyone

curious about MBSR. Written concisely, and packed with concrete
examples, the authors provide an informative manual for delivering
MBSR contextualized in the history, philosophy, and aspirations of
the program. I was blown away by the quality of writing, especially
on how a teacher can best embody mindful presence, and it was so
helpful to see common pitfalls identified as well. Highly
recommended!”
—Norman Farb, PhD, associate professor of psychology at
the University of Toronto Mississauga
 Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject
matter covered. It is sold with the understanding that the publisher is not engaged in rendering
psychological, financial, legal, or other professional services. If expert assistance or counseling is
needed, the services of a competent professional should be sought.
Distributed in Canada by Raincoast Books
Copyright © 2021 by Susan Woods and Patricia Rockman
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
Cover design by Amy Daniel; Acquired by Ryan Buresh; Edited by Karen Levy; Indexed by James
Minkin; Illustrations by M. Lee Friedman
All Rights Reserved

Library of Congress Cataloging-in-Publication Data

Names: Woods, Susan L., MSW, author.
Title: Mindfulness-based stress reduction : protocol, practice, and teaching skills / Susan Woods,
Patricia Rockman, Diane Reibel, Jon Kabat-Zinn.
Description: Oakland, CA : New Harbinger Publications, [2021] | Includes bibliographical references
and index.
Identifiers: LCCN 2020041612 (print) | LCCN 2020041613 (ebook) | ISBN 9781684035601 (trade
paperback) | ISBN 9781684035618 (pdf) | ISBN 9781684035625 (epub)
Subjects: LCSH: Mindfulness (Psychology) | Stress (Psychology) | Mental health.
Classification: LCC BF637.M56 W66 2021 (print) | LCC BF637.M56 (ebook) | DDC 158.1/3--dc23
LC record available at https://lccn.loc.gov/2020041612
LC ebook record available at https://lccn.loc.gov/2020041613
In memory of Ferris Buck Urbanowski, 1940–2019. —S. W.
To Evan Collins. —P. R.
 CONTENTS

Foreword
Introduction

Part 1: The Landscape of Teaching Mindfulness-Based Stress

Reduction
Chapter 1: From Buddhism to Present-Day Mindfulness
Chapter 2: Becoming an MBSR Teacher: What Do You Really Need?
Chapter 3: Teaching Frameworks

Part 2: The MBSR Curriculum/Protocol

The Orientation Session
Session 1: Introduction to Mindfulness and “Being” Mode of Mind
Session 2: The Role of Perception and Learning to “Be” with All Experiences
Session 3: “Being and Doing”
Session 4: Stress and Stress Reactivity
Session 5: Responding to Stress
Session 6: Stressful Communications
The All-Day Retreat
Session 7: Interacting with the World, Skillful Choices, and Self-Care
Session 8: Keeping the Practice Alive

Part 3: Beyond Curriculum/Protocol into the Heart of Teaching

Chapter 4: Presence, Form, and Process: Embodiment
Chapter 5: Presence, Form, and Process: Inquiry

Part 4: Adaptations of the Curriculum/Protocol

Chapter 6: Applying MBSR to Clinical Populations
Chapter 7: Mindfulness in Education and in the Workplace
Chapter 8: Diversity and Cultural Relevance: Reaching Underserved
Communities
Chapter 9: Research, Limitations, and Risks

Part 5: The Professionalization of MBSR: Maintaining

Competence
Chapter 10: Training and Professional Development
Acknowledgments
Appendices
Intake/Assessment Form
Consent to Participate and Waiver of Responsibility
Confidentiality Agreements
Client Acknowledgment and Agreement
Consent to Use Electronic Communications (when there is no encryption)
Midcourse Check-In
Meditation Scripts
Mindful Yoga
Poetry
Teaching MBSR Online: Considerations
References
Index
 FOREWORD

“Let the beauty we love be what we do.” —Rumi

What a joy to immerse myself in reading Mindfulness-Based Stress

Reduction: Protocol, Practice, and Teaching Skills. I wish this book had
been available to me as a beginning teacher of Mindfulness-Based Stress
Reduction (MBSR) twenty-five years ago. Simply stated, it is an engaging,
comprehensive, and up-to-date guide for teaching MBSR.
Susan Woods and Patricia Rockman have been training teachers of
MBSR and mindfulness-based cognitive therapy (MBCT) for years. Their
collaboration offers gems: wisdom, insight, and practical instructions
supporting the development of new and experienced teachers. With
exquisite clarity, they emphasize how skillful teaching depends upon one’s
personal practice, the use of specific teaching skills, and fidelity to a
curriculum. I truly appreciate their reference to the MBSR curriculum as a
“living document.” Certainly, the teacher must know the curriculum
intimately, and at the same time be open and flexible to be able to respond
to what arises in the classroom moment to moment. This requires the
teacher’s “embodied mindful presence.” The authors illuminate the
distinguishing features of this essential quality of embodiment in teaching
MBSR.
Readers will appreciate the exploration of mindful inquiry, which is
often reported by new and experienced teachers to be the most challenging
aspect of teaching. The form and process of skillful inquiry are illustrated
through numerous detailed examples found in the book.
It is a service to all teachers that the authors address tensions inherent
in our rapidly changing field. Chief among them is maintaining the integrity
of mindfulness-based programs as they are adapted for specific populations
and different settings. With the increasing influence of a marketplace
wanting quick-fix programs, this can be especially challenging.
 The lack of consensus regarding MBSR teacher training programs and
best practices is another source of tension. Perhaps some of us would rather
turn away from these tensions to simply do what we love—and that is, to
teach. Yet, it is imperative that, individually and collectively, we turn
toward these issues, addressing them in open dialogue within the greater
mindfulness teacher community. It is encouraging that conversations on
these complex issues have already begun among international mindfulness
teacher trainers.
The publication of this book comes at a critical time. As I write this
foreword in July 2020, we are in the midst of a global pandemic.
Consequently, MBSR programs have had to quickly transition to virtual
formats around the world. I am thankful for the host of practical suggestions
the authors have for delivering MBSR virtually. They include ways to adapt
MBSR content, how to work with technology, and direction for creating
group guidelines.
Not only are we in the midst of a health crisis worldwide, but here in
the United States we are also experiencing historic mass protests against
systemic racial injustice. There is a monumental call to action on every
level to achieve racial and social equity. The chapter on diversity and
cultural relevance is particularly timely, and reading it was very meaningful
and inspiring to me both professionally and personally. One may assume
that the principles of mindfulness would engender diversity and inclusion.
In reality, there is a lack of diversity in MBSR program participants and
teachers. This is compounded by limited access to mindfulness programs in
underserved communities and scant research about mindfulness and health
outcomes in diverse populations.
It is heartening to know that there is increased interest and dialogue in
the field on these highly relevant and important issues of diversity and
equity. There is a pivotal change happening at many mindfulness and
meditation centers to bring mindfulness to underserved communities and to
train teachers from a variety of racial, ethnic, and socioeconomic
backgrounds.
There are barriers to disseminating mindfulness to diverse groups, and
many challenges doing this work. We all have a great deal to learn about
adapting programs that are inclusive, culturally sensitive, and accessible to
a wide range of people.
 May we embrace the many invitations to deepen and expand our work
and may we serve well.
I offer my deep gratitude to Susan Woods and Patricia Rockman for
this invaluable book.
—Diane Reibel, PhD
Director, Myrna Brind Center for Mindfulness
Clinical Associate Professor, Department of Integrative Medicine
Sidney Kimmel Medical College
Thomas Jefferson University
 INTRODUCTION

This book is our attempt to provide you with a guide on how to teach
MBSR that relies on the structure or frame of the curriculum or protocol,
the embodiment of the teacher’s practice, and his teaching skills. The
intention is to explicate a clear foundation from which to teach that also
gives you flexibility to respond to the needs of your group. It is often said
that there is “freedom in structure,” and we believe this to be the case when
learning to teach MBSR. By coming to deeply know the modularity and
content of this program, you, the teacher, can develop a frame of reference
upon which to draw in any given moment. Both the modularity and the
content are elements of this book that are clearly laid out in a way that we
believe meet the needs of the novice or experienced teacher.
There is also consensus that embodying mindfulness practice is an
essential aspect of teaching any mindfulness-based program (MBP). We
know that embodiment occurs over time, coming out of the teacher’s direct
experience and practice of mindfulness. Thus, it is a developmental process,
one of maturation that ultimately enables the teacher to teach from practice
when delivering the meditations and cognitive exercises and when engaged
in the post-practice dialogue known as inquiry. For these reasons, we felt it
vital to weave a discussion of both embodiment and inquiry throughout this
book to help you deepen your personal and teaching practice.
Another intention of this book is to help you enhance your teaching
skills. This is an area of training MBSR teachers that is often not explicitly
addressed, and we believe that to be a good teacher, in addition to a
curriculum/protocol and embodiment, knowledge of some best practices of
teaching, particularly as they relate to delivering MBSR, is vital.
Given how broad its reach, and the complexity of mindfulness as a
model for reducing suffering, there seems to be some confusion around
what mindfulness is, and how best to teach it. This is potentially
problematic in a field in which there is increasing interest in teaching this
work in numerous settings. There are a variety of training centers and
pathways to teaching MBSR, but it is also unclear what makes a competent
teacher or how long training should be. There is also a lack of standards and
a lack of knowledge regarding the essential elements necessary for
achieving good participant outcomes or what aspects of the program, if any,
may cause harm.
The field is also professionalizing, meaning that it is seeking the
mandate to control its own work and increase its credibility and status
through the development of professional training programs, the creation of
associations, and perhaps ultimately through regulation. Training to deliver
mindfulness is being offered to any number of occupations, including
medicine, social work and other fields of health care, business, and
education, with attestations to a multitude of benefits—some substantiated
and others not.
A recent internet search on current mindfulness books brought up a
banner of over fifty, and these numbers are rapidly increasing, with
mindfulness being applied to a variety of areas, including stress, depression,
anxiety, insomnia, eating, racism, relationships, parenting, birth, cancer,
pain, addictions, games, children, resilience, work, and education, just to
name a few. A review of the research literature shows that there are,
perhaps surprisingly, only a few books on how to teach mindfulness, or how
to specifically teach MBSR. This book, then, is our contribution to the field.

Teaching MBSR: Origins and Current

Context
It has now been forty years since Jon Kabat-Zinn opened a stress reduction
clinic at the University of Massachusetts Memorial Medical Center. In
1990, he wrote Full Catastrophe Living, a book created for anyone who
would engage in the process of discovery that mindfulness entails. This
book has by default served as a manual for many who would deliver MBSR
to the public. Teaching MBSR, however, is not the same as training others
to deliver it.
However, much has changed since Jon Kabat-Zinn first created
MBSR. We are in a culture of rapid change. People often want everything
now and in short sound bites. We often hear how our attention spans have
drastically decreased to the level of a goldfish! While mindfulness invites
us to be present, it also invites us to slow down. This is discordant with the
way most of us live. Mindfulness is in the mainstream and is changing and
being changed by the Western culture in which it appears to be firmly
ensconced. How it is taught is at risk of being diluted in the interest of those
who would learn it quickly, with their own ideas of what they will teach, in
settings for which it was not originally intended (e.g., corporate culture),
often delivered in an individualistic manner valued by Western society
(meaning people can actually teach whatever they like and call it
mindfulness). And there are many people all over the world wishing to
learn to teach it. Thus, there is a tension we are holding here in which we
are attempting to maintain fidelity to the practice and what it can provide
and also adapting to the requirements and cultural context of those who
would learn it in this time and place. This is important to pay attention to in
order that we do not ask so much of learners that they simply reject what
mindfulness can offer or ask so little of them that what they learn may
provide no benefit.

Why Write This Book

We have been teaching together for the last few years nationally and
internationally, and we have jointly and separately seen a range of skill and
content delivery of what is called MBSR. Sometimes it is not recognizable.
Although this is not the only reason, it is a central one that led us to write
this book. As MBSR is being subjected to increasing research and there is a
global demand to learn the program, we would suggest that to maintain the
integrity of MBSR as it was intended, there is a need for the provision of a
more overt structure and explanation of the underlying assumptions and
principles of this work. We think that too little attention to a protocol can
result in a program that is chaotic, not replicable, and perhaps actually not
even helpful. It is essential that those learning and teaching mindfulness
understand what they are teaching from both an experiential and a
conceptual perspective. Training is required.
As we have discussed, teaching from the practice is essential, but a
“good” meditator does not necessarily a good teacher make. Meditation and
teaching both require specific skills that take time to acquire. Educators
have a well-developed body of knowledge and pedagogy, and this is true of
yoga, psychotherapies, and group psychoeducation. MBSR draws from the
practices of mindfulness and meditation, yoga, psychoeducation, teaching,
and psychotherapy. Of course, it is now informed by research and has
resulted in several adaptations primarily as a result of its entry into health
care. These adaptations are also to be found in the workplace and in
education, raising many issues regarding the common elements necessary
and sufficient for MBSR to be effective and how to best make it more
accessible to diverse communities. We think that an understanding of how
some of the underlying principles and assumptions of these disciplines from
which it both originates, and has entered, can assist in the development of
best practices and competencies for teaching MBSR.
This book deals with teaching MBSR in a manner that has not been
addressed and provides frameworks for assisting teachers to teach, utilizing
their personal practice, teaching skills, and maintaining fidelity to a
curriculum.

Structure of the Book

This book has been divided into five parts. Part 1 consists of an exploration
of the landscape of teaching MBSR. This includes its origins and history—
from Buddhism to contemporary mindfulness—what a teacher requires to
teach the program, its modularity, and some models to help the reader
develop a frame of reference from which to teach. Part 2 covers the
curriculum/protocol in depth from the orientation session through to the all-
day retreat and the culmination of session 8. These sections take the reader
step by step through each session and include a way to think about each one
by addressing its theme, rationale, intentions, and practice skills. Part 3
moves beyond the curriculum/protocol into what we have called the heart
of teaching. This heart consists of embodiment and inquiry, and these are
viewed from the perspectives of presence, form, and process as a way to
discuss them conceptually, pragmatically, and experientially. Part 4
addresses adaptations of MBSR to clinical populations, education, and the
workplace. We also turn our attention to diversity and cultural relevance as
they relate to modifications to the original curriculum and finally discuss
the state of the research, associated risks, and limitations. Part 5 deals with
the current and potential future training of MBSR teachers, including
supervision and mentoring as well as continuing professional development.
It addresses the context of delivery and the complexity that results from
teachers originating from regulated and unregulated occupations regarding
such issues as scope of practice, potential medical legal responsibilities, and
what should be considered as the requirements for entry into a training
program. Lastly, the appendices provide the reader with such useful
resources as meditation scripts, handouts, teaching movement practice, and
information about teaching online. There are also materials available for
download, including agendas for each session, illustrated yoga poses,
meditation scripts, and participant forms, at the website for this book:
http://www.newharbinger.com/45601. (See the very back of this book for
more details.)

Who We Are
Why us? This book is co-authored by a licensed clinical social worker and a
physician working in the mental health field, academia, education, and the
workplace. We are mindfulness teachers and mentors to trainees in both
MBSR and MBCT. We frequently teach mindfulness to people from a
number of disciplines. We consult with a variety of organizations in the
areas of mindfulness, stress reduction, and mental health with respect to
program development and delivery. We have been engaged in adult
education (for those in training or for continuing professional development)
from a multidisciplinary perspective for more than forty years.
This is all to say that we are familiar with the issues and struggles that
mindfulness teachers face, whether they are novices or have considerable
experience. We have faced them ourselves. The field of mindfulness is
rapidly changing, and we have been involved for decades with this shifting
landscape from the perspectives of professionalization, delivery, research,
assessing competence, and the inherent politics that exist in any evolving
endeavor.
Mindfulness is also about verifying our experience and ultimately
becoming the authority of our own life. It is about staying open to many
perspectives. We believe it is about becoming deeply immersed in our life,
investigating it all: the wanted, the unwanted, and what appears
insignificant. We do not wish to be rigidly adherent to one view of how this
work should be delivered without questioning what we are doing and its
effects.
 We have come to hold the view that both practice and protocol are
essential to teaching MBSR. To be a good teacher, we must understand, as
best we can, what we are doing and why. Teaching MBSR as we conceive it
is both a way of being and a way of doing. It is what makes teaching this
work so exquisite. When teaching from a place of being in practice,
grounded in the protocol, we can work within a clear structure that allows
the foundations of mindfulness to be expressed. In this way, teaching
MBSR can be intentional, developmental, embodied, and present to the
needs of the group. We hope that this book assists you on your path to
becoming an MBSR teacher, or, if you are one already, to deepening your
engagement with and practice of teaching this work to all those who may
benefit.
 PART 1:

The Landscape of Teaching

Mindfulness-Based Stress Reduction

In this first part of the book, we lay out a brief history of mindfulness, its
genesis, and how its practice informs the mindfulness-based stress
reduction (MBSR) program and teacher. Understanding the roots of the
MBSR program is valuable in that it provides important information about
the philosophy and psychology of mindfulness. We then move to discuss
becoming an MBSR teacher and what we think are essential considerations
for guiding a teacher’s development. These include the usefulness of having
a protocol or curriculum, the significance of having a mindfulness practice,
and the development of specific teaching skills. In the final chapter in this
section, we consider some teaching frameworks trainees and experienced
teachers have found helpful in their continuing professional development
and in facilitating their teaching competencies. These frameworks include
the five agents of change (program protocol, mindfulness-based practices,
individual learning, group process, and the embodied mindful presence of
the teacher) and the themes, rationales, intentions, and practice skills (TRIP;
Woods, Rockman, & Collins, 2019) that can be applied to each session as
well as used to unpack each practice. These approaches help teachers
organize their thinking, understand the underlying principles of each session
and practice, and understand the rationales for the teaching methodologies
used.
 CHAPTER 1:

From Buddhism to Present-Day

Mindfulness

Knowing the history of the mindfulness-based stress reduction (MBSR)

program has value for the MBSR teacher. Studying the past allows us to
reflect on the origins of MBSR and provides us with an account of the
historical threads and contemporary practices that underlie the program.
This, in turn, provides an important perspective for our teaching. In
understanding the roots of MBSR, we draw closer to its diverse origins,
including Buddhism, yoga, Western psychology, and medicine. In this
chapter, our focus is on its Buddhist roots. Additionally, we will review how
mindfulness has been adopted by Western culture and contemporized, and
how this has shaped its use. We will also consider some of the tensions that
result from the widespread acceptance of mindfulness and what effect this
has for future teachers and for those of us who are already teaching MBSR.

Mindfulness: A Brief History

The mindfulness practices embedded in the MBSR program have their
origins in Buddhist practices, which originated from the teachings of the
Buddha. The Buddha, or “enlightened one,” came from an aristocratic
background and lived in the northern part of what is now India and Nepal. It
is thought that he lived between 500 and 400 BCE, although historians
debate the precise dates. Known as Siddhartha Gautama before his
enlightenment, he lived a sheltered and entitled existence unaware of the
vicissitudes of life and human suffering, until he witnessed for the first time
the reality and associated suffering of aging, sickness, and death when he
saw an old person, a sick person, and a corpse. This was a profound
moment of revelation for him, for he recognized the truth that none of us
will escape these fates.
It was this insight about the nature of human suffering that caused him
to leave his life of ease and luxury at age twenty-nine to become a homeless
holy man and ascetic, to seek clarity into the human condition in order to
end suffering. His search took many forms, involving studying with various
spiritual teachers who demanded practices of austerity and self-
mortification, but none of these provided him with the answers he sought.
He eventually abandoned a life of asceticism for a path of moderation after
a vision of himself as a boy sitting under a tree in a serene state of mind. He
persisted in studying meditation as a way to achieve this serenity while
continuing to pursue an understanding of the vicissitudes and suffering of
the human condition. It is said that after sitting in meditation for seven days,
Siddhartha gained insight into the causes of suffering through an
appreciation of mind states and their contribution to unhappiness. With this
knowledge, the Buddha (Awakened One) reluctantly took on the role of
teacher, traveling throughout northern India, sharing his understanding with
anyone who was interested. Over time, he attracted followers who traveled
with him, itinerant monks relying on the patronage and generosity of others
to offer them shelter, food, and clothing.
For many years after his death, it was these followers/monks who took
on the responsibility of handing down the Buddha’s teachings and practices
through an oral tradition. It wasn’t until much later, as Buddhism spread
(between 35 and 32 BCE), that the teachings known as the Suttas (talks
believed to have been given by the Buddha) and the Vinaya (rules of
conduct mainly for monastics) were recorded in Pali (an ancient language
native to India). Some of the texts were originally written in Sinhala
(Sinhalese), most likely related to the arrival of Buddhism in Sri Lanka.
Between them, these two languages played a major role in the transmission
of the original Theravada Buddhist teachings and allowed scholars to study
this ancient wisdom tradition.
As Buddhism spread, moving first into Southeast Asia, then into
Central Asia, China, and Tibet, it absorbed the customs and values of that
country without losing its essential teachings, although the method and
what was emphasized changed. This is not uncommon for religions, but
Buddhism has shown a remarkable ability to adapt to the customs and
religious traditions of the countries it meets. For example, in migrating
around Southeast Asia, Buddhism took on elements of Hinduism; in China
and Korea, Confucianism and Taoism; in Japan, Shintoism; and in Tibet,
the Bon religion.
It is beyond our scope to explore in detail the various Buddhist
traditions, philosophy, psychology, and practices or a full history of its
trajectory into academic and lay culture. We will concentrate on the practice
of Vipassana (insight) meditation, which serves as an underpinning for
MBSR. Vipassana is the cultivation of mindfulness—an awareness of a
moment-by-moment flow of experience—and is a meditative practice based
on a primary Theravada Buddhist teaching, the Satipatthana Sutta (the Four
Foundations of Mindfulness). These foundations are (1) mindfulness of the
body, (2) mindfulness of feeling tones (pleasant, unpleasant, and neutral),
(3) mindfulness of mind (observing one’s mental state and its qualities), and
(4) mindfulness of physical and mental processes (Dhammas—the essential
teachings of the Buddha—the direct experience of reality). In its
description, the Satipatthana Sutta presents an all-encompassing instruction
for the training and practice of a specific form of attention/awareness that
teaches a way of relating to the quality of one’s experience, leading to a
clear understanding of the human condition, promoting compassion and
wisdom.
The first translator of the Satipatthana Sutta was an Englishman,
Thomas William Rhys Davids (1843–1922). He, along with other
colleagues, set about translating many of the early Buddhist texts from the
original Pali. Pali is the language of the Pali Canon, a collection of
scriptures in the tradition of Theravada Buddhism. In 1881, Rhys Davids
established the Pali Text Society so that Pali texts could be published in
English. These translations began the process of making the Buddha’s
teachings widely accessible, and it is Davids who was responsible for
translating the key Pali word sati (literally to “remember” or “bear in
mind”) as mindfulness. A current edition of the Satipatthana Sutta was
translated by Bhikkhu Nanamoli and Bhikkhu Bodhi (Nanamoli & Bodhi,
2005). Bhikkhu Bodhi is an American Buddhist monk and Pali scholar who
has been involved in translating many of the original texts.
In the nineteenth and twentieth centuries, the practice of meditation,
while still primarily based in the monastic tradition, became more readily
available to lay practitioners. With the colonization of Asian countries in
the nineteenth century, interest in Buddhist traditions and philosophy
increased, initially from an intellectual perspective. It was U Ba Khin
(1899–1971), the first accountant general of Burma (Myanmar, as it is now
known), who played a pivotal role in teaching meditation to the general
public. This was in some ways a reaction to colonialism and a preservation
of Eastern values and traditions. In 1952, he founded the International
Meditation Center (IMC), which authorized laymen and laywomen and
Westerners to teach. The IMC inaugurated the ten-day Vipassana retreat
structure that is now commonplace in Western meditation centers.
One of U Ba Khin’s students, Satya Narayan Goenka (1924–2013),
was influential in bringing Vipassana to the West. Goenka left Burma and
moved to India in 1969 to teach meditation to laypeople, and he accepted
students of any gender and race. Furthermore, because he spoke English,
his teachings were accessible to young Americans, Britons, and Europeans
interested in Eastern spiritual practices. By making the practice of
Vipassana meditation available to a lay audience, the teachings, philosophy,
and psychology of mindfulness spread into the West. And mindfulness
became contemporized. Many well-known present-day teachers, such as
Ram Dass, Sharon Salzberg, Joseph Goldstein, Jack Kornfield, and Daniel
Goleman, were students of Goenka. Note that this is not to exclude
Buddhist teachers and influencers from other traditions, such as Thich Nhat
Hanh, the 14th Dalai Lama, Chögyam Trungpa, D. T. Suzuki, or Alan
Watts, but our focus is on one of the traditions that had a direct influence on
the development of MBSR.

The Contemporizing of Mindfulness

In 1975, the Insight Meditation Society in Barre, Massachusetts, USA, was
founded by Joseph Goldstein, Sharon Salzburg, and Jack Kornfield. This
provided a retreat center where lay practitioners could go for extended
periods to practice Vipassana meditation. All three founders had spent time
in India and Thailand practicing with various Buddhist teachers. In 1983,
Christina Feldman and Christopher Titmuss founded Gaia House, a UK
retreat center for the practice of meditation. Feldman and Titmuss had also
spent time in Asia practicing various forms of meditation. In 1998, Spirit
Rock Insight Meditation Center in California began offering residential
retreats as well as one-day retreats. There are now many retreat centers
around the world where people can engage in various meditation practices
from any number of traditions for a weekend or for several months.
Jon Kabat-Zinn, a molecular biologist working at UMass Memorial
Medical Center in Worcester, Massachusetts, is another significant person
influencing the spread of mindfulness in the West. A student of Zen
Buddhism, Vipassana, and yoga, Kabat-Zinn was on a ten-day Vipassana
retreat when he had an insight that the teaching of meditation in a secular
context could help people with chronic disease who needed more support
than standard health care could offer (Kabat-Zinn, 2011).
MBSR teachers are encouraged to develop a mindfulness practice in
order to teach the program, and attending silent teacher-led meditation
retreats is a requirement from most centers training future teachers. Without
doubt, the philosophy, psychology, and practice of mindfulness have much
to offer in terms of how its practice can support and strengthen an
awareness that develops resilience and well-being. Furthermore, the ability
to adapt to the vicissitudes of life, fluid and contingent upon circumstances,
leads to less reactivity and emotional turmoil. This, in turn, promotes
skillful, kind, and generous ways of interacting with ourselves and others.
These are important attributes for any of us to aspire to and are significant
for the teaching of MBSR.
Still, the contemporizing of mindfulness—its dispersal into secular
settings—also gives some cause for concern. We are all being urged to be
mindful these days. To stay in the present moment. To pay attention in a
particular way. To be nonjudgmental. To be compassionate. And yet do we
really understand what we mean by mindfulness and how it is being applied
in both public and professional domains? Indeed, any discussion about
mindfulness is confounded by the lack of consensus on its definition as it is
applied in secular settings. This has implications for research and for
increasing our knowledge about which mindfulness practices can be most
useful, in what situations, and for which populations. Indeed, as
mindfulness has spread in the public domain, it has come to mean many
things depending on the context and how it is applied. This can lead to
confusion, misunderstanding, and inflated promises about what it can do.
This is not without risk. In fact, many of the popular claims made on behalf
of mindfulness are unsupported and outstrip the evidence.
 Mindfulness is also being brought into education, business, and law in
addition to health care. In Britain, members of parliament made
comprehensive recommendations, suggesting that mindfulness be integrated
into health, education, the workplace, and the criminal justice system. This
is ambitious indeed! (Mindfulness All-Party Parliamentary Group, 2015)
More recently, we have seen the development of numerous
mindfulness apps, most of them suggesting that a few minutes of practice
will be of benefit. On the other end of the continuum, there are retreat
centers for lay practitioners, offering anything from five-day to three-month
teacher-led silent retreats. Adding to these choices, and possibly to the
general confusion, are different meditation traditions that offer a variety of
ways to practice. In a relatively short space of time, mindfulness has gone
mainstream. How did this happen?

Mindfulness-Based Stress Reduction and

Mindfulness-Based Programs
For many years in the West, mindfulness meditation largely remained part
of a subculture seeking meaning in an increasingly secular world. In 1979,
Jon Kabat-Zinn, PhD, founded the Stress Reduction and Relaxation
Program (SRRP) at UMass Memorial Hospital. For a considerable period,
this program remained under the radar. Other than the participants attending
the program, referring health professionals, and word of mouth, the clinic
had yet to reach a wider audience. In 1990, Kabat-Zinn published the book
Full Catastrophe Living, in which he outlined the MBSR program offered
by his clinic for the treatment of transdiagnostic conditions. This program
was practical, accessible, and took an optimistic stance to being human and
to managing life stressors (Kabat-Zinn, 2013). The program offered and
continues to provide participants with an eight-week training in a
mindfulness-based approach that does not require attendees to have any
previous understanding of meditation. It was the creation of this program
and the subsequent interest in its delivery that were to have significant
implications for the dissemination of mindfulness.
In 1993, the Public Broadcasting Service (PBS), a television network
in the United States, produced a documentary called Healing and the Mind
with Bill Moyers, a five-part series that focused on innovative programs
working outside traditional forms of healing and focusing on mind-body
health. In one episode, the SRRP program was featured. This became a
seminal moment for Kabat-Zinn’s stress reduction clinic. It also led to an
overwhelming response from people wanting to train as MBSR teachers. In
due course, this led to the creation of a professional certification pathway.
The Center for Mindfulness (CFM) in Medicine, Health Care, and Society
trained thousands of teachers, supported the foundation of international
MBSR training centers, and reached many thousands of participants
through its eight-week programs. Interestingly, MBSR does not rely on a
manual for training future teachers. In fact, it was only in 2017 that an
“authorized” curriculum was published through the CFM’s website
(Santorelli, Meleo-Meyer, & Koerbel, 2017). This raises some important
questions about how teachers have remained faithful to the ethos of
teaching MBSR; it also has implications for training future teachers.
Another pivotal moment for mindfulness arose from the development
of mindfulness-based cognitive therapy (MBCT). This program, created by
cognitive behavioral researchers and therapists Zindel Segal, Mark
Williams, and John Teasdale (Segal, Williams, & Teasdale, 2002, 2013),
combined the structure of MBSR and aspects of cognitive behavioral
therapy (CBT) to target the problem of depression relapse. MBCT provided
a detailed and specified protocol that made it relatively easy for therapists
with or without a background in CBT or mindfulness to teach the program.
However, the founders did stress the importance of being familiar with CBT
and in having a personal mindfulness practice.
Having a clearly delineated protocol has several benefits. For one, it
provides a standardized structure for teachers to follow—a necessary part of
quality assurance. A protocol also allows for replication of delivery and
ease of research. Much-needed data and evidence can then be generated for
determining participant/patient outcomes.
However, while having a clear explanation of what to teach is
extremely useful, there is a tension between adherence to a protocol and
addressing and facilitating the themes and practices of mindfulness. As
mindfulness-based teachers, we cannot solely rely on a protocol to illustrate
what teaching mindfulness has the potential to offer. A protocol is a
structured approach, and mindfulness is experiential. Training to a protocol
is relatively easy. Ultimately, we must have a mindfulness practice of our
own to help convey what no protocol can capture. But, developing and
sustaining a mindfulness practice takes time, deepening over the years and
becomes a way of being, supporting the growth of experiential and
intellectual understanding. This doesn’t mean that a teacher must have years
of mindfulness practice before she can teach. What it does require is a
commitment to practice. In the next section, we will discuss what this
means for the training of mindfulness-based teachers.

Practice, Training, and Delivery Tensions

Initially, the teachers at the CFM in Worcester, Massachusetts, brought with
them many years of personal meditation practice, including attendance at
numerous teacher-led silent retreats. Lately, with the popularity and
adoption of mindfulness-based programs, we are seeing that would-be
teachers are not coming to training programs with this background and
experience. More typically, they are just beginning to develop a meditation
practice. Furthermore, the requirement by training centers to attend silent
teacher-led retreats of five to seven days or more is difficult for them to
meet, given work responsibilities, family life, and other caretaking
obligations. For our part, we see it as vital for teachers to attend formal
silent teacher-led retreats. We also believe that it is equally if not more
significant that practitioners are engaging in mindfulness practice
personally, interpersonally, and in their daily activities as a way to enrich
and support their teaching.
Another issue the field faces as a result of the worldwide reach of
mindfulness is that there is no consensus regarding standards of training or
best practices. This was not as pressing a matter in the early development of
MBSR, but the increasing dissemination of mindfulness-based programs
into mainstream health care as an accepted treatment for a variety of
conditions, and the interest in researching them, has changed the context in
which these programs are delivered. There is an increasing need for a
standardized and readily replicable protocol and set of best practices for the
delivery of programs such as MBSR. Standardized protocols allow for
better research, helping to establish the evidence base, ensuring fidelity, and
lessening the almost inevitable personalization and dilution of original
curricula. Furthermore, those who teach MBSR come from heterogeneous
backgrounds, teaching inside and outside of the health care field. All of this
makes it a complex endeavor to ensure that what is actually being taught is
MBSR as it was intended.
An additional tension derives from the fact that MBSR has always
been delivered by clinicians and non-clinicians alike. Indeed, although
MBSR originated inside a hospital at a clinic and in the formal health care
system, it was always taught by both these groups and offered patients
meditation as a nontraditional form of alleviating suffering. Clinicians who
deliver it do so as designated professionals controlled (regulated) by
governing bodies and state/national licensure to protect the public. Some
insurance companies will pay for MBSR if the teacher is a
licensed/registered clinician or if a physician refers participants to the
program. On the other hand, lawyers, educators, life coaches, yoga teachers,
people in the corporate and human resource sector, who are trained or self-
taught, offer MBSR as a form of education. This can be problematic
because no one in these occupations will receive oversight for its delivery.
The teaching of mindfulness is not necessarily benign. It encourages
increased attention to present moment experience, which is not always
perceived as positive. For example, some participants may have increased
somatic symptoms of anxiety or activation of past trauma. This then brings
into question issues of responsibility and public protection. There is thus
confusion about what MBSR actually is: education, a treatment modality, a
form of psychological self-study, a tool for managing stress, a way to wake
up fully to what life has to offer, or perhaps all of these.
Added to these tensions, the field is undergoing a process of
“professionalization” as those who work in it seek more public credibility,
status, and power. To be professional has many meanings, such as a body of
knowledge, expected behaviors from workers, or the mandate to control
one’s own work (self-regulation). Occupations that work with people’s
mental or physical health have the potential to improve people’s lives—and
to cause harm. Anything with the power to cause harm should require
regulation. As such, those who deliver MBSR must consider its ethical
foundations and the professional responsibilities that come with working
with the public.
It is interesting to note that as people in the field seek to define the
teaching of mindfulness as a profession, issues related to its potentially
adverse effects as well as its benefits are being examined and discussed.
The early investigation into its risks is often directed at populations not
targeted for MBPs, such as long-term meditators who have attended
extended silent retreats. In addition, given that these studies are generally
uncontrolled, qualitative, and retrospective, it is hard to know the actual
cause of these negative outcomes. While early research is examining these
potential adverse effects of mindfulness (Britton, 2019; Lindahl, Fisher,
Cooper, Rosen, & Britton, 2017; Britton, Lindahl, Cahn, Davis, &
Goldman, 2014), it remains unclear what these are and how they relate to
recipients of MBSR. Much work needs to be done in this area, particularly
as mindfulness weaves its way into so many aspects of society.
Trainers of future MBSR teachers and teachers themselves are
disseminating a 2,600-year-old tradition that has underlying assumptions
about the benefits of its practice. Rather than taking these on trust, we are
encouraged to investigate these philosophies and principles for ourselves,
through the experiential practice of mindfulness versus engagement in a
purely intellectual pursuit. We are also being informed by emerging
outcomes from science and research, as well as data for MBSR’s suitability
for various populations. We can draw upon these findings and test their
usefulness with our participants, holding the information with a degree of
openness but never forgetting that we are still in the process of uncovering
the mechanisms of mindfulness and its utility.
This means that the MBSR program and the training of future teachers
will need to be regularly updated and informed by research and the clinical
evidence for its use. This, in turn, raises questions about the kinds of
professional trainings that best support competency and professional
development while appreciating that one of the essential drivers for
proficiency in teaching is the growth of our own mindfulness practice.
We believe that a way to hold this is to confirm the necessity of having
a structure (protocol) from which to teach a mindfulness-based program on
the one hand, and equally, if not more significantly, to develop and sustain a
mindfulness practice that has relevance for our teaching and our lives. A
protocol is essential if we are to study and investigate what we are teaching
inside and outside the sessions. It lays a foundation to support important
insights gained and enhances the reliability of the evidence that what we are
teaching is objectively beneficial. But teaching a mindfulness-based
program cannot only be derived from a protocol. To be rigidly adherent
would be to lose the heart, skill, and art of the teaching and produce
teachers unable to fully meet the needs of their participants. It is the
primacy of having a mindfulness practice that cannot be overemphasized. If
we can remain true (but not fixated or rigid) to the map provided by a
clearly defined structure, as well as to an unfolding process and flow
founded in a mindfulness practice, then we have the ability to offer
something truly unique.
As discussed, the MBSR program provides us with a contemporary
form of mindfulness. While Buddhist psychological concepts inform MBPs,
what we are teaching and practicing is not a religion, nor is it being taught
in a sequestered setting. What we could say is that we are offering a
practice (the Dhamma), a way to wake up and live one’s life more fully.
This reiterates what Jon Kabat-Zinn has spoken to many times, that the
Dhamma is universal rather than attached to a specific philosophy, religion,
or method, and may be seen as an aspect of reality to be discovered.

In Closing
MBSR utilizes teachings from the ancient tradition of mindfulness, as well
as Western psychology. As such, it provides approaches that offer relief
from stress-related problems, including those associated with chronic
illness, and also strengthens resilience and general well-being. In this
chapter, we have discussed a brief history of mindfulness, the roots of
MBSR, how mindfulness has been adopted by Western culture, and the
current tensions in the field. A brief historical perspective of mindfulness
gives us understanding about the foundations of MBSR, the mindfulness
movement, and its contemporary nature. We also reviewed the tension
between holding a protocol and teaching the practice of mindfulness as an
experiential process. We then outlined some issues currently related to the
professionalization of the field.
In the following chapters, we address what is entailed in teaching
MBSR, highlighting the importance of having a protocol, a teacher’s
personal mindfulness practice, and the development of teaching skills. In
this way, we hope to assist mindfulness teachers to embody the practice,
understand what they are teaching, and develop the skills necessary for both
their teaching and their professional development.
 CHAPTER 2:

Becoming an MBSR Teacher: What Do

You Really Need?

Becoming an MBSR teacher, or a teacher of any MBP, requires a deep

understanding of what is involved in teaching a program grounded in
delivering the practice of mindfulness. In this chapter, we will discuss
essential foundations in the development of MBSR best practices, fluency,
and competency. These are (1) a strong foundation in the MBSR protocol or
curriculum, (2) an ongoing mindfulness practice, (3) an understanding of
Buddhist psychological concepts, (4) teaching skills, and (5) an
understanding of learning theories relevant to adult education.

Protocol/Curriculum
As previously stated in chapter 1, the MBSR program was originally
delivered within a hospital and taught by both clinicians and non-clinicians.
The founder, Jon Kabat-Zinn, was a molecular biologist and scientist, and
Saki Santorelli, who succeeded Kabat-Zinn as executive director until 2017,
was an educator. Therefore, the original program was developed and
overseen by non-clinicians in a hospital setting. Now, MBSR is delivered in
health care, education, science, and business. This raises the question: Is it a
protocol, as in health care; a curriculum, as in education; or a set of skills to
be learned, as in business? These are essential antecedents for how the field
has developed and the confusion that has ensued around what is being
delivered.
To begin answering this question, it is important to delineate the
difference between the terms “protocol” and “curriculum” because this is
relevant to understanding the contexts in which MBSR is offered. The use
of the word “protocol” is usually found in science and health care. A
protocol may be defined as a detailed plan, guidelines, or a set of
procedures or rules to be followed during a study or treatment. The
intention of a clinical protocol is to maintain or improve care and simplify
or reduce variability among practitioners in what is being delivered.
“Curriculum,” a word typically used in education, generally refers to the
content of what is being taught (e.g., the lesson plans), how this is
implemented, and the desired outcomes of a program. A curriculum
consists of that which is made explicit, the stated curriculum; that which is
covert, the hidden curriculum; that which conveys norms and expected
behaviors; and that which is not covered, the excluded curriculum (what is
deliberately left out) (Haralambos & Holborn, 1991; Wear & Skillicorn,
2009).
Jon Kabat-Zinn’s book, Full Catastrophe Living (1990, 2013), while a
groundbreaking introduction to the practice of mindfulness and MBSR for
the public, is neither a protocol nor a curriculum to train teachers. Even
though various centers around the world are training future MBSR
instructors, there is not yet an identified and agreed-upon protocol, and this
lack of standardization has resulted in a huge range of interpretations
regarding its implementation.
Furthermore, of note, MBSR initially served those with chronic
conditions. Currently, it is more likely that groups will include those with
generalized personal and work-related “stress” issues or problems with
mental health and addiction. “Stress” is the identified problem to be treated,
but stress is actually not a defined clinical condition. It is a general and
subjective term with diverse meanings. This is relevant when we are
considering the purpose of MBSR: to whom it is being offered and in what
context it is being delivered. For example, if I say, “I’m stressed,” what do I
mean? Am I referring to my overwhelming and racing thoughts, or my
quickly beating heart? Do I mean I’m anxious or pressured, or overloaded
with work, or having thoughts that I can’t cope with the pressures of daily
life? Or am I referring to the dis-ease accompanying a diagnosis of a
catastrophic illness or the grief that ensues from the loss of a loved one?
The multiple ways in which stress is understood makes MBSR accessible to
heterogeneous groups. However, it adds to complexity for teachers because
“stress” can be perceived in a variety of ways and participants may be using
the word “stress” differently.
 Therefore, we believe having a protocol or curriculum provides a
skeleton for the delivery of the MBSR program. Without a skeleton, you
have no structure from which to hang your teaching. It is then easy to drift
away from the central tenets of the program until what you are teaching
may not resemble MBSR at all, but rather some set of unrelated principles
and practices. This is potentially problematic because if we don’t have
inter-teacher reliability around what we are teaching, we can’t really help
each other be better teachers, and we may not even know what we are
teaching. How can we maintain the quality of teaching, or ensure we get the
outcomes we are seeking for our participants, if we are all doing something
different? And lastly, how can the public discern where to go to take MBSR
if there is no standard program? A dedicated protocol or curriculum is
necessary for those who teach MBSR to know what they are teaching and
for those who receive it to know what they are learning.
Another consideration, as we stated in chapter 1, is that MBSR is
unregulated. When clinicians who have a designation and are overseen by a
governing body, or members of other occupations that receive oversight,
such as lawyers, engineers, or teachers in education, offer MBSR, there is at
least some safety for the consumer through regulation. Those who have no
designation receive no governance. The consumer is not protected,
especially considering the confusion around whether what is being taught is
a curriculum, a treatment protocol, a set of skills, or simply tools for self-
regulation, applicable to any professional, business, or social situation.
Accountability and scope of practice are at issue here. An MBSR teacher, if
he does not wish to cause harm (assuming we think MBSR can cause harm,
and we do), needs to know his own limits and the potential effects of the
MBSR program. A clear protocol and defined training pathway can help
those people who fall outside professional regulation learn about the risks
and benefits of MBSR, as well as develop an understanding of their scope.
This means knowing whom they can teach safely and whom they should
not, because they don’t have the necessary knowledge or skills. While not
foolproof, a protocol and comprehensive training program can provide
consistency for teachers and go a long way toward protecting the public
interest and maintaining the quality of instruction.
An agreed-upon protocol or curriculum also has benefits for research.
Replication of what is being taught is ensured, and this increases the
likelihood that research results will be generalized to the community.
Finally, teaching from a protocol is essential for the training of future
teachers. Centers around the world have different training pathways, but all
subscribe to the belief that MBSR is best learned by an intellectual (top-
down) and experiential (bottom-up) process. This typically includes being a
participant-observer in the eight-week program, attending foundational and
advanced training intensives, ongoing experience with silent teacher-led
retreats, and teaching experience with oversight from a senior MBSR
teacher. A protocol or curriculum is invaluable in providing the clear
training pathway that is necessary for this to happen.

Personal Practice
In addition to the importance of a protocol or curriculum and a clear
training pathway, an MBSR teacher needs to develop and sustain a personal
mindfulness practice. A teacher’s personal practice is a significant factor in
the delivery of effective teaching. It’s worth noting, however, that emphasis
on a personal mindfulness practice has sometimes come at the expense of a
focus on the protocol. For instance, Santorelli and colleagues claim in their
2017 MBSR curriculum that the “real curriculum” is “the non-instrumental
actuality of MBSR, the intelligence that is already complete within you—
and within those with whom you work.” They also write, “This intelligence
does not need to be acquired, but rather, remembered. This is the real
curriculum…the real guide…the deep spring from which MBSR flows out
of you and makes its way into the world. You might consider returning to
this water whenever you need a reminder of who and what you are behind
all the words and forms described in this Curriculum Guide” (Santorelli et
al., 2017, 2–3). We would argue that an embodied practice helps you, as a
teacher, build capacity from the grounding the protocol provides, not the
other way around.
While Santorelli and colleagues do give credence to instrumental
learning and the need for a structure, at the same time the implication here
is that the “real” curriculum is already inside you and only needs to be
recalled. This is a huge assumption. The authors may be referring to being
mode of mind that has particular and identifiable characteristics or an
embodiment of the practice that we think can also be articulated clearly.
However, the way the “non-instrumental actuality of MBSR” is described
we find confusing and difficult to translate as it relates to teaching. What
does this “non-instrumental actuality” look like? We would argue that
learning and maintaining fidelity to a protocol or curriculum with respect to
teaching MBSR is as important as embodiment of the practice for attaining
skills in teaching and learning. Becoming an MBSR teacher is a synthesis
of skills and knowledge that unites several areas of competency and best
practices, of which a personal practice is one.
So why is a personal practice in mindfulness meditation and the ability
to bring that learning to one’s teaching important? In contrast to how we
often typically learn—from the “top down” by employing cognitive and
intellectual skills—mindfulness meditation practice requires “bottom-up”
learning. This means that when we practice mindfulness, we are
recognizing all experience as incoming, arising, and passing sensory
information. This includes emotions with physical correlates, thoughts as
events or sensations of the brain/mind, and impulses as thought behaviors
or body urges. By observing the movement of experience, we have access
to what we tend to hold on to, push away, struggle with, or chase. These are
moments of reactivity that add to our stress, leading to more suffering. With
mindfulness practice, we actually see what is happening within
(intrapersonally) and between us (interpersonally). In this way, we realize
we have choice in how we respond and behave. This is a key component of
learning to pass on to our participants—and a key element to pair with
fidelity to the protocol when teaching MBSR.
Therefore, participating regularly in teacher-led silent retreats,
preferably in the Vipassana tradition, upon which MBSR is based, is
important. Attending silent retreats provides the experience of formal
practices (sitting, walking, standing, eating, and lying down) as well as
informal practices of daily living, such as helping in the kitchen and general
domestic jobs. All of this takes place in a sequestered environment, for an
extended duration and with sustained periods of silence. Part of what is
experienced with prolonged silence is a realization of how frequently
automatic thinking occurs and how we react and respond to it. This allows
for a range of experiences, wanted and unwanted, the exploration of how to
meet these, and the arising of insight as a result. This is extremely helpful
for the teacher to understand, and normalize, when her participants
encounter similar mind states in the MBSR program.
In addition to the development of a meditation practice, MBSR
teachers are expected to have familiarity with yoga practice and be able to
offer this. The practice of yoga has its own meditative philosophy, of which
the Yoga Sutras of Patanjali is the most commonly cited (Hartranft, 2003;
Satchidananda, 2012). Yoga trains an attentional focus to the experience of
the body in motion as well as when holding the poses. By this means, the
student gains access to the information the body provides as well as to mind
and mood states.
In order to teach the mindful movement sequences, an MBSR teacher
must have familiarity and personal access to the felt sense of what happens
when he practices yoga. He will have experienced how to work wisely
when meeting physical limitations, investigating and safely navigating what
is possible. Through this process, he learns to be present with what is,
recognizing the tendency to compare, compete, or strive. This correlates
perfectly with mindfulness and its present moment orientation, and it
demonstrates, as mindfulness does, how the mind is frequently judging
experience.
We have discussed the importance of an MBSR teacher having a
formal practice that consists of mindfulness meditation and yoga and entails
repeated meditative periods in which one is bringing attention to experience
as it unfolds. But a formal practice in and of itself is not enough. What is
learned through the formal aspects of meditation needs to be applied to
everyday life. Bringing the practice into each day through informal
practices, such as intentionally bringing attention to mundane tasks, is very
much a part of a teacher’s personal practice as well as for teaching MBSR.
Our lives are the perfect container for bringing awareness to each moment,
allowing us to regulate our attention, emotions, interactions, and behaviors.
A teacher’s personal practice is the perfect medium for helping his
participants develop an experiential vocabulary to describe what is being
encountered after a meditation practice or exercise because he will have
access to this knowledge himself. Identifying and tracking experience is a
core component of mindfulness and an ongoing process of meeting the
challenges and reactivity of mind, mood, and body. A teacher understands
this, and he comfortably and safely holds the container for the group and for
those moments of difficulty that are expressed during inquiry—his own
informal and formal practice prepares him for this. As a teacher’s practice
matures, it becomes a more important factor than protocol, driving his
teaching and the learning of his participants. An added support to the
understanding gained through the experience of personal practice is having
a foundation in Buddhist psychology.

Foundations for Practice and Teaching in

Buddhist Psychology
There are many aspects of Buddhist psychology that we could discuss as
relevant to the teaching of MBSR. While these are not absolutely essential
to becoming an MBSR instructor, they are frameworks for understanding
the underlying principles and practices and they help inform our teaching.
While a full discussion of Buddhist psychology and its relevance to MBSR
is beyond the scope of this book, we feel it is important to address here the
aspects we see as most helpful. These are the Four Noble Truths, the Four
Foundations of Mindfulness as outlined in the Satipatthana Sutta, and the
Three Marks of Existence.

The Four Noble Truths

The Four Noble Truths are considered foundational to Buddhism.
Traditionally, they are outlined in the following way: The first truth,
suffering, refers to aging, sickness, and death, and reflects that life is
“unsatisfactory” or imperfect. This is what it is to be human. The second
truth is that what arises out of this imperfection is “craving,” or wanting
things to be other than they are. Craving describes all our “habitual and
instinctive reactions to the fleeting, tragic, unreliable, and impersonal
conditions of life that confront us” (Batchelor, 2015, p. 96). The third truth
is that this craving can cease, and the fourth refers to the Noble Eightfold
Path, a way to conduct oneself (a set of ethics) that includes such actions as
right speech, right effort, right mindfulness, and so on, which can contribute
to one’s liberation. From a religious perspective, then, Buddhism is a truth
model, telling us how things are, rather than a process of discovery and
learning to respond to what life brings. In this case, the Buddha may be
seen outside of a religious context, as a physician, and his teachings as
medicine for working with the human condition.
Many authors have expanded upon these truths, but the Buddhist
scholar Stephen Batchelor discusses them in a manner we see as
particularly applicable to the teaching of MBSR (Batchelor, 2012, 2015). In
Batchelor’s opinion, “The Buddha was a pragmatist, concerned with what
works, not what’s true. He was presenting a strategy or hypothesis to be
tested, for people to find out if it enables us to respond more
compassionately to ourselves and others” (Batchelor, 2019). Thus,
Batchelor views the Four Noble Truths in a secular manner, not as truths to
be believed but as four tasks we can work to accomplish as a means to
living life less controlled by reactivity.
The first task is to fully comprehend and embrace suffering. The
second task, with respect to craving, is to see our reactivity (wanting things
to be other than they are) and let go of it. The third task is to see and
experience the ceasing of this reactivity and to therefore no longer be
controlled by it. And the fourth is to learn what it is to not be driven by
reactivity, thus having the freedom to respond and the choice to live in a
nonreactive way (this is the Noble Eightfold Path). Mindfulness then in this
case is nonreactive awareness. This doesn’t mean that reactivity doesn’t
occur but rather that we do not have to be swept up in it. Batchelor writes,
“Buddhism starts with suffering, not truth. Secular (or contemporary)
mindfulness brings us back to the origins of what Buddha taught…It’s a
therapy” (ibid.).
Within the context of MBSR, a teacher guides his participants to see
“stress” as part of life, to be understood and accepted (the first task). Life is
not perfect. When we are controlled by our reactions and do not accept our
lives as they are but insist that they be different, this makes stress much
worse. Through the mindfulness practices embedded in the MBSR program,
understanding and accepting this reality is an important learning. This is not
to say that we should be resigned or passive. Rather, we respond with
discernment, taking action if necessary.
Mindfulness practices reveal how we react to what we encounter and
when we want things to be different. The second task is to let go of this. A
teacher understands it requires energy and intention for participants to learn
to work in this way. Typically and habitually we tend to resist what we
don’t like as reflected in such statements as “This should not be,” “This
isn’t fair,” or “Why me?” The teacher guides his participants in recognizing
these moments of aversion, meeting them with acceptance and letting them
go.
 The MBSR program cultivates awareness of the changing nature of
experience and provides training not only in noticing reactive moments, but
also in being able to see when stress reactivity diminishes. One of the
values inherent in MBSR is that the witnessing and being with experience is
worthy of attention. This then prepares the ground for the third task, to see
when reactivity is not present and to have the embodied experience of its
absence.
Throughout the eight weeks, participants learn to develop a different
relationship to stress, enabling them to respond to life challenges in a more
considered manner, allowing for flexibility related to the context in which
they find themselves. The teacher emphasizes this process of being present
to whatever life brings and to the transient nature of experience.
Participants develop a crucial understanding of how they can relate to
themselves, to others, and to their lives with more ease, kindness, and
equanimity. Implicit in this and in the content of the curriculum is a way of
behaving that embodies the understanding that how we act has implications
for ourselves, others, and our world (the fourth task). This corresponds to
the Noble Eightfold Path, consisting of a way to end suffering through the
cultivation of wisdom, ethical behavior, and meditative practice, which
ultimately becomes a way of being.

The Four Foundations of Mindfulness

As you might recall from chapter 1, the Four Foundations of
Mindfulness play a key role in Vipassana meditation, which is central to the
MBSR program. The first foundation, mindfulness of the body, refers to
bringing intentional attention to the body (senses and sensations) when in
motion and in stillness. The body is affected by and reacts to mind and
mood states and is therefore a source of information. The body scan
meditation, introduced in session 1 of the MBSR program, teaches
participants to sequentially place attention on different parts of the body,
explore with curiosity what is arising, and then shift attention to another
part. By paying attention to the body in this way, with awareness, the
tendency to be immersed in thought is reduced and a different relationship
to experience is cultivated. It is this awareness that enables participants to
observe moments of reactivity that can contribute to stress both in formal
practice and in daily life. Awareness of this body/mind connection is further
supported by the yoga and walking meditation practices taught in session 2
and in successive sessions.
The second foundation, known as mindfulness of feelings, is about
understanding the primary nature of experience as pleasant, unpleasant, or
neutral. In Buddhist psychology, this is known as vedana, or feeling tone,
and refers to the first reaction to any given situation. It is generally believed
that this occurs before we name an experience. It is a felt sense. In MBSR,
attending to this valence of experience helps participants identify what they
like (the pleasant), what they don’t like (the unpleasant), and what has no
charge (the neutral). What is interesting is that we tend to want more of
what we like and push away or resist what we don’t. The neutral commonly
goes unnoticed and may even lead to boredom and seeking stimulation.
Awareness of these reactions can help participants (1) learn to appreciate
the pleasant without clinging to it; (2) see how controlled we are by what
we like and don’t like and how this relationship often determines our
behavior; (3) become aware of the neutral that is often missed but can be
the early precursor to a stressful state (e.g., how boredom may quickly
spiral into a bad mood); and (4) identify the kinds of thoughts, emotions,
and body sensations that accompany these reactions and how they influence
each other. This knowledge helps participants manage stressful states more
skillfully.
The third foundation, the contemplation of mind, involves the quality
and experience of mind (e.g., agitated, ruminating, or distracted mind).
MBSR separates this investigation of mind into thoughts and emotions, not
by analysis but rather by learning to identify and describe them through the
practice of mindfulness. Observing the movement of mind allows
participants to develop a different view, take a step back, and gain
perspective.
The last foundation, contemplation of mind objects, the “inner
landscape of mental experience” (Olendzki, 2004), is investigated during
meditation practice in MBSR. These experiences include but are not limited
to what gets in the way of being present, such as sleepiness, restlessness,
agitation, wanting a different experience or not liking what is happening, or
doubt in the usefulness of the meditation. By identifying these as states of
mind that arise in meditation practice, participants learn not to get lost in or
too attached to them. The MBSR teacher helps his group understand that
mindfulness involves coming to fully know experience as it is, bringing
curiosity and interest to whatever comes. By understanding what the mind
can present, participants learn what is useful to let go of and what is helpful
to explore. This has a direct correlation to the way we might manage the
difficulties of life.

The Three Marks of Existence

The concept of the three marks, or characteristics, of existence is
central to the practice of Vipassana meditation. We have found them to be
particularly useful for guiding participant practice and for facilitating
inquiry, the post-practice dialogue that follows meditation (see chapters 4
and 5). These three characteristics, considered to be conditions of life, are:
(1) life is imperfect (we all suffer), (2) everything is impermanent
(everything changes), and (3) what happens in life is impersonal (the
difficult concept of “not self”). Participants will meet all of these conditions
in the MBSR program. When practicing mindfulness, they come in contact
with the experience of stress and suffering. Part of the teacher’s role and
function is to assist participants in noticing these when they arise and when
they pass. Through continued practice of this skill, participants learn that all
experience that is observed but not acted upon ultimately changes. Through
this process of observing thoughts, emotions, and body sensations as
components of experience, participants create distance (de-center) from a
fixed view of self (a rigidly held belief of who one is).

Learning and Psychological Theories

Learning to be an MBSR teacher or other MBP provider, at present, most
frequently takes place within the realm of continuing education. Adult
learning theory developed by Malcolm Knowles in 1968 postulated that
adults require a different approach to teaching and learning than that used
for children (Merriam, 2001). But since such theories are not common
knowledge to those teaching MBSR, student teachers often do not have an
understanding of what is required of an adult educator. Given that there is a
large body of literature devoted to adult education, and that MBSR is
delivered in the majority to adults, there are some specific skills and
knowledge we would suggest are useful for teacher trainees to learn derived
from this discipline.
 Those coming to learn MBSR or to teach it are predominantly self-
directed learners who have chosen, for their own internally driven reasons,
to study this program. They are rarely mandated, and this is important,
because for adults, this intrinsic motivation is a necessary factor in their
learning (Knowles, 1988). Those choosing to take the program at a
particular point in time are doing so presumably because it is congruent
with where they are in their personal and professional lives. This is a
critical piece for teacher trainees to understand. For both themselves and
their students to learn optimally, it is important that they are interested and
motivated, and the time is right (ibid.).
Secondly, it is valuable to know that there are a number of ways adults
learn. One of these is called experiential learning (Kolb & Fry, 1975). In
experiential learning, in contrast to direct instruction, people first have a
concrete experience, engage in reflective observation about it,
conceptualize it in a way that makes it relevant and applicable to their lives,
and finally, actively experiment and practice with what has been learned. It
is a process of discovery and exploration versus the one-way imparting of
information to the learner by the teacher as in direct instruction. There is
evidence that this method has a positive effect with respect to the student’s
perception of learning as well as the actual learning, particularly when
learning is to be applied (Burch et al., 2014). However, the literature is
mixed on the effectiveness of this approach. For some, minimal instruction
may not be as helpful as the provision of more direct teaching. It ultimately
depends upon the individual learner’s experience.
Nevertheless, MBSR is an applied program that relies heavily on
experiential learning. And either way, the teacher needs to ensure that what
he is delivering, whether it is direct instruction or the opportunity for
experiential learning, is relevant to his participants’ needs. This is partially
determined by understanding what participants wish to get out of the
program and eliciting these intentions from the group in the orientation
meeting and again in the first class. Teachers should also provide
participants the context for learning, which will include such experiences
with guided meditations (that have a present-oriented focus) and yoga. As
much as possible, teachers elicit the content they intend participants to learn
through skillful questioning, listening, and reflections. This enables
participants to engage in reflective observation. In MBSR, interactive
discussions facilitate abstract conceptualization to help participants
cognitively process and integrate what is being learned. Finally, teachers
assign home practice and review it in subsequent sessions to encourage
active experimentation with the material and concepts of the program.
Additional concepts derived from self-determination theory (SDT)
may be helpful here to round out this discussion of theories that can support
the teacher in her instruction. People, according to SDT, have three innate
psychological needs that are directly tied to health and well-being: (1)
competence, (2) relatedness—that is, interpersonal connection, (3) and
autonomy, meaning the ability to behave “in accord with…(one’s) needs
and values (and to experience)…willingness and choice when acting” (Deci
& Vansteenkiste, 2004). We would suggest that at least part of what
teachers of MBSR are doing is reinforcing these qualities in those they
teach. Participants coming to the MBSR program are often overwhelmed
and discouraged by the stressors they are dealing with. The instilling of
hope is one of the teacher’s functions to help participants increase their
competence and self-efficacy in managing stress. Hope can become an
internal resource and motivator for change for those who suffer from
psychiatric disorders, and there is no reason to suspect that this is not also
the case for those attending MBSR groups (Russinova, 1999). A hopeful
stance by the teacher models an attitude for participants that, if they can
internalize it, will motivate them toward their own growth and well-being
(autonomy). Holding these psychological concepts and the value of
instilling hope in mind in a group setting promotes relatedness and
connection for the participants. The teacher is there to enhance the
participants’ ability to make use of their internal and external resources in
the service of stress reduction, therefore meeting the needs outlined in SDT.

In Closing
In conclusion, in this chapter we have discussed the importance of having a
structured approach to teaching, one that includes a protocol/curriculum and
a mindfulness practice that the teacher develops and maintains. We also
discussed the utility of Buddhist psychological concepts in teaching MBSR
and particular psychological and adult learning theories that are relevant to
teaching MBSR. This is all directly related to the acquisition and expression
of teaching skills. We now turn our attention to two conceptual frameworks
that can assist the teacher in developing these skills. These are the five
agents of change that operate in the delivery of all MBPs and the themes,
rationales, intentions, and practice skills (TRIP) that are present in all eight
sessions of MBSR, which a teacher can draw upon to make the instruction
comprehensive and effective (Woods, Rockman, & Collins, 2019).
 CHAPTER 3:

Teaching Frameworks

Teaching MBSR can seem deceptively easy when one is watching a skilled
teacher. It can look effortless when teacher and participants are working
together and the learning unfolds, demonstrating its own natural rhythm. In
the previous chapter we discussed some essential considerations for
becoming an MBSR teacher. In this chapter, we will turn to the actual act of
teaching—the tools the teacher can employ to support her instruction. To do
this, we will employ a framework that Woods initially developed in 2013 as
a resource for training future teachers. This framework consists of two
approaches that help organize a teacher’s thinking about what they are
teaching and the rationale for what they are doing. The two approaches are
(1) the five agents of change in MBSR and any mindfulness-based program
—the protocol, the mindfulness-based practices, individual learning, group
process, and the teacher’s own embodied mindful presence—and (2) the
themes, rationales, intentions, and practice skills (TRIP), which can be seen
to structure each MBSR session (Woods, Rockman, & Collins, 2016). It has
been our experience that these have provided additional contextual
assistance to MBSR teachers-in-training and encourage a teacher’s
development of best practices (Woods, Rockman, & Collins, 2019).

The Five Agents of Change

To restate, the five agents of change are (1) the protocol; (2) the
mindfulness-based practices through which participants come to understand
the patterns of thoughts, emotions, sensations, and behaviors that drive their
stress and begin to relate to them differently; (3) individual learning, which
can affect how a teacher approaches her material in any given moment; (4)
group process, which the teacher can come to understand and actively
facilitate; and (5) the embodied mindful presence of the teacher, which
informs it all. In this section, we’ll explore each agent in detail.

The Protocol
Protocols offer us a map and are a useful means from which to develop
our understanding of what we are teaching. Maps help situate us and
provide a practical view of where to start, the ground to be covered, and
where we are going. It’s worth noting that maps are two-dimensional; they
can only provide an outline for teaching, and they don’t really represent the
experience of teaching, or the art and the skill. Nevertheless, having a
protocol/curriculum to follow is beneficial, particularly for teachers new to
an MBP, as it provides a structure and reduces the understandable anxiety
that results from teaching something unfamiliar. With a protocol, there’s
less confusion about the various teaching modules and mindfulness
practices that need to be addressed for each session. A protocol enables us
to gain insight into and an understanding of the underpinnings of the
program, its modularity, and how each session builds on the previous one.
This provides a longitudinal view of the teaching arc over the eight weeks.
Furthermore, a recognizable protocol provides standardization that can be
replicated and researched, which is essential if we are to study the modality
and participant/patient outcomes.
Without a structure, misunderstandings and a disorganized program
may result because we are given the license to teach pretty much anything
without a frame of reference or oversight. Once we’ve worked with the
protocol long enough to internalize the foundation, we are free to discover
and work with the complex process of teaching MBSR. Teaching that is
solely reliant on the delivery of the protocol can then be released.
Though MBSR lacks a dedicated protocol, it does have a clearly
enumerated program, as reflected in Jon Kabat-Zinn’s seminal Full
Catastrophe Living and through the original work of the Center for
Mindfulness at the UMass Medical School and elsewhere. The MBSR
program consists of eight weekly sessions with an all-day retreat in the
sixth week. In the first half of the program, instruction focuses on the
practices of mindfulness meditation, both formal and informal, educational
material about the roots of stress, and how heightened levels of reactivity
contribute to our suffering. In the second half of the program, the practice
of mindfulness continues, strengthening a deepening awareness of the
movement of sensations (thoughts, emotions, body sensations, sounds),
with a growing steadiness in acknowledging the presence of challenging
experiences and becoming less caught by them. This process of self-
discovery promotes a sense of self-efficacy, calm, and compassion.
Instructive and informative modules are provided, highlighting the utility of
bringing mindfulness to triggering moments, increasing the capacity to
respond to these moments skillfully.
Each weekly session is typically two and a half hours long, and
generally follows a set outline. Each class opens with a mindfulness
practice (or several practices). This is followed by a conversation (inquiry)
about what has been experienced in the practice(s). After this, there is a
general dialogue about the previous week’s home assignments. The teacher
then presents a topic that ties into the theme for the week that leads to a
general conversation on that subject. The final part of the session agenda is
the setting of home practice for the week to come and, if there is time, a
short meditation practice.
The all-day retreat is typically held between the sixth and seventh
weeks and usually over a weekend. It provides participants an opportunity
to practice mindfulness for a sustained period in silence, with the teacher
leading the meditation practices that participants have been exposed to in
the previous weeks.
We will now summarize each session of the MBSR
protocol/curriculum. This outline provides an overview of the teaching
modules for each class. In part 2, we expand on this MBSR
protocol/curriculum in far more detail.

THE ORIENTATION SESSION OR PRE-CLASS

INTERVIEW
This is an important class and can be conducted in a group format with
individual follow-up, or can be facilitated by interviewing individual
participants. In this session, the teacher discusses the premise and content of
the MBSR program and talks about the risks and benefits. She reviews
informed consent and asks her participants to sign a waiver. (For sample
consent forms and waivers, see the appendices.) She will need to screen for
suitability, and, if she is a clinician, she will need a release to contact a
participant’s therapist/health provider depending on the diagnosis and
symptoms. It will be important to allow time for questions from the
group/individuals about participating in the program. This session prepares
the ground and sets the context for participation in the eight-week program.

SESSION 1: INTRODUCTION TO MINDFULNESS AND

“BEING” MODE OF MIND
In this first session, the teacher welcomes everyone. She may start with
a brief breath awareness practice, followed by a short standing yoga
sequence. She briefly restates the themes and the learning process of the
program and sets the guidelines (confidentiality, etc.) for the eight weeks.
She teaches two mindfulness practices: the raisin and the body scan. Both
of these are followed by a discussion about the experience, known as
inquiry. Lastly, she sets the home assignments for the coming week, which
includes an audio recording of the body scan (formal practice) and bringing
attention to an everyday task, like showering (informal practice). The
agents of change inherent to the raisin and body scan practices involve
learning to focus on and direct attention to the senses and sensations. This
assists participants in cultivating the skill of a present moment orientation.
Learning to steady attention on a particular object of interest also
illuminates noticing the movement of experience (non-doing mode),
enabling them to see how easy it is to get caught up in automatic reactivity
(thinking, emotions, sensations, and behaviors).

SESSION 2: THE ROLE OF PERCEPTION AND

LEARNING TO “BE” WITH ALL EXPERIENCES
Session 2 consists of the following formal practices: a brief standing
yoga sequence, the body scan, and a brief guided sitting meditation. This is
followed by inquiry. The previous week’s home assignments are discussed
and then followed by a short seeing meditation and inquiry. The teacher
facilitates an exercise illustrating the role of perception and perceptual
biases. How we “see” something frequently determines how we respond
and react and determines what we do next. At the end of the session, the
teacher assigns home practices for the coming week. This session, as the
others, reinforces learning through repetition of the practices and by
reviewing home practice. By bringing awareness to cognitive and
perceptual biases, participants begin to question conditioned assumptions
and judgments, seeing how these can often limit new learning.

SESSION 3: “BEING AND DOING”

In this session, the teacher facilitates a longer yoga sequence, a
walking meditation, and a sitting meditation practice and inquiry. She
discusses the previous week’s assignments and assigns the home practices
for the coming week. Participants are now becoming familiar with the
experience of observing what is arising in the practice and learning to be
with the various sensations (thoughts, emotions, body sensations, and
impulses/urges) without the need to immediately react or do anything about
them. And, in acknowledging what is present and learning to turn toward
what is being experienced, participants gain insight into how reactivity and
resistance amplify stressful moments. They are learning they have choices
in how they respond.

SESSION 4: STRESS AND STRESS REACTIVITY

In this session, the teacher starts with a standing yoga sequence,
followed by a sitting meditation (with a focus on how to work with intense
physical sensations) and inquiry. The week’s previous home assignments
are discussed, helping to reinforce learning, not only through the formal
practices but also in how mindfulness is being applied to everyday life. The
teacher leads a discussion about stress and its impact on the body/mind as
well as how people tend to cope with it. Next week’s home assignments are
handed out.
There are several factors influencing participant learning in this
session. The first involves approach versus avoidance, using the practice of
investigating intense physical sensations. The second involves staying with
these sensations when possible, enhancing distress tolerance. The third
highlights how there can be a mismatch between expectations and outcome.
This is important because participants engage in experiential
disconfirmation—that is, they discover that what happens isn’t always what
they predict and learn that predicting outcomes or allowing past experiences
to inform the present are obstacles to change. The fourth factor involves a
discussion about stress reactivity that utilizes various ways of considering
how stress affects our psychobiology. The fifth factor, directly tied to the
home practice for the coming week, is an awareness exercise that asks
participants to monitor their stress reactions as these show up in their
thoughts, emotions, body sensations, and behaviors or impulses to act. All
of these factors provide an anchor for examining the effects of stress and
begin the process of intentionally investigating them when they arise.

SESSION 5: RESPONDING TO STRESS

This session starts with an opening meditation, some yoga poses, and a
guided sitting meditation (practicing with several foci) and inquiry. The
week’s previous home assignments are discussed, assisting learning and
reinforcing their applicability to everyday life. The teacher leads a
discussion that offers a brief review of the previous week’s session on the
psychobiology of stress. She then guides the discussion to the role of
bringing mindful awareness to how we respond to these moments,
reinforcing participants’ understanding that responses can be chosen. The
following week’s home assignments are handed out. Learning continues
with the repetition of meditation practices and employing different ways of
working with attention. Participants are continuing to explore their
signatures of stress (body sensations, emotions, thoughts, and behaviors)
and now employing how they might respond to those moments or intervene
adaptively using mindfulness skills.

SESSION 6: STRESSFUL COMMUNICATIONS

In this session, the teacher facilitates a yoga practice, a sitting
meditation practice, and inquiry. There is a discussion of the home practices
of the previous week. The teacher leads an exercise and discussion on
difficult communications followed by a brief sitting meditation practice.
Next week’s home assignments are handed out and the teacher prepares the
participants for the all-day silent retreat.
Review and repetition continue to be drivers for learning. This class
introduces a common area of stress for all of us, the interactions with
others. Learning about some of the typical roles we can inhabit when
immersed in challenging conversations allows participants to develop
empathy for another’s perspective, as well as their own, providing adaptive
behavioral options.
 THE ALL-DAY RETREAT
This is a day (or half a day) when participants have the opportunity to
practice in silence, with the teacher leading them through the meditation
practices from the previous six weeks. This will include the body scan,
sitting meditation practices, mindful movement (based on yoga poses), and
walking meditation. Time is allocated for lunch (or a snack in the half day)
so that participants have the experience of relating to eating as a mindful
practice. The silent hours of practice support an intentional, attentional
focus on single objects of interest (e.g., the breath), as well as holding a
wider frame of awareness where whatever is appearing within the
meditative field is noted. Maintaining silence enhances attention to and
reinforcement of a present moment orientation, being with, non-doing, and
awareness of how experience comes and goes. At the end of the day, the
teacher facilitates the transition out of silence and gives instructions for
going home.

SESSION 7: INTERACTING WITH THE WORLD,

SKILLFUL CHOICES, AND SELF-CARE
In this session, the teacher starts by inviting individual participants to
choose a yoga pose and teach it to the group. This is followed by a
“changing seats” exercise, where participants are invited to choose a
different place to sit in the room from where they normally sit. A discussion
ensues about what it was like to lead the yoga and to choose a different seat.
The teacher guides a sitting meditation, followed by inquiry. There is a
discussion of the all-day retreat and of the previous week’s home practice.
She then leads a review of the MBSR program and facilitates the
participants talking about what they have learned about their relationship to
stress and the practice of mindfulness. There is a discussion about what we
are exposed to every day as “a diet” (e.g., television, technology, etc.) and
how we relate to those things can increase or reduce stress. Next week’s
home assignments are handed out. The review of the program and
continuing practice (formal and informal) reinforce learning. The discussion
highlighting how we relate to the world serves to extend the learning and
utility of mindfulness skills to the practicalities of everyday living.

SESSION 8: KEEPING THE PRACTICE ALIVE

 The teacher facilitates the body scan, a yoga practice, sitting
meditation, and inquiry. There is a discussion of the home practices from
the previous week. The teacher leads a discussion and reviews with the
participants what has been learned and elicits reflections on how they will
continue to practice. She also leads a closing ceremony to mark the end of
the program and to help participants let go of the group. This session moves
participants into the future, supporting them to continue the learning and
practice of mindfulness to promote self-care and wellness.
As an agent of change, the MBSR protocol is not static or rigid, but it
does provide a structure for developing a mindfulness practice and guides
participants through the process of how to relate to stress differently, while
developing adaptive responses and behaviors. Teaching a mindfulness-
based protocol is a dynamic, organic process. This will be affected by the
presence of the teacher and the choices she makes in responding to her
participants.
The protocol can be adjusted depending on the population being
served, by the group dynamics of a particular group, and by how
individuals are working with what is being presented. For example,
working with a group where chronic pain is the predominant identifier will
be different from working with a group of parents with adolescent children.
This means that sometimes different aspects of the protocol will need
emphasis at the expense of or downplaying others. Furthermore, individuals
learn in diverse ways and at different rates. A teacher’s sensitivity to this
diversity will influence how to organize the protocol. It may necessitate her
spending more time on one particular theme or module in a class. What is
less subject to being changed are the meditation practices.
Additionally, the protocol will, over time, be subject to updating and
informed by science and clinical studies, as these are bringing insights into
how the MBSR program affects change. A teacher will need to keep abreast
of this, as well as developments in the Western understanding of mind and
mood, and integrate this information when necessary into her teaching.

Mindfulness-Based Practices
The MBSR program offers both formal and informal mindfulness
practices. These practices are fundamental to the MBSR program and a
crucial driver for change, as they train attention, enhance body awareness,
expand perception and view, reduce automaticity and reactivity, and
increase choice and responsiveness. The formal practices are the body scan,
mindful movement that is typically based on yoga poses, walking
meditation, various sitting meditations, and eating meditation. The informal
practices involve bringing attention to everyday tasks that are typically
completed automatically. Ultimately, the learning is for participants to take
what has been practiced and integrate it into their everyday lives and
interactions with others.
The formal practices as a change agent train attention in a way that
enhances a present moment orientation and transforms the way we
understand and relate to thinking patterns, mood fluctuations, and habitual
behaviors. We learn to be curious about what we are experiencing,
becoming familiar with the automaticity of thoughts, moods, and behaviors.
As a result, we become less trapped in believing that every thought is true.
Over time, the need to hold to a specific view is lessened. By not avoiding
the movement of sensations (thoughts, emotions, body sensations), but
allowing ourselves to be present for them, we steady an allowing and being
with whatever is arising. The upshot is less reactivity and less judgment
directed at ourselves and others. There is less defensiveness, less avoidance,
and less need to hold anything rigidly. This ultimately strengthens kindness
and compassion. And over time, our thoughts, emotions, and behaviors
become more skillfully responsive to the situations in which we find
ourselves.
There is no doubt a teacher could simply learn the scripts for
mindfulness meditation practices and deliver them. But this would be a
poor substitute for conveying the essential elements of this change agent,
which is what live teaching practice has to offer. What we mean by live is
that the teaching relies on a present moment orientation for its delivery and
a commitment to be in practice when guiding. This will cause the wording
for these practices to change (to some extent) from one week to the next,
depending on what is current and applicable to group learning at any given
moment. For example, if a teacher notices restlessness in a group, she may
allude to this in her guidance, saying, “Noticing restlessness if that is
present.” The intention behind the instruction, which is often related to the
particular theme(s) of a class, remains consistent.
 Informal practices, on the other hand, are those where we bring a
deliberate focus to a task that is often mundane or one that we execute
regularly. Examples of these would be brushing our teeth, showering, or
taking out the garbage. By paying attention to these tasks and behaviors, we
begin to understand how frequently our minds are on automatic pilot and
not present to what we are doing. Our minds are thinking about something
else—planning a vacation, focusing on a worry, or ruminating about
something that has happened or about to take place. Informal practice
allows participants to see the applicability of mindfulness to everyday life,
using the routine task as an anchor for training attention.
There is also evidence that people are happier when they exist in the
present moment, and by paying attention to ordinary activities of daily
living, we increase our sense of well-being and give a boost to positive
affect (Killingsworth & Gilbert, 2010; Brown & Ryan, 2003). By bringing
attention to everyday activities, we are less likely to be governed by
automatic thoughts, emotions, and behaviors. By directing attention to the
task at hand, we learn to appreciate the full range of what is being
experienced. Thus, informal practice is both diagnostic and preventive.

Individual Learning
Adults learn in different ways, tend to have preferred learning styles,
and bring life experience to their learning. Additionally, having an
understanding of the rationale and context for what is being taught
facilitates learning. Adults tend to be task-oriented and interested in solving
problems. Furthermore, they are most ready (motivated) to learn when a
specific need arises or through self-selection.
Some of our participants will be visual learners, others auditory, and
still others kinesthetic. Visual learners take in information primarily through
the sense of sight, auditory learners rely on the spoken word, and
kinesthetic learners prefer to learn through practicing something new, a
more hands-on approach. The MBSR program addresses all of these
through experiential mindfulness practices that can be kinesthetic, auditory,
and visual, and through various instructional exercises and discussions
(auditory and visual). The inquiry process uses auditory and visual learning.
Having a varied approach to learning fosters participant engagement and
attention to the material being presented, supporting interest. In all the
discussions, emphasis is given to the relevance and practicality of
mindfulness practices and the rationale for practicing them, which is
underscored in the weekly home practice assignments where participants
have the opportunity to experiment on their own.
MBSR encourages experimentation, self-directed curiosity, and
investigation of direct experience—self-reflection—through the in-session
instructional exercises and the formal and informal mindfulness practices.
The models of adult learning developed by Malcolm Knowles (1988),
David Schön (1983, 1987), and David Kolb (2015) propose that adults are
self-directed and will acquire and expand upon new skills through the
process of self-reflection that results from direct experiences. What a
student learns can then be tested in various settings that are relevant to that
individual. This builds trust, self-efficacy, and self-mastery of the new skill.
Through assigning home practices, newly acquired insights and skills are
tested in vivo. This provides reinforcement for the learning in between
sessions, with relevance to the integration of the practice into everyday life.
Building upon the above discussion, there are some additional
principles from self-determination theory (SDT) (Deci & Vansteenkiste,
2004), which can give us another lens through which to view motivational
factors in learning. SDT, in addition to its explanation of human
psychological needs, is also a model that describes adult motivation and the
influence of external and internal factors. The theory suggests that there are
two main types of motivation—intrinsic and extrinsic—that influence our
behaviors. Intrinsic motivation is based on a person’s interests, core values,
and moral compass. Extrinsic motivation, like it suggests, arises from
external influences, such as being promoted, the respect of colleagues,
praise from a trusted friend, or being thanked for volunteer work.
We can see the SDT model operating in the MBSR program in a
number of ways. Mindfulness meditation practices develop an individual’s
internal awareness and exploration of the fluctuations of thoughts, body
sensations, emotions, and reflections on behaviors. A teacher encourages
her participant(s) to trust this process of investigation. In so doing, she is
promoting self-efficacy (autonomy) and an internal (intrinsic) locus of
control, leading to a developed understanding of what contributes to
suffering and what eases it. This increases motivation to continue to
practice. Over time, through the direct experience of this process, a
participant becomes a participant-observer, rather than being so tightly
identified with these experiences. This loosens the story of who they think
they are and offers flexibility and adaptability contingent on what they are
experiencing. This is frequently expressed as ease; being less reactive and
not so easily triggered; and feeling more relaxed, less anxious, and less
depressed. This in turn acts as another intrinsic motivator for continuing to
practice.
Extrinsic motivation comes from the exchanges between the
participants as well as directly with the teacher. The inquiry process
facilitates extrinsic motivation in the sharing of challenges, but not to the
exclusion of individual and group insights. Certain behaviors and norms of
mindfulness are rewarded in implicit ways by what the teacher pays
attention to and what participants are expressing. For example, the teacher
will tend to ignore or interrupt narratives because this reinforces a sense of
self that when identified with too strongly may enhance suffering. She will,
however, pay close attention to and reflect upon participant descriptions of
the components and sequential nature of their experiences. By supporting
individuals in their personal learning, the teacher is also fostering an
environment where the group process becomes an additional key agent of
change in increasing extrinsic motivation.

Group Process
The teacher’s ability to understand and facilitate group process is a key
skill and catalyst for change in the MBSR program. The way an MBSR
group, in particular, connects and learns to trust the teacher, themselves, and
others in the group will change over the eight weeks. Understanding this
movement and how to guide it is an important agent of change because
much of the group’s learning throughout the program is assisted by
participants’ responses to, and engagement with, the various exercises,
discussions, and inquiry. While there are a number of group process
models, for our purposes here we will map the MBSR program onto
Tuckman’s work (Tuckman & Jensen, 1977) on the developmental stages of
group formation. In Tuckman’s model there are five stages: forming,
storming, norming and performing, and adjourning.

FORMING
 The forming stage, which starts at the orientation session and
continues through the first few sessions, is where group members are
learning about the structure of the program, individual and group
expectations, and the guidelines that are set to establish trust, respect, and
safety. Typically during this stage, where what participants are experiencing
is new and unfamiliar, the teacher tends to be more active than in later
sessions, and the participants are more dependent on her and her clear
guidance, instruction, and feedback.

STORMING
The next stage is storming, where the group identifies the struggles
and challenges of what is being asked of them. This can show up in several
ways in the MBSR program. Doubt, confusion, irritation, and frustration are
typical responses. Individuals speak to concerns about the difficulty of
finding the time to practice at home, of “not getting it,” or of not doing it
right. At this point, a teacher might see missed sessions and experience
direct challenges to what she is teaching.
For the novice teacher, this can be a particularly demanding time,
which can result in her retreating into various roles and default behaviors to
manage her discomfort. Depending on her professional background,
training, experience, and personality, these might be categorized as
archetypes, such as professor (who has all the answers), educator (too
didactic), psychotherapist (who probes too much and preferences emotion),
caretaker (who rescues and has to look after everyone), or coach (the
cheerleader). The retreat into the safety of one’s professional role is a signal
that the practice of being a mindfulness teacher has, in those moments, been
lost. The more experienced teacher will encounter these moments with
awareness, allowing her to understand the stage of the group’s
development, meet participants where they are, and integrate their concerns
and difficulties into her teaching.

NORMING AND PERFORMING

The next stage in a group’s development is norming and performing. If
an MBSR teacher has acknowledged the difficulties in the previous stage
and helped the participants work through the obstacles they are
experiencing and normalize them, the group enters into a phase of working
with the material in the way that is being asked of them. In this stage, as the
teacher continues to maintain appropriate boundaries of respect and safety,
and processes the unevenness of learning within the group, the participants
settle, trusting the process and the teacher, with a sense of being part of an
identified whole.
In addition, the rationale for developing a mindfulness practice
becomes more evident in relation to developing a different relationship with
stress. The group moves into teaching itself, with the teacher taking less of
a leadership role. She continues to guide and reinforce the learning, as she
remains responsible for the content delivery. However, she furthers this
process by facilitating discussions that are interactive, eliciting key learning
and information from the group rather than engaging in lecturing.

ADJOURNING
This is the final stage of group process and is one that often elicits
anxiety about finishing, sadness about ending, and the desire to continue.
Letting go is not easy, particularly in this context where the group has often
bonded and come to understand the commonality of the human condition,
and where members no longer feel alone with their challenges and stressors.
This will be manifested in a variety of ways and is often expressed by
wanting to continue with the same group members and the same teacher. In
session 7, a teacher will remind participants that there is just one session of
the program left, preparing them for the ending that is approaching. She
will start the process of reviewing what has been learned over the previous
weeks and, in session 8, help participants determine what practices they will
continue to work with after the program.
Some teachers will provide drop-in sessions after the program ends,
once a week or on a monthly basis. These can be helpful, but they tend to
be unsustainable unless there are sufficient numbers (the teacher is teaching
a number of programs each year) and the teacher organizes it. Some
teachers provide booster sessions—a sequential series of four to six classes
typically lasting an hour and a half for each session. These have been more
successful.
 Embodied Mindful Presence
Of all of the agents of change, we see embodying mindful presence as
central to the delivery of the MBSR program. The teacher as an essential
agent of change expresses the practice of mindfulness overtly in her
guidance of all facets of the program, her facilitation of inquiry, and
nonverbally through her presence. Although studying Buddhist texts,
reading about mindfulness, and familiarizing yourself with the emerging
science are all useful and informative, relying on knowledge that is
cognitively acquired is insufficient for an authentic expression of mindful
presence. This is because embodying mindfulness requires a commitment to
developing and maintaining a personal mindfulness practice and is therefore
a capacity that develops over time. Contrary to some of the publicity,
mindfulness practice is a lifelong endeavor, where understanding is
generated from knowledge gained through experiencing the practice, a
bottom-up process. This is in contrast to the more typical reliance on
intellectual understanding, a top-down process of acquiring expertise. We
are not suggesting that before a teacher starts to teach MBSR she needs to
be an expert. But what it does mean is that there is an expectation that a
teacher has a mindfulness practice, and that she understands it will evolve
and mature over time, becoming central to her teaching.
An embodied mindful presence reflects some principal attitudinal
foundations of mindfulness. These are patience, trust, beginner’s mind,
nonjudging, acceptance, non-striving, and letting go (Kabat-Zinn, 1990,
2013). To this list we would like to add curiosity and compassion (Woods,
Rockman, Collins, 2019). These attitudes are embedded in Buddhist
psychology but are understood through their lived experience and not as an
intellectual pursuit. A teacher’s direct experience of them in her own
practice enables her to present them with authenticity, both nonverbally
through her demeanor and verbally in her conversations with her
participants.
In embodying mindfulness, a teacher draws upon words that best
convey her intentional focus as she guides the mindfulness practices. Her
responses to her participants, along with the facilitation of inquiry, will be
governed by her discernment of the fundamental teachings of mindfulness
practice—that suffering (which none of us will escape) is inevitable but can
be understood and safely endured. In this way, we can develop a different
relationship to it, seeing that everything changes, and that although we tend
to personalize what happens to us (making it all about us), it is actually
impersonal. As a teacher engages in the process of inquiry (an outward
manifestation of an embodied mindful presence), she recognizes that her
questions and responses act as catalysts for her participants, influencing
how they come to know the practice experientially. It also impacts the other
four agents of change (the protocol, mindfulness practice, individual
learning, and group process), shaping the way the program is both delivered
and experienced.

The Five Agents of Change in Action

Here we give two examples of the five agents of change in action to
illustrate how they might be understood and applied. The first illustration is
from session 2 (The Role of Perception and Learning to “Be” with All
Experiences), where participants are discussing their experience of the body
scan meditation. The teacher is interested in hearing from as many
participants as possible (expressing two of the agents of change: group
process and individual learning).
Teacher: I am interested to hear what showed up in this practice.
Participant 1: I think I fell asleep! Did I snore?
Teacher: Do you have a sense of when you fell asleep?
Participant: (Pauses) I think it was at the left knee. I woke up when I
heard people moving.
Teacher: It’s not unusual to fall asleep when we lie down. It’s such a
conditioned reflex.
Participant 2: I was aware of lots of thoughts. Honestly, my mind!
Teacher: It’s amazing how much thinking there is. Were you aware
of any body sensations with the thinking?
Participant 2: Yes, but it was short-lived!
Participant 3: I felt restless. I couldn’t settle.
Teacher: When did you notice this restlessness?
 Participant 3: Somewhere in the middle of the body scan.
Teacher: Could I ask, how did that show up?
Participant 3: I think it was a sense of when is this going to end!
Teacher: (Smiling) It can feel like a long time.
Participant 4: I felt relaxed. I’m not sure why, as I have had a tough
day. So I wasn’t expecting to feel calm.
Teacher: So this was unexpected. Expecting one thing and then
something else shows up.
Participant 4: Yes.
Participant 5: I noticed pain in my shoulder. It was hard not to get
pulled into those sensations. I think I heard you say at one
point to breathe into and out of an area of pain if pain was
present?
Teacher: Yes. Did you have a chance to experiment with that?
Participant 5: I did. And it was sort of helpful.
Participant 6: I think I tuned out!
Teacher: How did that show up?
Participant 6: Sort of daydreaming, I think.
Teacher: It’s so interesting to see how many experiences show up
when we practice in this way. There was sleepiness, thinking,
restlessness, relaxation, pain, and daydreaming. Some are
pleasant, some are unpleasant, and some things we don’t
even notice.
At the end, the teacher is summarizing the participants’ responses. She
is not favoring any one response, but rather is interested in collecting a
range of reflections supporting group process. By not privileging one
response or its valence (positive, negative, or neutral) over another, she is
stimulating individual learning and modeling equanimity. It is week two for
the participants and it is important to normalize what shows up in practice,
promoting trust and patience for the learning process.
The next scenario is taken from session 5 (Responding to Stress),
where participants have just finished a forty-minute sitting meditation led
by the teacher. Although the theme of this session is responding to stress,
that doesn’t mean that is what a participant will be working with. And
inevitably, individual learning will vary from one participant to another. In
such situations, the teacher’s grasp of such agents of change as individual
learning and embodied mindful presence, and her understanding of how to
deploy the agents in a live setting, will be invaluable.
Teacher: I am wondering, what showed up in this sitting practice?
Participant: I am still struggling with all of this.
Teacher: In what way?
Participant: My mind is everywhere but here. It’s so frustrating. It
won’t stop.
This is a potentially challenging spot for a teacher to be in. She might
feel pulled to make the participant feel better, to ease the sense of
frustration and helplessness that the participant is describing. Or, equally,
she might want to make a teaching point as a way to encourage the
participant. If she does that, she will not be staying with what the
participant is describing (a present moment orientation), which is a key
component of embodied mindful presence.
Teacher: It’s not easy to be with a busy mind. Do you have a sense of the
thinking—what kinds of thoughts?
The teacher steadies the participant by addressing the frustration of a
lot of thinking, highlighting the quality of thinking versus the content,
containing her responses as they relate to the practice. She is working
directly with the potential here for individual learning as well as supporting
group understanding and process. She is not trying to emphasize the stress
response, the theme for session 5, but is embodying a sense of curiosity and
interest. She is also demonstrating the tracking of experience, another
aspect of learning and embodied mindful presence.
Participant: A lot of the thinking was about how I can’t do this.
 Teacher: Were you aware of any emotions or body sensations with
this thinking?
Participant: (Pausing) Tight neck and shoulders. In fact, I can feel
them now as I am talking about this.
Teacher: Would it be possible to direct your attention to those areas
now, breathing into them and out? (Teacher waits.)
Participant: It’s interesting. It feels a little easier.
The teacher is staying with (being with) the participant. She
acknowledges the difficulty the participant is facing but doesn’t get caught
up in any story about “I can’t do this.” She displays curiosity and interest in
the possibility of turning toward challenging mind states—in this case,
thinking. She investigates labeling of thoughts (not narrative driven), along
with any additional components of experience, emotions, and body
sensations. The teacher is embodying acceptance, non-striving, patience,
and trust. She is also not attached to an outcome for the participant and this
is a critical part of the process of the inquiry.

The Themes, Rationales, Intentions, and

Practice Skills
For MBSR teachers-in-training, a second approach, identifying the themes,
rationales, intentions, and practice skills (TRIP) for each session, and
indeed for the eight-week arc of the MBSR program, is helpful for
developing best practices. Developed by Woods in 2013, and further
described in Mindfulness-Based Cognitive Therapy: Embodied Presence
and Inquiry in Practice (Woods, Rockman, & Collins, 2019), TRIP is an
approach that provides a means to deconstruct each session, addressing the
underlying assumptions and principles. For teachers, TRIP enhances a
teacher’s skills by structuring her thinking and helping her examine and
explore her understanding of what’s being taught. For the more experienced
teacher, TRIP acts as a reminder, a cognitive anchor to what is important to
emphasize, helping to keep a teacher close to the intention of the MBSR
program and the direction for the learning.
 As the word suggests, the themes describe the subject and context for
each session; the rationales explain the “why” of teaching, the reasons for
what is being taught; the intentions relate to what is being taught—the aim
or purpose; and the practice skills describe the method, or how this will be
facilitated. As such, the practice skills will relate to what a teacher needs to
develop in terms of competence and best practices. In part 2, we will
discuss in more detail the use of TRIP for each of the eight MBSR sessions.

In Closing
In this chapter we have discussed two approaches, the five agents of change
in depth, and given a brief description of the themes, rationale, intentions,
and practice skills (TRIP) that we have found useful when working with
teachers-in-training. The five agents of change provide a multifaceted
approach to various operational variables at work in the MBSR program.
Understanding and employing these builds best practices and teacher
competence.
Both the five agents of change and TRIP are approaches designed to
serve as a guide for teachers. In part 2, for instance, TRIP will be used as a
frame of reference for developing teaching skills and competence for each
module of each MBSR session. Of course, the tension inherent in any
structured approach to teaching is that it can easily become formulaic,
narrowing the teacher’s perspective. But teaching MBSR is anything but
mechanistic. Ultimately, the five agents of change and TRIP are teaching
aids meant to stimulate and organize the teacher’s thinking—an aid to
inspire reflection in support of best practices and competence.
 PART 2:

The MBSR Curriculum/Protocol

In this section, we lay out the framework of the MBSR program. We have
based the outline of the protocol that follows on three sources: Jon Kabat-
Zinn’s seminal book, Full Catastrophe Living (2013), the curriculum
identified by the Center for Mindfulness at the University of Massachusetts
Memorial Medical Center in Worcester, Massachusetts (Santorelli et al.,
2017), and the protocol, which we use extensively both when teaching and
with teachers-in-training. As mentioned in the previous chapter, we will
also use the themes, rationales, intentions, and practice skills (TRIP) to
orient and organize our thinking about what needs to be covered in each
MBSR session. As a reminder, the theme is the subject and context of the
session, the rationale is the reason why the teacher is doing what he is
doing, the intention is the teacher’s aim, and the practice skills are how he
will deliver the information and address questions.
We strongly recommend the novice teacher maintain fidelity to the
protocol during the delivery of a significant number of eight-week
programs. Undoubtedly, there will be variation between teachers in terms of
how many times they teach the program before they should consider
adapting it. For the more experienced teacher, part 2 will be a review and a
reframe. In addition, for experienced teachers who have developed their
own curriculum for working with the general public, we suggest they might
experiment with what we are offering as a reset.
There is of course a risk inherent in writing out an MBSR curriculum.
That risk entails the possibility that a written curriculum loses the vitality of
a living document (one that is informed by ongoing learning, the trajectory
of teaching, feedback from participants, and changes in the field) and
becomes fixed, rigid, and tightly held. Nothing could be further from our
intention. Rather, we intend this section to serve as a map and an anchor for
our teaching, giving us structure and guidance. Then, as we become more
secure in embodying mindfulness, the need to hold anything rigidly falls
away and the art and skill of being a mindfulness-based teacher can be fully
realized.
 THE ORIENTATION SESSION

The orientation session is an important meeting and an integral part of the

MBSR program. This section covers the essential topics of the orientation
session, including an initial welcome, introductions, history, broad outline
of the program, risks and benefits, program expectations, and general
guidelines for participating in the group. Here and in subsequent sections,
we will present a summary of TRIP along the lines below.

Orientation Session

THEME
General introduction to the MBSR program.
Gathering relevant participant information.

RATIONALE
For consumer protection, participants must know the risks and
benefits, provide informed consent, and meet screening criteria.

INTENTION
To clearly describe the MBSR program and expectations for program
participation.
To assess participant suitability.
 PRACTICE SKILLS
Program Based: Presenting MBSR accurately, group guidelines, and
managing time.

Teacher Based: Embodying the practice—present moment orientation,

patience, and kindness.
There are a variety of ways this session can be conducted. Most
commonly, there is a group presentation followed by a short interview with
each participant. The purpose of the individual interview is to gather
additional relevant information, such as their ability to commit to the home
practice or attend all the sessions, and to ensure the program will be a good
fit. What type of material collected will depend on the teacher’s
professional designation and the setting in which he is teaching.

Introduction: Brief History and Research

The orientation includes the teacher introducing himself, and he declares his
professional background, as this has relevance to his scope of practice and
his degree of legal and ethical responsibility to the group. He then discusses
the history and gives an overview of the MBSR program, providing a
background and context for what participants will be learning. Elements of
this discussion should include the following: the tradition upon and setting
in which MBSR is founded; the founder; why the program was started and
for whom; and how the program has been adapted and for what. A brief
outline of the efficacy and effectiveness (research) provides current support
for participant outcomes. This enables potential participants to have enough
of an overview to make an informed decision about whether the program
will work for them.

Structure of the Program

MBSR is an eight-week group program with a specific structure: a modular
approach to learning that allows participants to develop mindfulness skills
in a sequential and graduated manner. Coming to each two-and-a-half-hour
weekly class is essential, as one class builds on the next. It is important for
the teacher to explain what kind of commitment attending the program will
entail. And this aspect of the discussion has become increasingly necessary
to cover, given the upsurge of interest in mindfulness; for contrary to
popular understanding, developing a mindfulness practice takes energy,
commitment, and time. Attending each session provides the optimal
learning environment and enhances the cohesiveness of the group, so this,
too, needs to be reinforced in this session. The teacher will also establish
the assignment of weekly home practices as an integral part of the learning,
with the expectation that the participants set aside at least forty-five minutes
a day to practice. In order to facilitate this learning, audio recordings and
weekly handouts will be provided. Participants are instructed to use the
recordings that they are given rather than seeking alternatives from other
sources, because there are clear intentions and specific guidance for the
meditation practices used in this program.

Group Norms and Guidelines

Establishing group norms and guidelines begins with the group members
introducing themselves, as well as talking about their reasons for attending
the program. In the spirit of an open and invitational stance, participants are
invited to speak, with an understanding that not everyone is comfortable
talking in groups. Speaking in the group, while encouraged, is not coerced.
However, participants, from the outset, are asked to consider the amount
they speak: for those who like to speak a lot, it can be a gift to make space
for others, and for those who don’t like to speak, it is helpful to the group to
hear their contributions.
Group norms may be developed collaboratively by asking the group,
“When thinking about what would be most helpful to your learning, how
would you like us to interact?” Some typical responses to this question are
“a safe environment,” “respectful communication,” and “confidentiality.”
This primes the way for a discussion about communication norms that
involve the teacher describing expectations for how the participants will
speak to each other. Such considerations include speaking from your own
experience, letting others have their experience and not interrupting them,
and refraining from giving advice, admonishment, or reassurance. It is
common to want to give advice and reassure when we hear from others that
they are struggling. Similarly, we often want to spontaneously hug another
when we see that someone is in pain, but it is essential to ask permission
before doing so. Ultimately, what is emphasized in the MBSR program is to
make space for difficulties, allowing them to be present without having to
fix or take care of another. Rather, the teacher suggests that the group offer
a stance of empathic neutrality, which supports and bears witness to the
pain of the other.
Meanwhile, guidelines for the group will consist of such items as
coming on time, including reporting to the teacher if one is going to miss a
session or drop out. Of course, it is not always easy to be punctual, as these
sessions are often held at the end of the day. Participants are instructed that
if they are going to be late to simply come in and join the group. Logistics
such as parking, public transportation, management of the space, getting
into the building, signing in, identifying the location of restrooms, bringing
food, wearing comfortable clothing, and whether or not shoes should be
removed will also need to be covered.
The teacher also discusses the optimization of learning during the
program. She asks participants to refrain from the excessive use of
substances (such as alcohol or marijuana), not to come high to the group,
and if on psychoactive medications (such as antidepressants or anxiolytics),
to not change or discontinue them without a health care provider’s
guidance. Depending upon one’s professional designation, a clear
explanation of the teacher’s legal and ethical responsibilities needs to take
place. If one does not have a professional designation, there may be
mandatory state legal and reporting requirements to consider. These may
include limits of confidentiality and mandatory reporting (neglect or abuse
of dependents, sexual misconduct, suicidal or homicidal risk, and driving
under the influence). It is essential that participants have a clear
understanding of these requirements because safety is paramount. (For
sample confidentiality agreement forms, see the appendix.)
Group and individual safety risks and benefits of the program also
need to be discussed. These are part of informed consent and participants
need to know that there are other modalities (e.g., yoga, psychotherapy,
exercise, medication) in addition to MBSR that can address their stress. In
addition to legal risks to self and others, there are psychological and
physical risks to participating in the program. Practicing mindfulness can be
experienced as emotionally dysregulating. This is because participants turn
toward and meet the conditions of stress and their reactivity experientially.
This may temporarily increase difficult emotions but ultimately leads to a
different perspective and a new way of relating to stress. The physical risks
revolve around the aspects of movement practice in the program. These are
largely dependent upon the health of the participants and therefore it is
important to encourage participants to stay within their physical limits and
take care of themselves as needed.

The Individual Interview

The extent of the individual interview and intake form will be dependent
upon the professional designation of the teacher and the context in which
the program is being taught. It is incumbent upon those who are governed
by a clinical professional body to know what is required of them when
collecting personal information on their participants. However, if one is
teaching in an educational, business, or community setting that does not
have clinical requirements, the need to gather personal information beyond
basic demographics will be limited. For a sample intake form, see the
appendix.
At minimum, the interview needs to address participant suitability and
screening to ensure the program is a good fit. It is also an opportunity for
participants to ask questions or disclose aspects of personal history that they
do not feel comfortable revealing in the group. For clinicians, suitability
criteria for participation may include the ability to emotionally regulate
oneself, sobriety of six months to one year, having processed trauma, no
recent hospitalization for suicidality or homicidality, ongoing follow-up
with a primary health care provider, no active psychosis or acutely severe
mood disorder, and the ability to participate in the group and engage in
home practice.
Safety is always a consideration regardless of the context in which one
is teaching, and it is entirely possible that there may be participants in the
group who display mental and emotional distress beyond your capacity.
When this is the case, appropriate referrals are indicated.
All participants sign forms related to informed consent and waivers
related to accident and injury. In addition, should the teacher wish to record
the sessions for learning purposes, an additional consent form stating this
needs to be signed by all participants in order to proceed.
Keeping Records
Any record keeping that is necessary, such as the initial assessment and
weekly group and/or individual notes, is directly dependent upon the
professional requirements of the teacher and the setting in which he is
teaching. It may be helpful to prepare a template for chart notes that
outlines the material to be covered in each session and the home practice to
be assigned that week, followed by space for specific notes on each
participant. If the MBSR program is covered by third-party insurance, the
teacher needs to maintain accurate attendance records. The record includes
the waivers and relevant consent forms. It is important that these records be
kept in a secure setting to protect confidentiality.

In Closing
The orientation session sets important parameters for the learning and
participation in the MBSR program. In addition to the history and structure
of the curriculum, expectations, risks, and benefits will also have been
discussed and informed consent obtained. Group cohesion begins here
through participant introductions and questions, and norms are established
for those who decide to continue following this session. The information
then obtained from the individual interview is intended to ensure participant
suitability and fit. All of this helps support participant retention and active
participation in the group.
Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Orientation Agenda (short form)—1.5 hours

Prior to the session, set up the room for the group, and make sure you have
appropriate materials, including the attendance sheet, pens, paper, intake
forms, scales (site/teacher/research dependent), waivers, and consent forms.
Welcome and introduction to mindfulness (10 minutes)
Overview of MBSR program—history/structure/research (15 minutes)
 Overview of mindfulness—what mindfulness is (15 minutes)
Group introductions and participant intentions (15 minutes)
Group norms (10 minutes)
Guidelines—risks and benefits, housekeeping (10 minutes)
Questions and answers (15 minutes)

Orientation Agenda (long form)—1.5 hours

Welcome and introduction to mindfulness (10 minutes). The teacher
introduces himself and welcomes the group.
Overview of MBSR program. The teacher reviews the
history/structure/research (15 minutes):

Brief history of MBSR and antecedents. Teacher includes the 2,600-

year-old tradition on which MBSR is based, the history and trajectory
of MBSR, and adaptations.
Structure of the eight-week program. The teacher explains the group
modality, the 2.5-hour sessions, and the importance of attending all
sessions as each builds on the previous one. There is an all-day retreat
in the sixth week.
Research. Since the inception of MBSR, research, while still early,
has been exponential; the teacher should review two or three recent
research articles (meta-analyses) that speak to the current evidence for
MBSR.

Brief overview of mindfulness (15 minutes). What is mindfulness?

Mindfulness can be talked about in a variety of ways, one of which is: the
practice of paying attention to present moment experience with interest and
friendliness, allowing us to meet life more skillfully. Why might it be
important to pay attention to present moment experience? It increases
awareness of all experience: thinking, emotions, body sensations, and
behaviors/ impulses, and this leads to a reduction in stress reactivity. It
allows for the potential for increased pleasure. It helps participants develop
tools to meet life events more skillfully. Note that the emphasis is on
experiential learning.

There is a lot of misinformation about mindfulness.

The real learning about mindfulness comes from practicing it, and this
takes time, energy, and commitment—home practice is important.
Meditation is not about attaining a special state.
Training attention through meditative practices allows us to increase
awareness.
Training attention and regulating negative thinking and emotions are
core skills. Our minds are busy, and attention habitually moves into
thinking about the past or future or becomes repetitive. Noticing this
is a part of mindfulness practice, as is intentionally returning attention
to an intended present moment focus.

Group introductions and participant intentions (15 minutes):

Ask people to introduce themselves and briefly state why they’re here
(consider dyads and then large group interaction).
Remind participants that if they are reticent to speak, they can simply
say their name.

Group norms (10 minutes). The teacher decides whether to elicit these from
the group or to state them, subsequently asking the participants for their
input:

When thinking about what would be most helpful to your learning,

how would you like us to interact?
Establishing trust
Confidentiality and its limits
Respectful communication
Speaking to one’s own experience and not offering advice or
reassurance
Listening without interrupting others
 Free of substance misuse throughout the program, as this inhibits the
ability to practice and learn

Guidelines, risks and benefits, and housekeeping (10 minutes):

It’s important to start and finish on time.

Feedback from participants is encouraged and needed.
Participants need to notify the teacher if they cannot attend the
session.
If participants want to drop out, they need to inform the teacher; the
teacher contacts participants if they fail to show up for a session.
Risks and benefits. Mindfulness is not a panacea. Physical risks—
potential for injury given that an extended part of the program is
movement and body based. Physical benefits—increased body
awareness, self-care, mobility, enhanced well-being. Emotional risks
—dysregulation (irritability, tearfulness, anxiety, frustration, doubt,
agitation); trauma reactivation or related distress (this is an important
discussion; consider a participant handout that is trauma informed).
Emotional benefits—regulation of emotion, enhanced well-being,
greater awareness of pleasurable moments, faster recovery from
difficult emotions, better understanding and management of reactive
moments, enhanced positive relationship to self and others.
The teacher hands out the intake form. This is to be completely filled
out and is a requirement for participation.
The teacher hands out consent form and waivers. For informed
consent, be sure to highlight that there are many ways of dealing with
stress. This is one. Participants sign consent form and waivers.

Questions and answers. The teacher allows time for questions and answers
about the program.

Interview—15 minutes per participant

Introduce the participant to the purpose of the interview—How did
you hear about the program?
 Review the intake form with the participant.
Address areas of omission in the intake—further questions dependent
upon professional designation.
Ensure dates/times/home practice required are compatible with
participation.
Explore any challenges and relative contraindications to ensure
suitability.
Review risks/benefits as they apply to the individual participant.
Check that the intake form, waiver, and consent are understood and
have been signed. It is a requirement that all participants fill out these
forms.

Please see the appendices for examples of an intake, consent form, and
waivers.
 SESSION 1:

Introduction to Mindfulness and “Being”

Mode of Mind

Session 1

THEME
Introduction to mindfulness and “being” mode of mind.
Mindful awareness—a present moment orientation.
Bringing attention to all six senses (in mindfulness, the sixth sense is
the mind).
Awareness of body sensations.

RATIONALE
Bringing awareness to each moment begins to develop a different
way of paying attention (or mode of mind) and highlights how we
relate to experience, which can provide us with more skillful options
for managing stress.

INTENTION
To guide participants to pay attention to the experience of the senses.
 To guide participants to develop awareness of and curiosity about the
landscape of body and sensation, and to notice habitual movements of
mind and associated judgments.
To develop mindfulness attention to process rather than content.

PRACTICE SKILLS
Program Based: Delivery of a brief breath awareness, standing yoga, the
raisin, the body scan, mindful inquiry, and home practice assignments for
the coming week.

Teacher Based: Intentionally directing attention to and describing the

senses and sensations; systematically placing, exploring, and releasing
attention around the body; and embodying the practice—present moment
orientation, patience, non-striving, and kindness.

Teaching as Practice: Anchoring the Teacher

As MBSR teachers, we are embracing a tension. It is standard practice
when teaching in any context to have a protocol/curriculum, as this presents
a necessary outline. As discussed previously, it is particularly useful for
training future teachers, as a protocol/curriculum provides an anchoring
structure for the novice. For those teachers who are more experienced, an
identified agenda helps prevent drift. However, adherence to a specific
protocol can lead to rigidity. Being an MBSR teacher requires a flexible
approach to teaching by meeting the learning needs of your participants and
adapting the program when working with diverse populations and
conditions, both of which may require some adjustments to the agenda. This
necessitates a teacher who is able to be both flexible and adherent, qualities
that are inherent to mindfulness.
So, although we will present the weekly session agendas, we want you,
the reader, to bear in mind that the lens of teaching mindfulness is always
based on your active engagement in the practice of mindfulness and how
that informs your teaching. Even when you are introducing a cognitive
exercise, how you present it and how it specifically relates to mindfulness
will be the frame of reference. To highlight this, and to act as a reminder,
we decided to label all aspects of teaching, from the opening of the session
to its closing, as mindfulness-based practices, thus continually reiterating
that teaching comes from this perspective first and foremost, and through
the teacher embodying the practice.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:

Welcome: In opening the session, the teacher provides the context and
prepares the group for this experiential learning based on mindfulness
practice.
Breath Awareness and Standing Yoga Practice: The teacher facilitates
a brief breath awareness and brief yoga practice (standing poses) to
introduce body-based learning. This provides an intentional shift from
the acquisition of knowledge solely derived from cognitive-based
processing to one of integrating the two types of learning.
Inquiry: A brief discussion follows, with the teacher paying attention
to and guiding participants to their internal experience. This is the
beginning of developing the ability to describe experience, a process
that supports mindful awareness.
Raisin Practice: The teacher facilitates the raisin practice,
highlighting attention to the senses and providing a present moment
orientation.
Inquiry: The inquiry emphasizes curiosity and steadying attention on
the sensorial experience (visual, touch, sound, aroma, taste, and
thinking).
Body Scan Practice: The teacher facilitates the body scan, training
attention to the body, systematically directing attention to placing,
exploring, letting go, and shifting.
Inquiry: The inquiry focuses on describing sensorial experience, the
movement of attention when it occurs, and its reorienting to the
intended focus.
 Home Practice Assignments: The teacher discusses home practice
assignments—their purpose and potential challenges as well as
emphasizing their importance as a process of discovery rather than
being outcome driven.
Closing: Closing the session can be done in a variety of ways to mark
the end. In this session, teachers frequently guide participants in a
brief sit, following which the session handouts are given out.

What follows is a comprehensive overview of session 1 that includes

logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
A review of the session curriculum while holding the key themes in mind is
essential for the novice teacher. For the more experienced teacher, going
over the session content acts as a reminder of what needs to be covered.
Setting aside time to have a brief pre-session meditation practice is
beneficial. This allows the teacher to check in with her current experience
—a present moment focus—and conveys the intention and direction for the
teaching. It also helps manage the transition from whatever the teacher has
been engaged in to settling into mindfulness and its embodiment.
The teacher sets up the room and ensures that all necessary equipment,
handouts, flip charts, markers, paper, and pens are available. Handouts
should be given out at the end of the class unless the material is required
during the session. This helps keep the participants in a present moment
orientation, rather than engaging with the content of the handouts and home
practice to come. The teacher brings the weekly attendance sheet, necessary
for tracking participant attendance and for generating third-party insurance
receipts. She will need a bowl for the raisins and a spoon, with napkins. If
she hasn’t asked her participants to bring their own yoga mats and blankets,
she will need to provide them. It is customary for the chairs (and cushions)
to be placed in a circle.

Opening the Session

The teacher welcomes everyone and begins the session with a brief breath
practice, providing an intentional transition into session 1. The teacher
introduces herself, and participants have the opportunity to introduce
themselves in dyads. Some typical questions that are asked to facilitate this
process are “What brought you here? What do you hope to gain from this
experience? What are your concerns? Did you have to organize a different
schedule to attend these sessions?” Once the introductions are finished, the
teacher will briefly reiterate the group guidelines, the importance of self-
care, the limits of confidentiality, the necessity of attendance, and the value
of doing the home practice.

Setting the Context for the MBSR Program

Setting the context for applied learning is important for adults. Therefore,
the teacher explains that this program offers a different way of learning, one
that is based on the experience of mindfulness practice. To that end, she will
say something along these lines: “Instead of first talking about what we are
about to do and learn about, and then experiencing it, we will be engaging
in a practice or an exercise first and then talking about it.” This is essential
because briefly setting the context provides enough information to
participants to help manage their expectations. Given that this is an unusual
way of learning, without stating this, participants may be skeptical or
become frustrated.
In addition, in the spirit of holding a present moment orientation, the
teacher will explain that they (the participants) will not be given an agenda
outlining the content of each session. The purpose here is to help
participants be exactly where they are in each moment, rather than thinking
about what is to come. This again is unusual, because when learning
something new, one would expect to know the agenda. Teachers should be
prepared that some participants may find this difficult to accept.
The teacher will briefly review the subject of mindfulness that was
covered in more detail at the orientation session. Novice teachers will tend
to talk too much at this point, giving out a lot of information in an attempt
to ensure that their participants understand. But doing this robs participants
of their own journey, the learning and discovery that come with engaging in
the practice, rather than being given a lecture on the subject. If we are
engaging in experiential learning, then in order to be consistent, the teacher
needs to allow participants to have their own experiences with the
mindfulness practices, with the teacher acting as a guide, eliciting what is to
be learned from those experiences, rather than telling them what they
should know. This fosters self-efficacy and competency in the individual
and the group.

Facilitating the Mindfulness-Based Practices

We have provided scripts for many of the meditation practices in the
appendices.

Brief Breath Awareness Practice

The teacher settles the group into a comfortable sitting position or any
necessary modifications due to physical limitations. She facilitates a brief
breath awareness practice to mark the transition from everyday life into a
present moment orientation, presenting the centrality of checking in with
current experience.

GUIDANCE
She guides the participants to become aware of the body sitting and its
posture, and then orients their attention to the sensations of breathing in the
body, to sounds, and to any thoughts and/or emotions, noticing whatever is
present. A brief discussion follows in which participants are asked to
“popcorn” out (one or two descriptive words from a number of people in
the group) what they noticed.

Short Standing Yoga

The teacher sets safety parameters, instructing participants to work
within their limits and to listen to what the body is signaling as they follow
the instructions. She invites participants to modify the poses as needed, to
sit out if necessary, or they can engage in visualizing the practice if they are
unable to do it. Note that it is not enough for the teacher to simply tell
participants to modify poses, but she will also need to demonstrate these
modifications so that they know what to do and how to do it. Visit
http://www.newharbinger.com/45601 to download a pictorial guide to
standing yoga poses.

GUIDANCE
She demonstrates a few poses (three or four), which are typically
based on yoga, while at the same time guiding the participants through
them. Guidance is clear, concise, and specific, and uses present participles
to maintain an invitational and present moment focus. Time is allocated to
each pose (each pose is repeated a few times), which allows participants to
become familiar with them and facilitates a personal experience of practice.
The teacher’s tone is conversational and well-paced, and she leaves some
silence between instructions, allowing participants to have time to follow
them and move into the positions. She brings attention to the transitions
between poses, moments that are often missed. Additionally, she will give
reminders to notice the breath throughout the practice.

Brief Discussion
The group engages in a brief discussion about the yoga practice, noting
what was experienced in the body and mind. The teacher uses a light touch
when engaging in this conversation, collecting many responses and
fostering group process, cohesion, and trust. The teacher needs to remember
that this discussion is the beginning of building mindful awareness along
with a descriptive vocabulary for and of experience. This is the start of
socializing the group to and normalizing this method of post-practice
dialogue that is referred to as inquiry.

The Raisin
The teacher sets the stage for the practice. She invites participants to
approach this practice as if they had never seen this object (the raisin)
before. The practice is in process as soon as she begins handing out the
raisins. This helps cultivate attitudes of beginner’s mind and curiosity,
important aspects of mindfulness practice.
 GUIDANCE
As the teacher hands out the raisins, she orients the group to bring
attention to the object as if they have never seen it before, which is true
(they never have seen this particular raisin before). She then directs them to
the sense of sight, exploring what is being received through that sense,
using some descriptive words related to those sensations to help build a
sensorial vocabulary. Examples of such words might be related to opacity,
shape, size, or color. She then moves systematically through the other
senses in a similar fashion, ensuring that she leaves enough silence for
participants to have their own experience. This latter point is one that
novice teachers tend to forget but is critical if participants are to learn from
the practice. Otherwise, what the group may simply learn is to attend to the
teacher’s voice rather than what is actually happening for them. Guidance
functions as a cue to attend to what is arising internally and externally
rather than governing participants’ experiences.
Some teachers guide this practice by having the group verbally express
what they are noticing while it is actually in process. We see a number of
potential problems with this form of guidance. One is that it can insert an
experience for another group member that they are not having; secondly, it
can rob another’s experience in the moment by adding verbal stimulation;
and thirdly, it can derail the inquiry process. We believe that inquiry is a
separate practice that needs to be clearly identified as such. This is because
inquiry facilitates overtly expressing the investigation of experience using
formal mindfulness practice as the vehicle. Ultimately, the practice (method
and skill) of inquiry becomes internalized, assisting participants in mindful
self-awareness that is then applied to the vicissitudes of everyday life.

Inquiry
Inquiry is the discussion that takes place between the teacher and
participant(s) after the mindfulness-based practices and cognitive exercises.
We see it as a “contemplative dialogue between teacher and participant(s)
that supports the investigation of experience arising from the practice of
mindfulness” (Woods, Rockman, & Collins, 2019). This practice is the one
that teachers frequently identify as the most difficult to embody and
verbalize. Inquiry has its roots in the principles and philosophy of
mindfulness and is therefore founded on a teacher’s ability to internalize
and express these attitudinal foundations. It is also an experiential and
interactive process, and as such does not rely on a prescribed script. We
write in detail about embodying the practice and inquiry in chapters 4 and
5.
Inquiry asks a lot of the novice teacher who is often dealing with a
high cognitive load when first delivering the curriculum, managing the
time, and facilitating the practices and the group process. Therefore, for a
new teacher, familiarizing herself with an approach that has become
formalized (Crane, 2008, 2017) can be helpful as a starting point in
understanding how to facilitate inquiry. This method consists of three layers
of questions relating to the noticing and awareness of experience, the
difference between mindful and habitual attending and/or the tracking of
experience, and the integration of these skills into daily life.
In the early sessions of the MBSR program (sessions 1 through 3), the
three layers of questions are asked in a way to collect as many descriptions
of what was experienced in the practice from as many people as possible.
This is known as horizontal inquiry. As the program unfolds, and as
participants meet the challenges of practice, the teacher may need to ask
more in-depth questions. This is known as vertical inquiry. We provide a
word of caution here about the use of vertical inquiry. It is tempting for
teachers to probe too much. There are a number of reasons why this
happens, including teacher anxiety, wanting to take care of the participant,
wanting to make a teaching point, losing the thread of what is being said,
and not picking up on the participant’s discomfort, to name a few. An
essential learning for the teacher is to develop an awareness of these
moments when they arise and an understanding of how they show up for
her so that she is not driven by them and her own agenda. We often advise
our teacher trainees that “less is more.”
What follows is a brief description of the questions in each layer, using
the raisin as a point of reference.
Layer 1: “What did you notice in this practice?” “What showed up?”
“Any surprises?” These questions initiate the development of mindful
awareness, reflecting a value on noticing and attending to experience
and making it salient. In this inquiry of the raisin practice, the teacher
ensures she covers all aspects of the experience by attending to all of
the senses, including thoughts, when the participant talks about them.
The teacher also needs to ask, “Does anyone not like raisins?” “Did
anyone struggle with this practice?” If this is answered in the
affirmative, she follows up with a couple of additional questions to
elicit what happened and what choices were made. She can expect
that one or two participants may not have eaten the raisin. It is
important for the teacher to maintain a nonjudgmental and accepting
stance because she needs to welcome all experience: unpleasant,
pleasant, and neutral. Lastly, important information is often elicited
from participants who express struggle with a practice in regard to
how they worked with it, as well as predicted versus actual outcomes.
Layer 2: “How might this way of paying attention be different from
how we usually pay attention?” “What struck you about this way of
paying attention?” These questions compare and contrast being
(acknowledging, being present with, being curious) and doing (doing
something about, problem solving) modes of mind. They encourage
participants to recognize that they are attending in a new way,
cultivating the skills of observing, reflecting on sensations, being
present, and maintaining a non-doing attitude. This begins the process
of dis-identifying from the narrative about an experience. The teacher
also needs to make sure that the group answers the question that is
being asked as it pertains to the raisin practice. It is not unusual for
this question to produce a story that is unrelated to the raisin.
Layer 3: “What has this got to do with reducing stress?” “What
might be the relevance of this practice?” These questions and their
answers help make the link between this practice and why
participants signed up. These integrative questions are essential to
assisting in the generalization of what is being learned and its
application to everyday life. Otherwise, participants fail to understand
the utility of what they have just experienced and will be less likely to
actively experiment with it. Furthermore, these insights are important
motivators for encouraging home practice and an ongoing
commitment to the program.
 While the layers are useful for providing a frame of reference and
method for engaging in inquiry, they can easily become formulaic and
lifeless, as the teacher becomes habitually attached to the questions
themselves rather than being genuinely interested in the participants’
experience. Inquiry, as a mindfulness practice, is an unfolding process
requiring an awareness of the verbal and nonverbal movement of
experience between the teacher and her participant(s). It does take time to
develop familiarity with this kind of expression and dialogue, as we
typically do not converse in this way in everyday life. However, from the
perspective of supporting and developing the practice of mindfulness and
its relevance to reducing stress, the process of inquiry is invaluable, as it
harnesses the experiential aspects of the practice with the cognitive
processing of it.

The Body Scan

The teacher instructs participants to find a comfortable position, lying
on a mat on the floor or sitting in a chair. She reminds the group that it is
not uncommon that mindfulness meditation practices may bring up a
variety of reactions, and that this is normal. If the teacher is aware that
some of her participants have a significant history of trauma or anxiety, she
will address this with some general instructions about the need to take care
of oneself. This would include the following: they become overwhelmed,
they can open their eyes, sit up, get a drink of water or a blanket, stay in the
room, and return to the practice when able.
The body scan is a practice that cultivates a number of mindfulness-
based skills. It is a systematic and intentional attentional training to the
sensations of the body as well as a practice of focusing, exploring, and
moving attention. In addition, it trains an ability to work with the automatic
tendency to be hijacked by thinking that may be future focused, past
focused, or aimless, using the body as a place to deliberately return
attention when this happens. A common pitfall for novice teachers is to
spend too much time making suggestions about comfortable positioning. A
body scan is an awareness practice in which we begin to bring awareness to
whatever is arising, versus trying to create the perfect conditions for a
problem-free practice.
 GUIDANCE
Beginning at one end of the body, most commonly at the feet, the
teacher systematically directs the moving of attention around the body. This
requires words that clearly convey the placing of attention, the exploration
of sensations that arise (if there are any), and the intentional letting go and
moving to the next body part. From time to time, she will describe various
sensations that may be showing up, such as numbness, tingling, tension,
heat, coolness, discomfort, or ease. She needs to leave periods of silence of
sufficient duration so that people can access what they are experiencing.
She will also give periodic reminders about any thoughts or other sensations
in the body that may be occurring, guiding participants to return to the
current body focus. Time management is important given the length of this
practice.

Inquiry
The teacher’s focus is to elicit from the group what they noticed in the
body, including any thoughts and/or emotions and various states, such as
restlessness, irritation, boredom, sleepiness, worry, memories, anxiety, and
so on. Again, if using the questions outlined previously, she will apply them
specifically to what was experienced in the body scan. The teacher needs to
remember that this practice is training participants to direct their attention in
a specific way to help manage stress reactivity, and she needs to ensure that
her participants make this link. In addition, her patience in accommodating
all responses (wanted and unwanted) conveys the value in slowing down,
thus providing the time and space to be with and to get to know the full
range of experience that is often overlooked. In doing this, participants are
being offered the opportunity to tune in to the body, seeing various
experiences come and go, without needing to always do something about
them. Over time, this builds stress tolerance (because you can’t always fix
everything and it eventually passes), compassion, and resilience.

Assigning Home Practice

The home practice assignments for the coming week are:
 The body scan for six out of seven days. Participants are given a
teacher-prepared audio recording to facilitate this practice of mindful
attention to the body. Participants are instructed that they will be
receiving specific audio recordings for each meditation practice and
that these are the ones they should use for the duration of the
program. With access to the internet, there is now a variety of
meditations available. However, it is important for the group to
consistently work with the same material.
The nine dots exercise (Kabat-Zinn, 2013); remind participants to
avoid the internet to find the answer.
Mindful eating practice, bringing attention to one meal or a part of a
meal (as per the raisin).
Informal practices of (1) cultivating attention to the breath, sounds,
body sensations, thoughts, and emotions several times over the period
of the day without judging those experiences; and (2) bringing
attention to a simple routine activity, such as showering, brushing
one’s teeth, taking out the garbage, etc.
Optional movement practice based on the ones done in the session.
Additional handouts, such as a brief review of the session and some
key learning points.
Home practice log.

It can be helpful for the teacher to discuss with her participants when
they might engage in these home practice assignments and what might get
in the way. The teacher closes the session with a brief breath practice (if
there is time), thanking the group for its participation and effort.

In Closing
In this session, participants are introduced to the practice and experience of
mindfulness through a brief breath awareness, a short standing yoga
practice, mindful eating (the raisin), and awareness of the body (body scan).
The teacher sets the context for the work, providing the appropriate
safeguards and guidelines for participation. She promotes an environment
of safety, building trust in her guidance and for the learning. She embodies
friendliness, calmness, patience, and openness and represents the
philosophic and psychological underpinnings of mindfulness.
Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 1 Agenda (short form)—2.5 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. She brings additional materials that include the
attendance sheet, pens, paper, raisins, bowl, spoon, napkins, and handouts.
Welcome and introduction to the session (10 minutes)
Brief breath awareness plus discussion (15 minutes)
Group introductions and participant intentions (15 minutes)
Short standing yoga practice plus inquiry (15 minutes)
Raisin practice plus inquiry (30 minutes)
Body scan plus inquiry (55 minutes)
Home practice assignment and discussion (10 minutes)

Session 1 Agenda (long form)—2.5 hours

Welcome and introduction (10 minutes). The teacher introduces
herself, welcomes the group, reminds participants of the learning
guidelines, and sets the context for this session.
Brief breath awareness practice plus discussion (15 minutes).
Participants bring their attention to their sitting posture. They bring
their attention to the breath with an acknowledgment that body
sensations, sounds, thoughts, and emotions will be present, but that
the primary attention is on breathing. The teacher leads a discussion,
eliciting several brief responses from the group about what was
noticed.
Group introductions and participant intentions (15 minutes).
Participants introduce themselves and state their reasons for coming.
The teacher may use this as an opportunity to build group cohesion by
placing participants in dyads to discuss this and then returning to the
large group to further the conversation.
Short standing yoga practice plus inquiry (15 minutes). The teacher
gives safety reminders for this movement practice, including any
modifications that are needed; guidance includes several standing
poses (e.g., four); each one is repeated at least twice.
Inquiry. The teacher elicits several brief responses from
the group about what was noticed.
Raisin practice plus inquiry (30 minutes). The teacher provides
guidance about attending to sight, touch, hearing, smell, taste, and
thinking.
Inquiry. The inquiry is focused on the senses: What did
you notice? The focus is on normalizing participants’
experience regardless of whether it’s pleasant,
unpleasant, or neutral.
Body scan plus inquiry (55 minutes). Participants are reminded that a
number of reactions may occur and that therefore it is important for
them to take care of themselves as needed, to adopt a position that is
comfortable and supports staying awake; guidance includes
systematically moving attention around the body and exploring
sensations with occasional reminders to return attention to the
intended focus when it habitually moves.
Inquiry. The inquiry is focused on body sensations and an
awareness of thinking and emotions as they come up in
this practice, normalizing this process. The emphasis is
on curiosity and not preferencing any one experience.
Home practice assignments and discussion (10 minutes). Over the
coming week, participants will do a body scan six out of seven days;
do the nine dots exercise (handout); practice mindful eating (one meal
or part of a meal); pursue informal practice; and do an optional
movement practice. The potential challenges are discussed and the
home practice log and any other handouts are distributed.
 SESSION 2:

The Role of Perception and Learning to

“Be” with All Experiences

Session 2

THEME
The role of perception in shaping our construct of reality.
Learning to be with all experience, including those moments we
perceive with dissatisfaction or dislike.

RATIONALE
Perception shapes our views and reactions.
In cultivating curiosity, non-striving, kindness, and patience,
awareness develops about what gets in the way of being present to
what is currently salient.

INTENTION
To support and strengthen awareness of body sensations, thoughts,
and emotions; to normalize and welcome challenges.
To facilitate awareness of moments of aversion, attachment, and
narrow perspectives.
 To disrupt certainty and reinforce the importance of home practice.

PRACTICE SKILLS
Program Based: Delivery of yoga, body scan, and mindful inquiry; home
practice review of the body scan, mindful eating, mindful activity, optional
mindful movement, and the nine dots exercise; seeing meditation, ways of
seeing/not seeing cognitive exercise (using various images such as duck,
vase, or additional examples); sitting meditation with focus on the breath.
Delivery of the week’s home practice assignments.

Teacher Based: Continuing to train attention to sensations and the senses;

building the vocabulary of experience; supporting the practice of
mindfulness; highlighting view as a potentially limiting construct and the
benefits of opening to other perspectives. Embodying the practice—present
moment orientation, curiosity, non-striving, patience, and kindness.

Teaching as Practice: Anchoring the Teacher

Reviewing the session curriculum and holding the key themes in mind is a
primary step before facilitating the class for all teachers. In preparation for
teaching, allocating some time to have a brief pre-session sit before the
class begins is always beneficial, as it acts as a reminder that the teaching to
come springs from the practice of mindfulness. This is especially helpful if
the teacher is rushing from another job or activity. If this is not possible, a
few mindful movement poses or a brief breath awareness practice is
constructive. These act as a prompt to underscore a present moment
orientation, a natural check-in that assists in the disruption of the mind’s
natural tendency to be on automatic pilot.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:
Standing Yoga Practice: The teacher begins with a brief yoga practice
(standing poses) to anchor the group in the body. Starting with a
movement practice instead of a sitting meditation is less disruptive to
those already in the room when participants are late.
Body Scan Practice: The teacher moves seamlessly into teaching the
body scan to give the group an extended period of practice without
interruption.
Inquiry: Inquiry follows and addresses both practices. The teacher
conveys interest in and curiosity about what is being experienced
from the practices. The teacher should note that the group may have a
tendency to talk about how practice has gone during the week and
needs to redirect and keep participants focused on the discussion of
the practices that have just occurred. It is not unusual for participants
to comment on the challenges of practice.
Home Practice Review: The teacher facilitates a general discussion
about the previous week’s home assignments, the successes, the
challenges, and how to meet them. Home practice review typically
lasts fifteen to twenty-five minutes but will depend on the session and
the needs of the group. It is essential to ensure home practice review
receives adequate time because this conveys its importance to the
group and acts as both an extrinsic and an intrinsic motivator for the
participants to continue doing it.
Seeing Meditation Practice: The teacher facilitates a seeing
meditation that brings attention to the sense of sight. If a window is
available, he directs participants to observe whatever is being seen (a
broad focus) and then guides them to focus on a narrower view,
concentrating on a single object, noting its qualities (e.g., shape,
positive and negative spaces, color, etc.). If a window is not available,
he may direct participants to observe their hand or another object
(e.g., flower, rock, shell, etc.).
Inquiry: A brief discussion follows with participants “popcorning”
out various responses to this practice around what they noticed.
 Perceptual Biases Practice: The teacher moves into an exercise that
illustrates perceptual biases (ways of seeing/not seeing) using a
selection of visual images that bring into question our usual way of
looking at things. It is essential to be attentive and bring sensitivity to
cultural, racial, and gender differences in the group when selecting
the images to use for this exercise.
Inquiry: A general discussion follows addressing how quickly we are
certain that we know what we see, along with the tendency to
immediately react to it, reducing our ability to be open to alternative
viewpoints. These key points need to be elicited from the group as
well as their relevance to managing stress.
Sitting Meditation Practice: The teacher provides guidance about
choosing a sitting posture and instructions about positioning the body.
The teacher then leads a short sitting meditation practice with a focus
on the breath at the tip of the nose and the breath entering and exiting
through the nostrils. Having a particular object of concentration—in
this case, the nose—is helpful to train focused attention and mindful
awareness.
Inquiry: The teacher leads an inquiry by asking the participants to
“popcorn” out what they noticed.
Home Practice Assignments: The teacher addresses the next week’s
home practice assignments, leaving time for any questions.
Closing: Closing the session can be done in a variety of ways to mark
the end of the session, following which the session handouts are given
out.

What follows now is a comprehensive overview of session 2 that

includes logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room and make sure that he has
all the materials he needs for this session, such as the handouts for the
exercise on perception.
Opening the Session
The teacher welcomes everyone and asks that they choose one of the yoga
mats already laid out and to take a standing position, or to find a space in
the room to place their own mat. Once everyone has done this, the teacher
will say a few words to remind the group about the experiential nature of
the program. Reminders are both helpful and necessary tools for learning,
and it has been a week since the first class. For example, he might say
something along these lines: “Welcome, everyone, to the second session of
our MBSR program. Please go ahead and choose one of the yoga mats to
stand on, or if you have your own mat, find a space in the room to lay it on
the ground.” The teacher leaves time for his participants to carry this out,
then continues. “As we prepare for our mindful movement practice, let’s
bring attention to how we make this transition from the busyness of our
lives and what we have been doing before we came here. So, bringing
attention to the movements associated with finding a yoga mat to stand on,
or finding a space in the room to place your yoga mat. We are intentionally
directing our attention to the experience of the sensations that we notice as a
result of these movements. So, bringing the attention to these moments now
—a present moment orientation. Our mindfulness practice is very much
about supporting and strengthening this awareness.”
In this example of dialogue, we can see that the teacher is already
using words ending in the present participle (words like bringing, finding,
directing). The English language is somewhat limited in its capacity to
convey that everything is in process and subject to change. One of the
underlying principles of the practice of mindfulness is that experience is
fluid and dependent on causes and conditions. The use of the present
participle is helpful here because it implies that there is no outcome
(subject, verb, object), but rather there is an invitation to be present with a
process that is unfolding.

Facilitating the Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.
 Short Standing Yoga
The teacher reminds the participants about self-care and safety and that
the movement practice is not about striving or pushing oneself, but much
more about listening to the body’s signals and what is possible in any given
moment. In addition, as the practice unfolds, the teacher includes guidance
directed at noticing the tendency of the mind to narrate, judge, and
comment. When this happens (a very normal occurrence), one can make a
note of it, and then redirect the attention back to attending to the movement
of the body and the co-occurring sensations. Visit
http://www.newharbinger.com/45601 to download a pictorial guide to
standing yoga poses.

GUIDANCE
After setting the safety parameters, the teacher leads the participants
through some yoga poses, demonstrating them as he instructs. He makes
sure that he can be heard, the directions are clear, and the language is
simple and explicit. His instructional focus is to draw attention to sensations
in the body as well as to being aware of the breath. He emphasizes a
practice of kindness toward the body, rather than judging what one can or
cannot do. He leaves time for participants to engage in the various poses,
repeating each pose at least twice.

The Body Scan

Making sure to mark the transition from the movement practice to a
lying-down practice, the teacher reminds participants how easy it is to
disengage our attention (automatic pilot) from finishing one action to not
paying attention to the changeover into the next activity. He might choose
to say something like, “Taking a moment here before we move into a lying-
down position on our mats or take a sitting position, and noticing what
sensations or thoughts may be appearing. And then sustaining this
awareness as we move to our next practice, extending kindness and self-
care to ourselves, so that we choose a position that allows us to be as
comfortable as we are able to be in these moments.”
 GUIDANCE
The instructional focus is the continuing development of a sensorial
awareness of the body. Attention is brought to systematically moving
awareness around the body, noticing what is experienced as a result.
Mindful attention can be linked to breath awareness, through the
establishment of attention in a particular part of the body on the inhalation
and its release when moving to another area with an exhalation. When
various thoughts, emotions, or feeling tones of like, don’t like, or boredom
emerge, rather than getting caught up in these experiences, the instruction is
to note them and then redirect attention back to the current body part in
focus. In this way, the teacher is supporting a present moment orientation,
offering patience and understanding about how easy it is for thinking to
hijack an intended focus.

Inquiry
In this part of the session, the teacher reminds the participants that they
have practiced a movement practice and the body scan. He elicits responses
from the group about their experiences and, if using the three layers of
questions, each question will be asked separately, eliciting several responses
from the group, before moving on to the next layer. In this early stage of
learning, it is important that the teacher gather as many responses as he can
from the group, horizontal inquiry. This is important because it shows the
universality of experience and begins the process of breaking down the
tendency to personalize it. Eliciting a range of experiences also makes overt
the common and isolating view that events and one’s reactions to them are
unique to the individual. If the group focuses on one of the practices to the
exclusion of the other, the teacher will specifically ask for any comments
from the missing practice.
As mentioned in session 1, novice teachers tend to shortchange inquiry
and move into explaining, caretaking, or problem solving, particularly when
faced with a participant who is struggling with the practice in some way.
This is problematic, as an important theme in inquiry is for the teacher to
embody an approach that facilitates discovery, learning how to stay present
and safely endure what arises, including difficulties. To highlight this, two
examples follow; the first is a response from a novice teacher and the
second, from a more experienced teacher.
Teacher: We just finished two practices—a mindful movement
practice and a body scan. What showed up? What did you
become aware of? Any surprises? Challenges?
Participant 1: The yoga poses really settled me.
Teacher: When did you become aware of this?
Participant 1: I’m not really sure. I just felt calmer.
Participant 2: I enjoyed the yoga. It felt good to stretch.
Participant 3: Me too! The movement is easier than the body scan.
Teacher: Can you say a little more?
Participant 3: In the body scan, my mind was all over the place! I
was irritated and frustrated.
Teacher: That happens in the body scan. It will get better. (This
response moves into reassuring the participant and predicting
it will get better, where it would be more consistent with the
intentions of the program to guide the participant to bring
curiosity to this aversive experience.)
Participant 4: My mind was all over the place as well. When will it
get better? (The teacher with his last answer now has a bit of
a problem on his hands! Let’s see how he answers it.)
Teacher: In time. (This answer is evasive and does not help the
participants learn how to work with what comes in practice.)
Taking exactly the same scenario, let’s see what a more experienced
teacher might say. The changed responses from the teacher and participant
are highlighted in bold.
Teacher: We just finished two practices—a mindful movement
practice and a body scan. What showed up? What did you
become aware of? Any surprises? Challenges?
Participant 1: The yoga poses really settled me.
Teacher: How did that show up? Body sensations? Thoughts?
Emotions? (The teacher is interested in the full range of
sensation and is highlighting the possible extent of what
showed up, along with curiosity.)
Participant 1: I’m not really sure. I just felt calmer.
Participant 2: I enjoyed the yoga. It felt good to stretch.
Participant 3: Me too! The movement is easier than the body scan.
Teacher: Can you say a little more?
Participant 3: In the body scan, my mind was all over the place! I
was irritated and frustrated.
Teacher: How did the irritation and frustration show up?
Thoughts? Emotions? Body sensations? (The teacher stays
close to the challenging aspects of what showed up,
demonstrating interest and modeling the exploration of
difficulty. This establishes that all experiences are welcome
and prompts the participant to reflect more deeply on what
exactly constituted irritation and frustration and not move
away from it.)
Participant 3: I guess it was thoughts. I remember thinking this is
hard, and I will never be good at it.
Teacher: Some negative thoughts. Anything else? Emotions, body
sensations? (The teacher is expressing what mindfulness
reveals, that experiences that can be quickly and narrowly
described are actually multifaceted and can be parsed into
components.)
Participant 3: I think I felt sad too and my body felt heavy.
 Teacher: This is interesting. We are doing our best to pay
attention and follow the instructions and we become
aware of other sensations. (The teacher normalizes the
experience itself as well as valuing the bringing of curiosity
to it.)
Participant 4: My mind was all over the place as well. When will it
get better?
Teacher: How did the “mind all over the place” show up? (The
teacher doesn’t answer this future-focused question, but
again is demonstrating interest in knowing more about the
experience itself and in helping the participant give a
concrete description.)
Participant 4: It was really hard to focus on each body part. I did
keep trying to return to the body part we were on.
Teacher: That’s very much part of the practice. We notice our
attention has been diverted in some way, and then we
remember to let go and return to whatever body part we
are attending to. (The teacher has briefly woven into his
response a key mindfulness skill, that of noticing the
movement of attention and then intentionally returning to the
object of interest.)

Review of Home Practice

An important part of all sessions is the review of the home practice
assignments that were allocated in the previous week. Practicing between
the weekly sessions maintains continuity and provides a way to help
participants integrate mindfulness into daily life. Of course, finding the time
to practice formally as well as informally is not easy. Participants are
already stressed, and adding one more component to their busy lives is
demanding. A teacher is very aware of this because he will have had similar
struggles. Nevertheless, spending time discussing how home practices are
going, the successes and the challenges, provides essential learning,
reinforcing the importance of continuity and over time enhancing
understanding, patience, and resilience.
 In this session, the review of home practice focuses on the body scan,
the mindful eating practice, what informal practice participants chose,
whether they decided to do some mindful movement, the nine dots exercise,
and what they noticed about engaging with these assignments. It is
important that the teacher touch on each one of the practices.
In discussing the body scan, the teacher will check on how the practice
of the body scan has gone, how many times participants were able to
practice, and what got in the way of doing it. He will listen for what is
being discovered with the moments of insight, hear about the challenges,
and address any questions. The teacher will refrain from directly answering
questions unless absolutely necessary. Instead, he will respond by
investigating the question with the participant(s), exploring a broader frame
of reference. This provides important learning for the individuals in the
group, supporting a sense of self-efficacy and competency. Nonetheless, the
home practice review can also be a time of assisting participants with some
of the practical logistics associated with home practice. The teacher is
acting as a guide, embodying interest, showing curiosity, and offering
support. An example of this follows.
Participant: It was tough to find the time to practice. My life is so
busy.
Teacher: What did you decide? (The teacher is redirecting the
question back to the participant.)
Participant: I experimented. I tried in the morning, but that didn’t
work too well. It’s a busy time getting the kids off to school
and me to work. Then I tried in the evening—forget it! I was
just too tired. The best time for me was over my lunch
period. I sat in my car and did some breathing practice and
on one of the days ate my lunch as mindfully as I could!
Teacher: What did you discover, if anything, when you did this?
(The teacher focuses on what was possible and is positively
reinforcing.)
Participant: It’s interesting. On the days I did it, I felt calmer for a
while.
 Here the teacher is allowing the participant to experiment, thus finding
her own way into building a practice. This demonstrates that there is
flexibility, portability, and utility to bringing practice into everyday life.
In discussing the nine dots exercise, the teacher’s interest is on how the
participants approached the exercise and the process of resolving the puzzle
rather than on the resolution itself. The teacher might draw nine dots on a
flip chart or whiteboard and then ask the participants how they went about
answering the problem. The nine dots exercise provides the opportunity to
talk about how we interpret instructions, approach challenges, notice our
reactions to them, and problem solve. The exercise also promotes thinking
“outside the box” by creatively expanding to a wider frame of reference of
what is possible.
Finally, the teacher will cover the other practices that were assigned
and will bring this time to a close by making reference to what is being
discovered through the practice of mindfulness and how that might
influence how participants relate to stress, problems, or challenging
moments.

Seeing Meditation
This is a short meditation practice that involves the sense of sight and
is a prelude and serves as a link to the next practice where perceptual biases
are explored. The teacher asks participants to move to a standing position so
that they can see out of a window. If a window is not available, participants
can remain sitting and the teacher will choose an alternative focus to allow
the gaze to center on a point in the room, or he may ask them to look at
their hand or another object.
What follows is an example of what a teacher might say in leading this
practice: “As we take a comfortable position (either standing or sitting),
allow the eyes to take in what they are seeing. We are not trying to impose
any direction on seeing, but rather letting whatever is in front of us be seen.
We can be aware of colors, shapes, textures, movement. There is no rush;
we are simply attending to seeing.” The teacher pauses for several moments
as participants follow the instruction. After a few moments, the following
instruction can be given. “When you feel ready, allowing your attention to
settle on a single object that is here in the landscape of seeing. Not directing
the eyes, but instead, allowing this object to reveal itself quite naturally. As
you attend to this object, noticing its qualities: the color, shape, and
texture.” The teacher allows for several minutes to unfold and then gives
the following instruction: “When you feel ready, releasing this single object
from seeing and allowing the gaze to widen, taking in the wider, broader
landscape that now appears.” Again, the teacher allows for a few minutes to
pass. Then he will offer these words or similar ones: “In a few moments, we
will be coming to the end of this seeing meditation practice. When you’re
ready, returning to our circle, and we will have some time to discuss what
you noticed in this practice.” If the seeing meditation has been done sitting,
then the instructions can be as follows: “In a few moments, we will be
coming to the end of this seeing meditation practice. Acknowledging this
transition as you bring this awareness to the next few moments. We will
then have some time to talk about this practice.” After this practice, the
teacher spends a few minutes discussing with the participants what was
noticed.

Perceptual Biases: Ways of Seeing/Not

Seeing Exercise
There are several ways a teacher can lead this exercise using some
visual pictures that illustrate the often unconscious perceptual biases and
interpretations we make that are driven by intrinsic and extrinsic influences.
Examples of common images used are the Rubin vase illusion, first
developed by Edgar Rubin (1915), which can be seen as a vase or two faces
in profile facing each other; the young woman/old woman ambiguous
figures (created by an anonymous illustrator in late nineteenth-century
Germany and later reproduced by William Ely Hill, a British cartoonist who
published the figure in the magazine Puck in 1915); and the ambiguous
image of the rabbit/duck, attributed to Wittgenstein (Malach, Levy, &
Hasson, 2002). Sensitivity should be employed when using the young
woman/old woman figure, as the image is Caucasian-centric.
The teacher might hand out a copy of the images to each participant or
walk around the circle showing the picture(s) to each participant. He asks,
“What do you see?” and stresses there is no right or wrong way. A general
conversation ensues. The essence of this exercise is that what we see is
subject to interpretation with diverse ways of “seeing.” What we focus on,
how we relate to and construe what we are seeing, has an impact on our
ideas, opinions, emotions, and behaviors. These are often narrow, reactive,
and automatic. In closing this particular module, the teacher facilitates a
discussion that reflects on the range of responses to the exercise and
questions the assumptions we make as a result.

Sitting Meditation: Awareness of Breath

The teacher gives clear instructions about how to sit comfortably
regardless of whether it is in a chair or on a cushion or bench or on the
floor. This is a short meditation practice where the focus is on the
movement and sensations of the breath as it enters and leaves the nostrils.

Inquiry
Following the sitting meditation practice, the teacher facilitates a
discussion about what was experienced in the practice. He is interested in
gathering responses from a number of participants (horizontal inquiry), as
this helps increase the group’s descriptive language around experience and
normalizes what is being accessed and noticed.

Assigning Home Practice

The home practice assignments for the coming week are:

Body scan for six out of seven days (the participants continue to use
the same audio recording from last week).
Awareness of the breath meditation for 10 to 15 minutes per day
(participants are given access to an audio recording).
Pleasant events calendar (Kabat-Zinn, 2013) for six out of seven days.
Participants choose a different informal daily activity from the
previous week.
Additional handouts.
Home practice log.
 The teacher closes the session with a brief breath practice, thanking the
group for its participation and effort.

In Closing
The MBSR program is modular in its approach, with one session building
on the previous one. In this session, the teacher is reinforcing session 1’s
exploration of mindfulness: paying attention in a particular way that is
present moment centered. The practices of mindful movement, the body
scan, and the awareness of breath sitting meditation provide a body- and
breath-centered focus for such attention. Having the sensations of the body
as a place to direct attention is easier than focusing on thoughts or
emotions, as the body is physically tangible and the breath can be felt
sensorially. (Attending to thoughts and emotions comes later on in the
program.) When the attention moves off of its intended focus, the
instruction is to return to the original object of attention. This helps stabilize
the mind so that participants start to see how frequently attention moves of
its own accord, into the past, ruminating over some event, or worrying
about the future—all habits of the mind that are significant drivers for
stress.
Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 2 Agenda (short form)—2.5 hours

Prior to the session the teacher sets up the room with chairs, cushions (if
using), and yoga mats. He brings additional materials that include the
attendance sheet, pens, paper, and handouts.

General welcome (5 minutes)

Brief standing yoga practice (10 minutes)
Body scan (35 minutes)
Inquiry of both the yoga and the body scan (20 minutes)
Home practice review (20 minutes)
 Seeing meditation plus brief inquiry (15 minutes)
Perceptual biases exercise plus inquiry (15 minutes)
Sitting meditation practice (10 minutes) plus inquiry (10 minutes)

Home practice assignment and discussion (10 minutes)

Session 2 Agenda (long form)—2.5 hours

Welcome (5 minutes). The teacher reminds participants of the
learning guidelines and sets the context for this session.
Standing yoga practice (10 minutes). The teacher reminds participants
of safety parameters and to respect their limits. Postures are repeated
at least twice. Guidance is clear and simple.
Body scan practice (35 minutes). Participants are reminded to find a
comfortable position, one that supports staying awake. They are also
reminded that a number of reactions may occur, and it is therefore
important to take care of themselves as needed. Guidance includes
systematically moving attention around the body and exploring
sensations, with occasional reminders to return their attention to the
intended focus when it habitually moves.
Inquiry of the yoga and body scan practices (20 minutes). The teacher
elicits several responses from the group (horizontal inquiry) with a
focus on body sensations but with the recognition that thoughts are
inevitably a part of what is noticed. If participants start to talk about
what happened during the week with this practice, they will need to
be redirected to the practice that just occurred. The emphasis is on
normalizing the experiences and being curious, patient, and kind
about them.
Home practice review (20 minutes). This is a general discussion that
reviews how the participants have engaged in the assignments.
Insights and challenges are treated equally, not preferencing one over
the other.
Seeing meditation and a brief inquiry (15 minutes). This meditation
can begin with a broad or narrow focus and then moves between the
two, allowing participants to become aware of changes in the visual
field.
Perceptual biases exercise and inquiry (15 minutes). The teacher
elicits from the group the relevance of this exercise to stress
reduction.
Awareness of breathing sitting meditation (10 minutes). The teacher
guides participants to bring their attention to their sitting posture and
to the movement of the breath, with a focus at the nostrils.
Inquiry (10 minutes). The teacher elicits several brief responses from
the group about what was noticed.
Home practice assignments and discussion (10 minutes). Over the
coming week, participants will do a body scan six out of seven days;
engage in informal practice, awareness of the breath meditation (10 to
15 minutes per day), fill out the pleasant events calendar six out of
seven days; and choose a different informal daily activity from the
previous week. The teacher distributes the home practice log and any
other handouts.
 SESSION 3:

“Being and Doing”

Session 3

THEME
Highlighting the difference between “being” and “doing” modes of
mind, present moment awareness, and how “being” mode and present
moment awareness build a different relationship to our perception of
suffering and stress.

RATIONALE
Awareness of the present moment assists in reducing stress reactivity
and reduces immersion in experience.
Using the breath and body sensations helps stabilize attention,
providing a place from which to witness experience.
Cultivating a curious and welcoming stance expands the capacity to
manage stress in everyday life.

INTENTION
To continue to build mindful awareness.
To encourage and support the directing of attention to the body and
breath, whether the body is in motion and/or stillness.
 To approach one’s limits with kindness and patience.
To use the body as a means to bring understanding that when faced
with challenges, skillful choices are possible.

PRACTICE SKILLS
Program Based: Delivery of awareness of breath and body meditation
practice, yoga, walking meditation, mindful inquiry, home practice review
of body scan, mindfulness of breath, mindful activity, and pleasant events
calendar (Kabat-Zinn, 2013). Assigning the week’s home practice.

Teacher Based: Maintaining the training of attention to a primary focus of

body sensations and the physical sensations of breathing; highlighting the
impermanent nature of experience; and continuing to build the vocabulary
and ability to deconstruct experience. Continued embodying of the practice
—present moment orientation, curiosity, beginner’s mind, patience,
acceptance, non-striving, letting go, and kindness.

Teaching as Practice: Anchoring the Teacher

It is helpful for the teacher to review the current session curriculum and
reflect on what was covered and discussed in the last session. This assists in
anchoring a teacher’s intention to where she is in the program, and how the
participants are progressing. What this will involve is a review of the
themes, practices, and home practice assignments from the previous week
as well as what is embedded in this week’s curriculum. We are again
suggesting the importance for the teacher to find the time to practice (a brief
sit or movement practice) prior to the session, fostering her intention to
embody mindfulness as best she can.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:
Sitting Meditation Practice: The teacher opens the practice by
inviting participants to engage in a sitting meditation practice,
attending to the breath and body, ensuring that they bring their focus
to the physical sensations of breathing in a chosen place (often at the
nostrils, chest, or abdomen). It is important that the teacher maintains
a light touch, highlighting during her guidance that there are other
sensations (thoughts, emotions, body sensations, sounds) occurring
inside and outside the body, but these are not the primary focus of this
practice. Noticing the habitual movement of attention is as much a
part of the practice as is its intentional return to the breath in the body.
The teacher also widens the focus of attention to take in the entirety
of body sensations.
Lying-Down Yoga Practice: The teacher moves the group into a yoga
practice (lying supine) to increase the group’s mindful attention to the
body in motion and stillness. Movement can often be a way to help
participants let go of what has come before (a busy day, a stressful
state, etc.) and brings them into a present moment orientation. (See
the appendix and visit http://www.newharbinger.com/45601 to
download a copy of the lying-down yoga sequence.)
Walking Meditation Practice: The group is then led through a brief
walking meditation practice (if time allows), providing yet another
focal point for attention to the body and assisting in making the
bridge to informal practice in everyday life.
Inquiry: Inquiry follows these practices. The teacher may need to ask
the participants about each practice in the order in which they
occurred to ensure that they are both discussed. The teacher’s stance
is curious, kind, and patient. She tries not to make assumptions about
what participants are saying and seeks clarification when needed. As
always, she will listen for the participants’ tendency to drop into a
narrative, associations, or when they begin referencing the previous
week. This is a common occurrence as participants begin to
experience the challenges of practice.
Home Practice Review: The teacher facilitates a general discussion
about the previous week’s home assignments that included the body
scan, mindfulness of the breath, an informal activity, and the pleasant
events calendar. She checks in to see how many people engaged in the
practices. Attention to home practice by the teacher continues to
reinforce its importance. The discussion allows the teacher to obtain
feedback from the group about how the home assignments are going,
as well as how people are meeting the inevitable challenges that arise.
This conversation also provides learning for the group as a whole,
because they hear how people are working with the practices
assigned, regardless of whether the practices are experienced as
difficult or easy. She also reviews the pleasant events calendar. If no
one or only a couple of participants have completed the handout, she
can (making sure she has brought copies of the calendar) ask people
to record a pleasant event from the previous week in the class. It is
vital for this exercise that participants read what they wrote down in
answer to the questions that head each of the columns, presenting
their responses briefly. The teacher listens for congruency or
discordance between described body sensations, emotions, thoughts,
and the post-practice reflection. She gently reflects on these as
required, to increase the language of experience and the
understanding of the interactive nature of its components. Key themes
of this exercise include the pleasure and power of being present, and
that pleasant experiences can highlight interconnectedness. Being
present to experience without needing anything more invokes
appreciation, and often it is the small things that can go unnoticed.
Participants often also bring attention to how much they miss in life
because they are focused on the unpleasant.
Home Practice Assignments: As with all sessions, time will be
allocated to a discussion of the home practice for this week. The
teacher will reference the unpleasant events calendar (Kabat-Zinn,
2013) and remind participants to bring the calendar (filled out) to the
following session.
Closing: Closing the session can be done in a variety of ways to mark
the end of the session, following which the session handouts are given
out.
 During this session and beyond, participants may express struggles
with the program. It is important to acknowledge that MBSR asks a lot of
its participants. Some may want to stay after class to discuss this with the
teacher. The teacher needs to decide how much of this she will do because
her own self-care and energy are important. If she spends too much time
with individuals this may have an impact on group cohesion; and while the
teacher’s role is to be a supportive guide, it is also her role to enhance
competency, confidence, and self-efficacy in her participants. Too much
caretaking of them and she may, unwittingly and with the best of intentions,
inhibit this process. This is why she should try to address the experience of
the practices and challenges with the program in the group as they arise,
rather than addressing them individually.
What follows now is a comprehensive overview of session 3 that
includes logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room and make sure that she has
all the materials for this session, including the handouts for home practice
and extra pleasant-events calendars.

Opening the Session

The teacher welcomes everyone to the session, and once again asks that
they choose a yoga mat, or use their own, get a cushion, or sit in a chair, and
lets the group know that it is going to be engaging in a sitting practice
followed by a mindful movement (yoga) practice.

Facilitating the Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.

Awareness of Breath and Body

 The awareness of breath and body meditation practice trains focused
attention to the physical sensations of breathing in the body and a wider
attentional skill of monitoring, using the whole of the body as a way to
assist participants in increasing receptive attention and open awareness. The
movements of breathing evoke sensations that provide a locus for attention
as well as a place to return attention when it is compelled elsewhere. The
breath provides an anchor from which to witness other aspects of
experience as they unfold. The body provides a manageable container for
the cultivation of an attentional focus that offers a more expansive
awareness, paving the way for widening attention to the entirety of
experience in later sessions.

GUIDANCE
Participants are guided to make the transition to take a comfortable
sitting position that embodies being alert and awake. They may choose to
sit in a chair, on a meditation bench, or on a cushion. As she did in the
previous week, the teacher spends a few minutes instructing and
demonstrating for the group how to sit in a way that can be sustained
comfortably for the duration of the practice. These instructions need to
respect people’s physical limitations, providing support or props when
needed. For example, if using a cushion, sitting cross-legged where one’s
knees are higher than one’s hips, the position will quickly become
uncomfortable, and this discomfort will be the focus for attention rather
than the meditation practice. The teacher will need to instruct the person
either to sit up higher, allowing the pubic bone to descend and the knees to
be released, or to support the knees with cushions or blocks. Alternatively,
they may move to a chair or find another posture.
The teacher opens the practice by asking participants to adopt a sitting
posture that is alert and comfortable. She then might say: “And now,
choosing to close the eyes or taking a soft, half-open gaze a few feet in
front of you on the floor. The spine is straight but not stiff, and the hands
are resting in the lap or on the thighs. Bringing attention now to the body
and the points of contact the body is making with the chair, the cushion, the
floor, noticing any sensations that are making themselves known and
attending to these as best you can.” She then clearly asks her participants to
shift their attention to the physical sensations of breathing at the nostrils,
bringing these into the foreground while allowing other sensations, sounds,
thoughts, and emotions to rest in the background. The teacher conveys a
light touch in the exploration of the movement of the breath in and out of
the body. After approximately 10 minutes she invites the group to shift
attention to the entire body, around the breath, to any and all sensations
inside the body, and at the surface of the skin. She emphasizes an open and
receptive stance to these sensations—one that is curious and reflects a
willingness to explore whatever comes and goes.

Yoga (Lying Down)

After the sitting meditation ends, the teacher reminds the participants,
as they transition into the movement practice, to bring the same quality of
attention they brought to the sitting practice (paying attention to the breath,
to the physical sensations of body movements), and that it is also important
to work within their limits, taking care of themselves as needed. If
necessary, they can feel free to modify the posture they are taking, to sit up,
or to lie still and visualize the movements if they are experienced as too
challenging. Again, the teacher may need to describe modifications for
participants who are not able-bodied. See the appendix or visit
http://www.newharbinger.com/45601 to download a pictorial guide to
lying-down yoga poses.

GUIDANCE
Guiding participants to lie down on their backs, arms by their sides,
feet falling away from one another, the teacher allows for this transition by
taking a few moments before bringing the participants’ attention to the
points of contact the body is making with the surface they are resting on,
and to any other sensations arising from the body. She instructs them about
choosing to have the eyes open or closed, and to bring attention to the
breath. Using enough silence during the guidance to ensure the group is not
only attending to the teacher’s voice but also to their own internal
experience, she takes them through a series of yoga poses, beginning in the
supine position.
The yoga practice as outlined in the appendix includes such
movements as leg extensions, leg lifts, hip flexion, bridge pose, and gentle
twists, to name a few. She may also work with her participants in side-lying
or prone postures but ensures that the practice ends with participants
spending some time in a supine resting posture to mark the end of the
practice and bring attention to the body in stillness. These movements may
be tied to the breath. If the teacher finds it difficult to coordinate the
instruction of the movements with the breath, she may simply, from time to
time, remind people to breathe. The beginning and ending of each practice
needs to be clearly delineated to enhance salient attention and mindful
awareness.
It is important for a teacher to remember that beginnings and endings
are markers of transitions. An aspect of guidance for any of the meditation
practices is bringing attention to those moments, ones that are often missed,
signaling that paying attention is not just for the more formal aspects of
practice but can be highlighted as we move from one activity to the next.

Walking Meditation Practice (Optional If

There Is Time)
Mindful walking is another way of engaging in a formal meditation
practice and a vehicle to bring informal practice into everyday life. The
teacher can start this practice in a variety of ways. These include
participants coming to standing at the back of their yoga mats (if the room
is small) and then walking back and forth on them, using the surface of the
mat as a path. They may also walk in the room, selecting a specific distance
between two chosen points. Alternatively, the group may walk in a circle.
The group needs to understand that they are not “going for a walk.” There is
no destination; the practice allows for a focused attention on the body in
motion, to the sensations that come and go and to the mechanics of walking.
The guidance of this practice will be inclusive of participants who need
accommodation. For example, if there are participants with canes, walkers,
or wheelchairs, instruction will need to describe how they can utilize this
practice through any necessary adaptations or by using visualization.

GUIDANCE
The teacher invites the participants to come to standing, bringing
attention to the body. She can say, “Unlike our usual way of walking, we
are going to slow this down, so that we can more easily pay attention to the
mechanics of walking, body sensations, and the sensations of breathing.”
She may then ask participants to bring attention to their posture, the body in
space, the soles of the feet, or the entire body as sensations come and go.
She then brings their attention to the physical sensations of breathing. She
demonstrates mindful walking, guiding participants to shift the weight to
the right (or left) side. She instructs the group to lift the left heel and foot
off the floor and take a step, placing it in front of them as the weight is
shifted onto the left leg. In this way, participants are guided into “lifting,
moving, and placing” their feet. They begin walking while bringing
attention to the sensations in the soles of the feet. As the practice
progresses, she may instruct participants to move their attention to include
the lower leg, the knee, the thigh, and the hip as the body moves. However,
the primary anchor for attention is the feet, and it is to the feet that
participants are guided to return attention when it inevitably moves into
thinking, emotions, or other sensations inside or outside the body.

Inquiry
With the inquiry process, as with the other mindfulness practices, it is
helpful for the teacher to set the context for the learner. To this end, she
reminds the participants that they will be reflecting on the sitting
meditation, the yoga practice, and the walking meditation. She will
encourage a range of reflections, ensuring that she gathers a breadth of
responses. In this way, she continues to help participants build a vocabulary
of experience that emphasizes description over analysis.
As described elsewhere, staying with the current practice can be
difficult for participants, who will often begin to narrate their experience,
seeking explanations for what occurred, or moving into talking about what
happened during the week. How the teacher deals with these tendencies
affects what the group is learning and the group process. Her modeling of a
present moment orientation in her inquiry reinforces what is being trained
in that describing direct experience is highlighted over past or future
narratives. It is important that she hold this teaching principle in mind
during these interactions, or the dialogue can move far away from its
intentions. Following is an example of when the teacher does not hold the
participants to the intentions of inquiry and when she does.
Teacher: So, I’d love to hear what showed up during that movement
practice.
Participant 1: The yoga was hard for me today.
Teacher: Hard, how?
Participant 1: I sprained my ankle last week and it’s tender and
swollen. So, I think that’s why I couldn’t do the poses
properly. I couldn’t even rest my ankle on my knee when we
were lying down. It also made it hard for me to do the
homework because I was having trouble staying on my feet. I
should have wrapped it in a bandage before coming. I kept
worrying about reinjuring it or hitting one of the participants
accidentally and disturbing their practice.
Teacher: So, it was a struggle. Hopefully, your ankle will get better
this week. You could consider not doing the movement
practice. (Here the teacher has moved into reassurance and
advice giving.)
Participant 2: I was really stiff. Everything felt tight.
Teacher: Anywhere in particular that you noticed this?
Participant 2: Everywhere! I’m just wondering if other people feel
the same way I do? (turning toward the other participants)
Teacher: Others? Did anyone else have a similar experience? (The
teacher is not staying with the participant’s individual
experience, but rather defaults to the assumed common group
experience, a frequent strategy of novice teachers who don’t
know what to do and are uncertain of what to ask next. The
teacher in this moment has lost her direction of the inquiry
process and has inadvertently allowed the participant to take
control.)
Participant 3: I felt tight, but it was a lot easier than at home. I really
like your voice. It’s so relaxing and it felt good to move. It
was harder doing it on my own this week because my dog
kept jumping on me. I got frustrated and gave up.
 Teacher: Thank you. It can be helpful, if possible, when doing the
home practice if you can be in a space without interruptions.
Alternatively, you can make the dog part of the practice! (The
teacher has moved from the practice just completed into
talking about the home practice. She is also doing the
participant’s work for him by giving advice rather than
eliciting suggestions.)
Here is an interaction that goes in a different direction. The changes
are in bold.
Teacher: So, I’d love to hear what showed up during that movement
practice.
Participant 1: The yoga was hard for me today.
Teacher: Hard?
Participant 1: I sprained my ankle last week and it’s tender and
swollen. So, I think that’s why I couldn’t do the poses
properly. I couldn’t even rest my ankle on my knee when we
were lying down. It also made it hard for me to do the
homework because I was having trouble staying on my
feet…
Teacher: Sorry to interrupt, I just need to clarify something. You
just said something important…you had ideas about why
you couldn’t do the practice. (The teacher interrupts as the
participant starts to move into an idea about why the practice
was hard and into narration about the past week.) So how did
you notice that today? In the body, thoughts, or
emotions? (She brings the participant back to the current
topic of conversation, the how and the what, versus the why
of this practice and gently nudges the person to focus on the
components of experience.)
Participant 1: I felt tense in my legs and had thoughts that I should
have wrapped it with a bandage. I was anxious about
reinjuring it or hitting one of the participants accidentally and
disturbing their practice.
Teacher: OK, so you had a lot of awareness about what was going
on—thoughts about how you might have looked after
yourself, as well as worry and anxious thoughts about
yourself and others. One more question if I may? (The
teacher has engaged in a simple reflection that reinforces the
value of awareness and description of experience and the
value of self-care; she also asks for permission to continue.)
How did you know you were anxious or worried?
Participant 1: I felt tight in my chest and I guess what my thoughts
were saying.
Teacher: So, you noticed a number of things going on. Thank
you.
Participant 2: I was really stiff. Everything felt tight.
Teacher: Anywhere in particular that you noticed this?
Participant 2: Everywhere! I’m just wondering if other people feel
the same way I do? (turning toward the other participants)
Teacher: How did stiffness show up for you? (She ignores the
participant’s questioning of the others, keeping a focus on
this person’s experience.)
Participant 2: Well, my back and the backs of my legs were really
tight, and it was hard to bend forward. I could see that others
could bend more than I could. I’m just not very flexible
anymore.
Teacher: You noticed tightness in particular areas of the body,
judgmental and comparative thoughts about yourself in
relation to others?
Participant 2: Yes, I guess I wasn’t really only into my own
movement practice.
Teacher: Nice awareness. Thank you.
 Participant 3: I felt tired and kind of weak, but it was a lot easier
than at home. I really like your voice. It’s so relaxing and it
felt good to move. It was harder doing it on my own this
week because my dog kept jumping on me. I got frustrated
and gave up.
Teacher: How did tired and weak show in this practice? (Here the
teacher has kept the participant in this practice.)
Participant 3: My body felt heavy and slow.
Teacher: Thanks.
This is session 3 and participants are still learning about what shows
up when they practice in this way. In the second scenario, the teacher has
been able to train a reflective focus on the practice just completed (a present
moment focus), and she has helped the participants track their experience
and name it. This is a key teaching, in that being able to break down
experiences, acknowledging the relationship we have to them (pleasant,
unpleasant, and neutral), is a key learning skill for understanding our
automatic reactions and stress reactivity.

Home Practice Review

As we have discussed previously, reviewing home practices is an
essential part of each session. By giving time to this discussion, participants
receive the message that the continuity of practice is of value because of the
support it provides to the learning between sessions. At this point in the
program, it will be clear that the home practice assignments take effort, and
participants may need help in meeting what may be perceived as barriers,
such as sleepiness, not wanting to do it, doubt about its value, boredom,
impatience, not liking it, forgetting to do it, or fitting it in. Part of the
teacher’s function, and the group’s, is to explore these issues using them as
yet another lens through which to examine their reactions to what they like
or don’t like or when difficulty shows up.
The teacher embodies a curious, receptive, and accepting stance to
whatever the participants present her with during the home practice review.
Whether wanted, unwanted, or neutral, it is all grist for the mill for
investigating experience. Working with challenges in home practice is a
parallel process to managing any stressor. The group process is a great
support to participants as they investigate and share ways to incorporate
mindfulness into daily life, as well as reviewing the successes and
difficulties that have arisen during the previous week.

Assigning Home Practice

The home practice assignments for the coming week are:

Alternating days of the body scan with lying-down yoga sequence,

using audio to guide them, for six out of seven days.
Unpleasant events calendar (Kabat-Zinn, 2013) daily for six days.
Awareness of breath and body sitting meditation practice for 15 to 20
minutes for six days.
Additional handouts.
Home practice log.

The teacher closes the session with a brief breath practice (depending
on time constraints), thanking the group for its participation and effort.

In Closing
Session 3 builds on session 2. In this session, the teacher continues to
reinforce paying attention with a present moment orientation, using the
body and the breath as the objects of attention and interest. Participants
have the experience of a longer mindful movement sequence that includes
an introduction to walking meditation, which provides a bridge to informal
practice. Having the sensations of the body and breath as a focus for
attention provides a place from which to witness experience as it comes and
goes, developing a different relationship to it. It is to be expected that
challenges within the session will be articulated and that difficulties with
home practices will feature in the discussions. How the teacher meets these
moments, embodying non-striving, kindness, understanding, and patience,
will continue to build trust in the process they are learning.
 Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 3 Agenda (short form)—2.5 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. She brings additional materials, including the
attendance sheet, pens, paper, and handouts.
Welcome to session (5 minutes)
Sitting awareness of breath and body meditation practice (5 minutes
sitting demonstration plus 15 minutes)
Lying-down yoga practice (60 minutes)
Walking meditation practice (15 minutes )
Inquiry of sitting, yoga, and walking (20 minutes)
Home practice review (20 minutes)
Home practice assignment and discussion (10 minutes)

Session 3 Agenda (long form)—2.5 hours

Welcome (5 minutes). The teacher reminds participants of the
learning guidelines and sets the context for this session.
Sitting posture demonstration (5 minutes). The teacher ensures the
participants are sitting in a posture that encourages comfort and
wakefulness. (This requires a demonstration using the chair, cushions,
and meditation benches.) The teacher leads an awareness of breath
and body meditation practice (15 minutes); guidance of the
meditation practice is clear and simple, containing adequate periods
of silence and clear shifts in focus when moving from a focus on the
sensations of breathing to the open monitoring of the body.
Lying-down yoga practice (60 minutes). Participants are instructed to
take a few minutes to move to a lying-down position on their mats.
They are also reminded to work within their limits and to take care of
themselves as needed. Guidance needs to be clear and paced with
periods of silence. Note that repeating poses helps participants bring a
focus to the body and allows them to attend to what comes and goes
throughout the practice.
Walking meditation practice (15 minutes). The teacher uses clear
instructions that anchor the participants’ attention in the soles of the
feet and to the mechanics of walking. These include guidance that
focuses on “lifting, moving, and placing” the feet as they walk slowly,
eyes downcast a few feet in front of them.
Inquiry of the breath, yoga, and walking practices (20 minutes). The
teacher elicits several responses from the group with a focus on body
sensations but with the recognition that thoughts and emotions are
also part of the practice. If participants engage in a narrative of the
practice or move into the past or future, they will need to be gently
redirected to the discussion at hand. This session is one in which
difficulties with practice may be prominent. The emphasis is on
normalizing these experiences and bringing curiosity to whatever has
occurred.
Home practice review (20 minutes). The teacher facilitates a general
discussion that reviews how the participants have engaged in the
home practice assignments. Insights and challenges are treated
equally, without preferencing positive experiences over difficult ones.
Both will be showing up in the home practice and will need to be
addressed.
Home practice assignments and discussion (10 minutes). Over the
coming week, participants will alternate a body scan with lying-down
yoga for six out of seven days; fill out the unpleasant events calendar
for six days; and do an awareness of breath and body practice (15 to
20 minutes) for six out of seven days. The teacher distributes any
other handouts and the home practice log.
 SESSION 4:

Stress and Stress Reactivity

Session 4

THEME
Exploring the physiology of stress and its impact on the body/mind
systems.
The role of mindfulness in recognizing automatic, conditioned
reactions to stress.
Developing an exploratory and flexible approach to stressors.

RATIONALE
Education around the psycho-physiological correlates of stress
normalizes how and why we react the way we do.
Recognizing our conditioning and views, and how they shape our
experience, opens up options for how we might respond with
awareness.
Identifying the internal and external sources of stress, patterns of
avoidance, and maladaptive coping highlights how we can begin to
work differently with what we encounter.

INTENTION
 To enhance the investigation of the components of stress reactions in
the body by being with difficult sensations as a parallel process to
working with other stress variables, such as negative thoughts,
difficult emotions, and habitual behaviors.
To introduce participants to a model of stress reactivity that
encompasses the neurophysiology of stress, the automaticity of
reactions, maladaptive coping, and how the practice of mindfulness
can be used to increase awareness as a first step to developing flexible
responses.

PRACTICE SKILLS
Program Based: Delivery of standing yoga practice, awareness of breath
and body meditation and how to work with intense physical sensations;
mindful inquiry; home practice review of the body scan, mindful yoga,
awareness of breath and body meditation, and the unpleasant events
calendar. Stress reactivity discussion; delivery of the week’s home practice
assignments.

Teacher Based: Continued focus on the sensations of the body and breath
to stabilize and regulate attention, highlighting tendencies of avoidance and
encouraging approach versus resistance to aversive states of body and
mind; continuing to build the vocabulary of sensation; highlighting the
deconstruction of experience as it relates specifically to stress reactivity;
embodying the practice—present moment orientation, curiosity, equanimity,
willingness, patience, and kindness.

Teaching as Practice: Anchoring the Teacher

This is week four of the eight-week program. Before the teacher starts this
session, it is helpful to remind himself of what was covered last week and
what the themes are for this session, and to briefly review next week’s class.
Reviewing the content of this session helps anchor the teacher’s attentional
focus to where he is in the program, while at the same time, reminding him
about what was discussed in the previous week and what he will be
covering in session 5. Sessions 4 and 5 are the keystones of the program,
providing participants with crucial information about the psychobiology of
stress and how the practice of mindfulness can be brought to these
moments, supporting the possibility of responding to stress in ways that are
adaptive rather than automatic and reactive. It is always valuable for the
teacher, prior to teaching, to spend some time (however brief) engaging in a
meditation practice as preparation for teaching this mindfulness-based
program.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:

Standing Yoga Practice: The teacher opens the session by inviting

participants to engage in a standing yoga practice and asks
participants to choose a mat, find a place in the room, and come to a
standing position. The teacher will then lead the participants through
a series of standing yoga poses incorporating attention to the breath as
he instructs the participants in the various postures.
Sitting Meditation Practice: The teacher moves directly from the
standing yoga practice into the sitting meditation practice, which
focuses on awareness of breath and body and working with intense
physical sensations. The focus of this practice is to highlight the
capacity to work skillfully and safely with intense physical sensations
as a forerunner to working with general distress.
Inquiry: Inquiry follows these practices. The inquiry will include a
discussion of both the yoga and the sitting meditation practices. The
teacher listens for those moments of challenge that may have arisen,
exploring these with the participants while embodying attitudes of
curiosity, compassion, and acceptance of whatever is expressed.
Stress Reactivity Triangle: The teacher introduces a model of stress
that illustrates its effects. This begins a discussion that has the group
identify and list internal, external, acute, and chronic stressors to set
the context and enhance the collective experience. This is followed by
an in-depth discussion of the stress reactivity triangle (or other
models of stress), which includes its neurophysiology, associated
reactive thoughts, emotions, and maladaptive coping behaviors.
The Circle of Awareness: The teacher describes an approach for
monitoring stress using the figure of a circle that helps participants
identify the components of their stress reactions as they are
sequentially noticed (body sensations, thoughts, emotions, behaviors).
Using this circle when stress reactions arise then becomes part of the
home practice for the coming week.
Home Practice Review: The teacher facilitates a general discussion
about the previous week’s home assignments that included the lying-
down yoga practice, the body scan, and the unpleasant events
calendar (Kabat-Zinn, 2013). Again, the teacher checks in to see how
many people engaged in the practices, sending the message that it is
his expectation that participants are doing them. Home practice
review is a necessary function for the group, assisting in the
development of their collective skills. Regardless of whether the
practices are experienced as difficult or easy, this needs to be
explored, particularly if people are struggling with practice. For those
participants who have not been able to find the time to practice, the
teacher emphasizes that it is never too late to start. Included in the
discussion is a review of the unpleasant events calendar (ibid.). Key
themes of this exercise include the learning that can come from
attending to that which we would rather not. Turning toward
challenging moments builds distress tolerance, self-efficacy, and
confidence in one’s ability to manage and provides opportunities for
experiential disconfirmation (things often don’t turn out as expected).
Hearing about one another’s unpleasant experiences and what has
been learned highlights the universality of the human condition. This
builds connection and reduces isolation. The teacher holds whatever
is arising in the room with equanimity, taking the same stance to the
unpleasant as he did to the pleasant events calendar (ibid.), discussed
the week before.
 Home Practice Assignment: Time is allocated to a discussion of the
home practice for this week.
Closing: Closing the session can be done in a variety of ways to mark
the end of the session, following which the session handouts are given
out.

What follows now is a comprehensive overview of session 4 that

includes logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room and make sure that he has
all the materials he needs for this session, such as the handouts for home
practice and extra unpleasant-events calendars (ibid.).

Opening the Session

As is customary, the teacher welcomes everyone to the session and asks that
they choose a yoga mat, or use their own, letting the group know that it is
going to be engaging in a standing yoga practice.

Facilitating the Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.

Standing Yoga Practice

The teacher introduces the practice by asking the participants to
choose a mat and place it in the room. He takes time to allow participants to
bring themselves to a comfortable standing position. Visit
http://www.newharbinger.com/45601 to download a pictorial guide to
standing yoga poses.
 GUIDANCE
He can then begin the practice by saying something along the lines of,
“Coming to the front of your mat, taking a moment to bring attention to the
body standing and particularly to the soles of the feet. Noticing what
sensations are present. And now, bringing attention up from the soles of the
feet to the ankles, the lower legs, the knees, the thighs, the hips, the
buttocks, and the lower abdomen, allowing the spine to gently lift, checking
in with the shoulders and shoulder blades, the arms and hands, allowing the
arms to rest comfortably alongside the body; moving attention to the neck,
the throat, and the face. There is no rush.” He then takes the group through
a series of standing poses, reminding participants to respect their limits and
to modify the practice as needed in the service of self-care. He repeats each
posture at least twice, in order to facilitate familiarity with the body, to
highlight the noticing of how experience changes from one moment, one
pose, to the next, and to modify predictive expectations. Throughout his
guidance, he will, from time to time, remind participants to take a moment
to pay attention to what is arising in the body and any associated judgments
or thoughts if those are present.

Awareness of Breath and Body: Working

with Intense Physical Sensations
This formal sitting practice, in addition to a focus on the breath and
monitoring of body sensations, brings attention to and an exploration of
intense physical sensations if present. The teacher models equanimity in
guiding the approach to such challenges, reducing the participants’
tendency to compound difficulty through resistance and avoidance. The
intention here is to show that by approaching difficulty—in this case, as
presented in the body—and being with those sensations and investigating
them, participants may learn that challenging physical sensations may be
explored and tolerated. This has direct implications for how we approach
difficulties in everyday life.

GUIDANCE
 The teacher moves into this practice by asking participants to take a
seated posture that will allow them to sit as comfortably as possible. After
he has allowed the group to settle by first bringing their attention to their
position and the physical sensations of sitting, he then guides them to bring
their attention to the sensations of breathing at the nostrils. Other sensations
such as sounds, thoughts, and emotions are part of the practice, and the
teacher acknowledges this, as he invites participants to let these rest in the
background without striving to change anything. Following a period of
focused attention on the sensations of breathing, he then clearly asks them
to shift attention to the entire body, to any and all sensations inside and
outside the body on the surface of the skin. He will leave longer periods of
silence to ensure that participants have a chance to be with the changing
nature of sensation. The guidance reflects that sensations in the body shift
and change, along with the recognition that thoughts and emotions will
arise, persist, and pass. In noticing this, the instruction will invite the return
of attention to its primary object of interest, that of the body. An open and
receptive stance to these experiences is a prelude to investigating and
working with intense physical sensations.
The teacher then guides the group to explore any challenging physical
sensations, getting to know their various aspects, such as shape, parameters,
depth, and qualities. There may be numbness, tingling, pain, or tension.
Whatever is present is to be acknowledged and accepted as best it can be.
There are some direct instructions to help participants use the breath as a
support for staying with, examining, and working with what is arising.
These include investigating the sensations themselves with curiosity,
breathing into the discomfort, if possible, and softening and releasing with
each out-breath. An added instruction for working with intense sensations
that are particularly difficult to examine is to set the intention to move, to
shift position. This may help reduce the intense nature of what is being
experienced; participants then return to the original position if and when
ready. In this way, the practice is not about toughing it out, but rather is a
way to work wisely within one’s limits. The teacher then asks participants
to return their attention back to the breath, closing the practice by asking the
group to open their eyes if they’ve been closed, and to move the body in
any way needed.

Inquiry
 In this session, inquiry is holding a particular focus. Approaching and
being with difficulty is often a foreign way to work with negative or painful
circumstances. It is likely that at this stage of the program, four weeks in,
participants are struggling with what practice is revealing in terms of
aversive states. Both the yoga practice and this particular sitting practice
reveal the difficulty of being with one’s experience, whether the result of
tension in the body, chronic illness, or preference, resistance, anxiety, or
other difficult mind and mood states. Therefore, intentionally asking
participants to deliberately face and explore what would often be avoided or
controlled is frequently counterintuitive to them. Inquiry models this
approach of turning toward discomfort as a skill to be learned, taking a
gentle but firm stance in asking and encouraging participants to engage in
this process. An example of this follows.
Teacher: We have just practiced some movement and a sitting
meditation where the instruction was to explore intense
physical sensations if they were present. I am wondering
what showed up. (The teacher takes an open-ended, general
approach to asking about these two practices.)
Participant 1: I really enjoyed the movement practice. The sitting
practice was difficult.
Teacher: That’s interesting. One practice was enjoyable and the other
was difficult. (The teacher reflects the participant’s
experience using their words.)
Participant 1: Yes. My knee was really painful in the sitting practice.
Teacher: What happened when you noticed the pain? (The teacher is
staying with the participant’s response of pain and not
making assumptions.)
Participant 1: I tried to breathe into the sensations, but that was
really hard.
 Teacher: It can be hard to turn toward pain in the body. I’m
wondering, what kinds of sensations did you notice? (The
teacher acknowledges the difficulty and holds the focus of
“turning toward” by asking for additional information about
the sensations of pain, encouraging this approach for this
individual and reinforcing this for others in the group.)
Participant 1: There was pulsing, achiness, and twinges in the knee.
Teacher: Not easy to pay attention to. (Pauses.) How might this
relate to working with stress, if it does? (The teacher is
helping the participant make the link of working in this way
with the body to stressful situations, generalizing it.)
Up to this point in the program, a teacher has been engaged primarily
in horizontal inquiry, gathering as many responses from the group as
possible to establish the commonality or universality of experience.
However, in this session the teacher is now actively engaged in supporting
participants to delve into a discovery process that requires they work
directly with distress. To this end, he will need, at times, to inquire more
deeply (using vertical inquiry) into the experience of a person who is
struggling. However, it is important not to turn this conversation into an
interrogation or to probe too deeply when a teacher is looking for a
particular outcome. It is essential that the teacher develop awareness of
personal signals of their own agenda to fix, reassure, advise, caretake, or
make a teaching point.

Home Practice Review

As always, the review of the home assignments is a critical aspect of
each session and for the program. By now the participants are familiar with
this discussion. Struggles to commit and find the time to practice at home
continue to be a focus, with the teacher embodying interest in how
participants are negotiating this and the challenges it raises.
It may be surprising to the participants when the teacher is equally
interested and supportive of creative or simple ways to practice, such as
taking a few breaths at the kitchen sink or meditating in the car (though not
while driving), or alternatively when somebody reports they were able to
practice for the required length of time. Because the actual duration of
mindfulness meditation practice required for benefit is unknown, the
teacher may stress that practice that occurs a little and often may be more
useful than one long practice per week.

Stress Reactivity: A Group Discussion

In this seminal piece, the teacher presents themes related to stress, its
effects on the body/mind, and our habitual reactions. There are a number of
ways that a teacher might conduct this particular module. Initially, it is
helpful to ask participants to describe their perceived stressors. What is
essential is to cover the following: the neurological, cardiovascular, and
endocrine physiology associated with perceived threat; the ensuing effects
on thoughts, emotions, and behaviors; and the subsequent coping strategies
that may ultimately become maladaptive. Maladaptive coping styles are
influenced by the intensity and duration of stressors and the automatic
nature of our reactivity.
While we recognize that our physiological activation often occurs
simultaneously with our identified emotions, cognitive correlates, body
sensations, and behaviors, for the purpose of this discussion, and to provide
clarity for our participants about stress reactivity, we have separated the
physiological activation and associated body sensations from our identified
behaviors, emotions, thoughts, and connected bodily reactions (reactivity).
An example of this is when a person jumps the line ahead of you. If you
become activated, you may experience an increase in heart rate, tension in
the body, and an urge to “fight.” This is the immediate physiological
activation of the sympathetic nervous system. We are calling the
recognition of the emotion of anger, tension in the body, and thoughts of
saying, “Hey, get in line,” as reactivity. The contrived separation is to assist
participants in recognizing (becoming aware of) the components of their
experience. This is in the service of continuing to build the skill of parsing
experience. It also lays the foundation for the next session, where the
practice of mindfulness is introduced as a skill for intervening in these
stress reactions.
There are various ways this part of the session may be conducted.
Possibilities include brief discussions of the work of Hans Selye (1956), Jon
Kabat-Zinn (2013), or other writers in the area of stress and coping (e.g.,
Lazarus & Folkman, 1984; Sapolsky, 1994). Here, we present the method
we use to conceptualize the cycle of stress reactivity and to facilitate its
discussion. The teacher begins by writing the categories of internal,
external, acute, and chronic stressors on a whiteboard or flip chart. This
may involve the need to define these categories, letting the group know that
this is a heuristic device to talk about stress and that there will be overlap
between them. He then asks the participants to popcorn out some examples
of stressors that fall under these areas. After gathering a number of
responses, he divides the participants into dyads and asks them to silently
consider and record the ways in which stress manifests for them using these
categories. They are then given time to talk about them in their dyads. After
this the teacher brings them back into the large group for a general
discussion.
He will then move to the flip chart or whiteboard and draw a triangle
(see figure 1). This figure illustrates the potential stressors, the automaticity
of stress reactions, how our physiology is activated (nervous, circulatory,
and endocrine systems) during stressful periods, the result of their intensity
or duration, and how we habitually react with respect to our thoughts,
emotions, body sensations, and behaviors. He discusses how the stressors
activate the sympathetic nervous system and how reactivity can, if chronic,
result in maladaptive coping strategies. These may increase the perception
of the stressors, and their effects, adding to the stress as we are locked into
doing mode (problem solving) that becomes ineffective over time. This is
an iterative process: one we may find ourselves feeling helpless to do
anything about.
 It is easy for this information to be imparted through direct teaching.
However, in the spirit of experiential learning, and the MBSR program, as
much as possible of this part of the session should be presented in an
interactive manner in which the teacher is holding a structure for the
learning but eliciting what is to be discovered from the group.

Circle of Awareness: A Group Discussion

The circle of awareness is a means to visually illustrate the process we
go through when faced with challenging situations. The teacher draws a
circle on the board or flip chart, writing out thoughts, body sensations,
emotions, and behaviors (or impulses to act) at the top and bottom of the
circle and on each side (see figure 2). He explains to the group that this is a
way we can be thoughtful about how we experience stress and identify the
process we go through when exposed to it. He asks for a volunteer from the
group to report on a recent stressful situation. Writing the situation in the
middle of the circle, he then asks the participant to talk about what
happened. The teacher asks whether there were any thoughts, emotions,
body sensations, and behaviors associated with the event and records these
as they are expressed in the circle. This exercise begins the process of
externalizing stress reactions that participants will continue to examine as
part of home practice. Participants are asked to use the circle during the
coming week to identify stressful reactions, simply bringing awareness to
them but without changing anything or doing anything about them.

Assigning Home Practice

The home practice assignments for the coming week are:

Alternating the body scan with the lying-down yoga sequence for six
out of seven days, using the audio recordings to guide practice.
 Awareness of breath and body sensations sitting meditation practice
for 15 to 20 minutes for six days, using audio recordings to guide
practice.
Awareness of stress reactions using the circle of awareness handout.
Additional handouts (for example, the midcourse check-in; see the
appendix).
Home practice log.

The teacher closes the session with a brief breath practice, if there is
time, thanking the group for its participation and effort.

In Closing
Session 4 represents a shift in the program, as the teacher overtly identifies
working with stress reactivity and its correlates in body, thoughts, emotions,
and behavior. The teacher encourages participants to approach challenges
explicitly through the body when working with intense physical sensations,
coming from a stance of interest and investigation. The group is then
introduced to a model of stress reactivity that elucidates the
neurophysiology as well as the habitual ways in which we tend to react and
cope. The teacher helps the group bring awareness to the components of
stress as they emerge in any situation. They are then invited to monitor how
these show up during the coming week. The mindfulness skills they have
learned and attitudes of curiosity, kindness, and witnessing experience are
now brought to bear on stressful situations and reactions of distress.
Monitoring these throughout the week paves the way for developing a new
perspective on stress, more skillful ways of responding to it that include the
use of mindfulness, and more choices that can lead to more adaptive
coping.
Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 4 Agenda (short form)—2.5 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. She brings additional materials, including the
attendance sheet, pens, paper, and handouts.
Welcome to session (5 minutes)
Yoga (standing) (35 minutes)
Awareness of breath and body, intense physical sensations (30
minutes)
Inquiry (20 minutes)
Home practice review (20 minutes)
Stress reactivity group discussion (20 minutes)
Circle of awareness group discussion (10 minutes)
Home practice assignment (10 minutes)

Session 4 Agenda (long form)—2.5 hours

Welcome (5 minutes). The teacher welcomes the group and allows
participants to settle.
Standing yoga practice (35 minutes). The teacher reminds participants
to take care of themselves as needed.
Sitting meditation practice (30 minutes). The teacher guides
participants in awareness of the breath and body, working with
intense physical sensations. Guidance needs to have extended periods
of silence and clear instructions to shift attention from breath and
body and to the gentle investigation of intense physical sensations,
bringing an attitude of curiosity to this process while taking care of
the body as needed.
Inquiry of the yoga and breath practices (20 minutes). The teacher
elicits several responses from the group with a focus on body
sensations but with the recognition that thoughts and emotions are
also part of the practice. This session is one in which difficulties with
practice continue to be addressed. The emphasis is on normalizing the
challenges inherent in practice, and how they relate to stress in
general.
Home practice review (20 minutes). This is a general discussion that
reviews how the participants have engaged in the home practice
assignments. Participants are still faced with the reality of finding
time to practice. The teacher continues to be supportive and realistic
about this but maintains an encouraging stance.
Stress reactivity (20 minutes). This is a group discussion about
potential stressors, the automaticity of stress reactions, the physiology
of stress, habitual reactions, and maladaptive coping.
Circle of awareness (10 minutes). This is a group discussion that
highlights awareness of the components involved in stress reactions.
Home practice assignments and discussion (10 minutes). Over the
coming week, participants will alternate body scans with lying-down
yoga for six out of seven days; practice a sitting meditation with
awareness of breath and body for 20 minutes six out of seven days;
and review the circle of awareness and monitor stress reactions. The
teacher distributes the home practice log and any other handouts,
including the midcourse check-in, telling participants to return it in
session 5 (see the appendix).
 SESSION 5:

Responding to Stress

Session 5

THEME
Cultivating a different relationship and response to stressful
situations using mindfulness as a platform for being with difficulty,
identifying what is present, and intentionally responding.

RATIONALE
Mindful awareness presents a different approach to noticing
stressors and their associated conditioned reactions, providing a
different perspective and promoting a relationship that encourages
choice.

INTENTION
To create space for the difficult, nurturing awareness with a
compassionate stance that honors the full range of experience.
To help participants view and interrupt their habitual reactions, while
stabilizing mindful attention and expanding options for managing
stress.
 PRACTICE SKILLS
Program Based: Delivery of standing yoga practice; sitting meditation
practice with breath, body, sounds, thoughts, and emotions; choiceless
awareness (open and receptive to experience) and back to the breath;
mindful inquiry; stress response discussion; home practice review of the
body scan, yoga practice, sitting meditation, and circle of awareness; and
assigning the week’s home practices.

Teacher Based: Continuing to approach, explore, and welcome all

experiences, with a focus on aversive states of body and mind; encouraging
equanimity in this process with an appreciation of the varied ways
individuals are engaging in the practice and with the material; using
practice to respond to stress skillfully and flexibly; and continuing to
embody non-striving, curiosity, compassion, and trust in the process of
mindfulness.

Teaching as Practice: Anchoring the Teacher

As has been previously mentioned, taking time to review current session
content is important. Equally essential is that the teacher allow time before
she teaches to shift from doing to being mode. This shift is important for a
teacher to consider. A “doing” mode of mind is essential for enabling us to
be productive and engaged in life. Additionally, a mindfulness-based
teacher is encouraging a stance of and willingness to engage in a “being”
mode of mind that harnesses the skill of awareness (being present with,
acknowledging), informing adaptive responding, rather than being governed
by conditioned impulses and behaviors.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:
Standing Yoga Practice: The teacher opens the practice by bringing
participants to a standing position in preparation for teaching the yoga
practice. The teacher will then lead the participants through a series of
standing yoga poses that will incorporate similar postures from the
previous weeks and will introduce new ones.
Sitting Meditation Practice: The teacher moves directly from the
standing yoga practice to the sitting meditation, which focuses on the
breath, body, sounds, thoughts, and emotions, and then to choiceless
awareness (open and receptive to experience; open monitoring; open
awareness); the focus then returns to the breath to end the meditation.
The intention of this practice is to shift from focused attention on the
breath to sequentially attending to several foci, and then to choiceless
awareness.
Inquiry: Inquiry covers the standing yoga and sitting meditation
practices. The teacher ensures that she elicits from the group what
happened in the sitting meditation, where attention was brought to a
receptive monitoring of the body, sounds, thoughts, and emotions, and
to an open awareness of the entirety of experience.
Stress Response: The teacher briefly reviews the model of stress
reactivity from last week. She then introduces a model of responding
to stress that is less about didactically imparting knowledge and
research and is more about exploring how one can bring mindfulness
to stressful moments, developing more adaptive coping skills. Using
the circle of awareness, the teacher gathers a couple of examples of
stressful situations from the week (home practice), examining the
reactions (thoughts, emotions, body sensations, behaviors) in a
sequential manner, and discussing with participants how they might
use mindfulness to work with these reactions.
Home Practice Review: The teacher facilitates a discussion about the
previous week’s home assignments, which included the lying-down
yoga practice, the body scan, and the sitting meditation practice with
awareness of breath and body sensations.
Home Practice Assignment: Time is allocated to a discussion of the
home practices for this week.
 Closing: Closing the session can be done in a variety of ways to mark
the end of the session, following which the session handouts are given
out.

What follows now is a comprehensive overview of session 5 that

includes logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room and make sure that she has
all the materials she needs for this session.

Opening the Session

As is customary, the teacher welcomes everyone to the session and asks that
they choose a yoga mat, letting the group know that they will be engaging
in a standing yoga practice.

Facilitating the Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.

Standing Yoga Practice

The teacher introduces the practice by asking participants to get a mat
and place it in the room. She takes time to allow participants to bring
themselves to a comfortable standing position. Visit
http://www.newharbinger.com/45601 to download a pictorial guide to
standing yoga poses.

GUIDANCE
The teacher takes the group through a series of standing poses, leaving
extended periods of silence to allow the participants to observe their
experience without the continual interjection of the teacher’s voice. This
increases the participants’ self-efficacy and capacity to attend to their
experience and to also notice the movement of attention elsewhere.
Participants are by now familiar with many of the poses. Knowing this,
the teacher reminds the group that with familiarity we may resort to
automatic pilot and so disengage from paying attention mindfully. The
teacher prompts the participants to check in with the sensations arising from
the body movements, using the breath and body sensations as anchors, and
noticing thoughts, stories, associations, emotions, or memories when they
appear and how they are relating to these.

Sitting Meditation Practice

This formal sitting practice, in addition to a focus on the breath, moves
the attention to body sensations, sounds, thoughts, emotions, and choiceless
awareness (open and receptive to experience; open awareness), ending with
a focus on the breath.

GUIDANCE
This sitting meditation includes a number of foci. Therefore, pacing
and spacing of the instruction are crucial. Participants take a seated posture
that allows them to sit as comfortably as possible for them. After settling,
the teacher brings their attention to the physical sensations of sitting, and
then guides them to shift their focus to the sensations of breathing at the
nostrils or wherever they best sense the body breathing. She then guides the
group to pay attention to body sensations. Her instruction includes phrases
that reflect an open and receptive monitoring of body sensations. She then
directs participants to sounds as sensations, attending to their qualities
versus the tendency to name them. Following this, she invites them to pay
attention to thoughts and emotions in the same receptive way as they have
been attending to sounds. Next, the teacher asks participants to expand their
attention to the entirety of experience, including body sensations, the
breath, sounds, thoughts, emotions, and choiceless awareness (open and
receptive to experience; open monitoring). Finally, she ends the sitting
meditation by instructing participants to return to attending to the breath.
 Inquiry
In this session, inquiry includes responses from the yoga and sitting
meditation practices. The teacher pays attention to how participants are
engaging in practice. This may include a variety of experiences, such as a
sense of resistance, overwhelm, or ease. For the sitting practice, the teacher
will include a discussion around the various foci, including what was
attended to and how. As part of the discussion, the teacher addresses
responses about the open and receptive monitoring as well as the narrower
focus. Of note, the teacher understands that it is not easy to pay attention to
thoughts and emotions as an observer of their movement. Participants are
not accustomed to considering their mental lives as sensations that come
and go. More commonly, one tends to be identified with thoughts and
emotions as part of oneself. The teacher must keep all of this in mind,
allowing these points to emerge from the group discussion rather than as
teaching points that she delivers. An example of this follows.
Teacher: One of the practices we did today was a sitting meditation
where we attended to several different aspects of experience.
I wonder what showed up.
Participant 1: When we came to the thoughts, I had none!
Teacher: That can happen! And it sounds like that was a surprise.
Did you notice anything else? (Here, the teacher normalizes
the experience, names the expressed emotion, and asks the
participant to reflect on other aspects of the experience.)
Participant 1: I was okay with the breath and body sensations, but I
really liked sounds.
Teacher: What happened when you noticed the sounds? (The teacher
ignores the preferencing of liking and asks for a description.)
Participant 1: They came and went, and I was able to just notice
them coming and going. Usually sounds are irritating to me.
Teacher: So you were able to let them be there. Thank you. (The
teacher reinforces the participant’s equanimity to the sounds.)
 Participant 2: I noticed after the thought bit, when you told me to
focus on everything, I couldn’t do it.
Teacher: What happened? (The teacher is not making any
assumptions about the participant’s experience.)
Participant 2: I was all over the place, but mostly I was thinking.
Teacher: Were you aware of any emotions or body sensations at that
time? (The teacher is bringing the participant’s attention to
other possible components of their reactions.)
Participant 2: (Pauses) Yeah, my head ached, and I was
overwhelmed.
Teacher: And then what happened? (The teacher is now tracking the
experience, because “overwhelm” and other difficult
emotions can have traction, but they will pass.)
Participant 2: I noticed my breath, and that was helpful. (Here the
participant is demonstrating a return to a more tangible focus
and that they have moved on.)
Here again, we see vertical inquiry in action. The teacher is spending
time with each of these participants to help them elaborate on their
experience. She works to assist the participants in addressing their reactions
in a more granular and explicit manner than they might without this
dialogue. At the same time, she holds the rest of the group in mind, as she
listens for specific mindfulness principles from each person.

Stress Response: A Group Discussion

This session is the progression from week 4 and introduces
participants to how they might respond and relate to stress differently using
what they have been learning up to this point. The teacher briefly reviews
the stress reactivity discussion from the previous week, as this provides a
useful context for this discussion. Similar to last week’s session, there are
any number of useful and informative ways to conduct this particular
conversation. Here, we present a method of facilitating the discussion using
the stress response triangle, which maps onto the stress reactivity triangle
that was used the previous week.
Moving to the flip chart or whiteboard, the teacher draws a triangle
(see figure 3). The teacher reminds the group that stress is an ongoing part
of our lives, and how we relate to it can offer us choice in how we respond.
Using the triangle from session 4, the teacher reviews the stressors, along
with awareness of the activation of our physiology, and adds mindfulness
versus automaticity and intentional responsiveness over reactivity. A
discussion ensues about how we might bring the practice of mindfulness to
adaptive coping, moving from habitual doing (problem solving) to being, an
awareness of experience that breaks the chain of reactivity, allowing for a
range of options about what one might do next, if anything. The teacher
remembers to lead this conversation as a dialogue and not a lecture.

As already stated, this session may be presented in a variety of ways,

as long as the teacher maintains fidelity to the principles and practices of
this approach. This means using the platform of mindfulness as the agent of
change and experiential learning, which should include reflective exercises,
the understanding of relevant abstract concepts, and how these ideas can be
integrated into daily life for stress.

The Circle of Awareness: A Group

Discussion
The conversation continues using the circle of awareness. The teacher
draws the circle again on the board or flip chart, identifying thoughts, body
sensations, emotions, and behaviors (or impulses to act) at the top and
bottom of the circle and on each side (see figure 4). She asks for a volunteer
from the group to report on a recent stressful situation that occurred in the
previous week. This was part of their home assignment. Writing the
situation in the middle of the circle, she then asks the participant to
sequentially walk the teacher through the components of their reactions to
the event. The teacher numbers each thought, sensation, emotion, and
behavior in the order described. It is expected that the diagram may
ultimately look chaotic, as what is an internal process is externalized. The
participant may move back and forth between the various components as
different thoughts, emotions, and so on come up during the discussion. The
teacher then asks the participant how they could bring a mindfulness
practice (formal or informal) to this scenario. Typically, this can include
pausing for a moment or two, breathing, checking in with body sensations,
taking care of oneself, or other skillful action. The teacher will then repeat
this exercise with another member of the group. The group will work with
the circle in this way in the coming week.
 Home Practice Review
At this point in the program, the home practice review will incorporate
not only how the practice is going logistically, but also what is being
learned and how it is being applied. The teacher recognizes that learning is
uneven in the group and is supportive of participants learning in their own
way and at their own pace. She listens for when participants are expressing
being mode (experiential) over doing mode (fixing), as the emphasis in this
session is on how mindfulness is being integrated into daily life. The
relevance of practice is a strong theme here.

Assigning Home Practice

The home practice assignments for the coming week are:
 Sitting meditation practice alternating with the body scan or lying-
down yoga sequence for six out of seven days, listening to audio to
guide the practices.
Difficult communications calendar (Kabat-Zinn, 2013) for six days.
Circle of awareness, bringing attention to moments of reactivity,
recording the components of reaction, and intervening with
mindfulness where possible.
Additional handouts.
Home practice log.

The teacher closes the session with a brief breath practice, if there is
time, thanking the group for its participation and effort.

In Closing
Session 5 has a pragmatic theme to it. Having brought awareness to
moments of stress reactivity, the group is now learning to actively bring
mindfulness to periods of distress. The teacher is continuing to encourage
participants to approach and stay with challenging situations that are not
only being met in the formal practices but also now resonate in the world.
Participants are being trained to meet their internal experience with a
witnessing stance, one that is open and receptive. In this way, they can gain
insight and distance from immersive experiences. This develops a different
perspective from which to view themselves and their circumstances (de-
centering).
Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 5 Agenda (short form)—2.5 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. She brings additional materials that include the
attendance sheet, pens, paper, and handouts.
 Welcome to session (5 minutes)
Yoga (standing) (15 minutes)
Sitting meditation (35 minutes)
Inquiry (20 minutes)
Group discussion of stress response (30 minutes)
Group discussion of circle of awareness (15 minutes)
Home practice review (20 minutes)
Home practice assignment (10 minutes)

Session 5 Agenda (long form)—2.5 hours

Welcome (5 minutes). The teacher welcomes the group and allows
participants to settle.
Standing yoga practice (15 minutes). The teacher reminds participants
to take care of themselves as needed.
Sitting meditation practice (35 minutes). The teacher facilitates
awareness of the breath, body, sounds, thoughts, emotions, and
choiceless awareness (open monitoring; open awareness). Guidance
will include extended periods of silence and clear instructions. An
attitude of curiosity, kindness, and compassion is brought to this
practice.
Inquiry (20 minutes). An inquiry of the yoga and the sitting
meditation practices follows. The teacher elicits several responses
from the group, making sure that both practices are discussed. Open
awareness and shifting foci of attention are discussed during the
inquiry of the sitting practice. The emphasis is on normalizing the
challenges inherent in practice, and how they relate to stress in
general.
Stress response triangle (30 minutes). The teacher facilitates a group
discussion. This is a general conversation using the triangle from last
week to talk about bringing the practice of mindfulness to moments of
stress reactivity and how this can enhance adaptive coping.
Circle of awareness (15 minutes). The teacher facilitates a group
discussion utilizing examples from the participants.
Home practice review (20 minutes). This is a general discussion that
reviews how the participants have engaged in the home practice
assignments. Participants are still faced with the reality of finding
time to practice. The teacher continues to be supportive and realistic
about this but maintains an encouraging stance.
Home practice assignments and discussion (10 minutes). Over the
coming week, participants will engage in sitting meditation practice
alternating with either the body scan or yoga (lying down) for six out
of seven days; use the circle of awareness to bring awareness and
monitoring of stress reactions; bring the practice of mindfulness to
those moments along with skillful actions when possible; and fill out
the difficult communications calendar (Kabat-Zinn, 2013), for six
days. The teacher distributes the home practice log and any other
handouts.
 SESSION 6:

Stressful Communications

Session 6

THEME
Intra- and interpersonal mindfulness: bringing attention to our
thoughts, emotions, expectations, desires, words, and actions.

RATIONALE
Communication can be stressful, and mindfulness provides a useful
platform from which to bring awareness to how we interact with
others.

INTENTION
To increase awareness of and attention to how we communicate when
difficulties arise.
To increase intra- and interpersonal resilience.
To emphasize choice and possibility around how we respond in our
interactions.

PRACTICE SKILLS
Program Based: Delivery of yoga (lying down and standing) practice;
sitting meditation practice with attention to the breath, body, sounds,
thoughts, emotions, choiceless awareness (open and receptive awareness),
and back to the breath; mindful inquiry; home practice review, including
review of the difficult communications calendar; difficult communications
discussion and exercise; brief sitting meditation practice; discussion of the
all-day retreat; and assigning home practice for the coming week.

Teacher Based: Harnessing the skills of mindfulness practice (focused,

open, and receptive attention); increasing the ability to de-center from
personal narratives; increasing empathy for self and others that has been
developed throughout the program; generalizing the practice of mindfulness
to offer flexibility to interpersonal interactions; emphasizing mindful
communication during difficult moments; and bringing kindness and
compassion to self and others.

Teaching as Practice: Anchoring the Teacher

As in the previous weeks, the teacher needs to attend to the transition from
what they have been engaged in prior to preparing for this mindfulness-
based session. Allowing for some time to practice before teaching will
continue to be important. As always, it is helpful to review the previous
week’s session and the themes and practices for this session. This acts as a
reminder to locate the teacher in the arc and modularity of teaching sessions
5 and 6 and highlights the movement of this session between intrapersonal
and interpersonal mindfulness.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:
Yoga Practice: The teacher takes the participants through a yoga
practice consisting of both standing and lying-down yoga poses. The
teacher reminds participants to take responsibility for working within
their own safety parameters. Once again, he normalizes the movement
of attention, recognizing the opportunity to return to the breath and
the body as a way of stabilizing attention to the present moment.
Sitting Meditation: The teacher moves the group into a sitting
meditation, which focuses on attending to the breath, body, sounds,
thoughts, emotions, and choiceless awareness (open and receptive
awareness) and then returning to the breath to end the meditation.
Participants are directed to move the attentional focus to different
objects of concentration, with a kind and compassionate emphasis
that understands that attending in this way is not easy because it gives
rise to various mind states, such as restlessness, agitation, boredom,
and doubt in the practice. The teacher guides the group to allow for
these shifting states without needing to change them, but rather
accepting what arises and passes.
Inquiry: Inquiry follows both these practices. The teacher will be
attending to the participant experience, with a particular interest in
challenging moments as they are expressed and also in how the group
is relating to these. He will reinforce the group’s learning and insights
when relevant to the key teachings and practices of the program.
Home Practice Review: The teacher facilitates a discussion about the
previous week’s home assignments, the sitting meditation alternated
with the body scan practice or the yoga practice (standing or lying
down), how people used mindfulness during stressful moments (circle
of awareness), and the difficult communications calendar (Kabat-
Zinn, 2013).
Difficult Communications Activity: There are a number of ways to
discuss stressful communication, with emphasis placed on bringing
awareness to difficult interactions. The group explores the felt sense
(physical correlates of emotion) of what comes up during these
interactions using various role-plays that highlight different ways of
both communicating and behaving.
 Sitting Meditation: A brief sitting meditation follows because the
above exercise can be activating. The practice reminds the group of
the self-regulating function of mindfulness practice.
Home Practice Assignment: The teacher discusses the relevant home
practice assignments for the week.
Closing: Closing the session can be done in a variety of ways to mark
the end of the session, following which the session handouts are given
out.

What follows now is a comprehensive overview of session 6 that

includes logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room and make sure that he has
all the materials he needs for this session, such as the handouts for home
practice.

Opening the Session

The teacher welcomes everyone to the session and moves into facilitating
the mindfulness meditation practices of yoga and a sitting meditation.

Facilitating the Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.

Standing and Lying-Down Yoga Practice

By now participants are familiar with always starting a session with a
formal mindfulness-based practice. The teacher lets the participants know
that they will be beginning with a yoga practice. Visit
http://www.newharbinger.com/45601 to download a pictorial guide to
standing and lying-down yoga poses.

GUIDANCE
The teacher guides the standing and lying-down yoga practice,
reinforcing what has already been emphasized: self-care, nonjudgment,
awareness of transitions, attending to the body, and noticing the movement
of mind with an intentional return to the body in motion and breathing.

Sitting Meditation Practice

This formal sitting practice is similar to session 5; however, the teacher
has a choice about whether to end the practice at choiceless awareness
(open and receptive to all experience) or to bring the group back to a focus
on the breath.

GUIDANCE
The teacher guides the group through attention to posture and settling
into the practice. Between the guidance of distinct foci, he allows expanded
periods of silence to enable participants to work with their experience. His
focus is on encouraging participants to acknowledge and accept what is
arising in order to continue developing the stance of a participant/observer
(de-centering) of any and all sensations that are coming and going
(thoughts, emotions, body sensations, sounds). This is an application of
what the group has learned about working skillfully with challenging
experiences in the practice (safely enduring). This inevitably encompasses
attitudes of kindness and compassion. Participants are reminded to take care
of themselves should they become overwhelmed. Such reminders include
returning to the breath in the body, opening their eyes, or drinking some
water as a way to work skillfully with what is arising. If and when they are
ready, they are invited to return to the practice.

Inquiry
 Challenges and how they are worked with continue to be an ongoing
focus of inquiry in the second half of the program. This will mean from
time to time that a teacher moves into vertical inquiry when needed. His
focus in these moments entails helping a participant work through moments
of avoidance and challenge, and process (track) what is arising within the
remit of mindfulness. Inquiry will always convey the understanding that all
experience may be accepted and allowed to be present. This does not imply
resignation or passivity but rather a willingness to encounter, when
possible, with equanimity. An example of this follows.
Teacher: I’m wondering what came up in this sitting meditation
practice?
Participant 1: This was really hard for me today.
Teacher: In what way? What showed up?
Participant 1: I was really irritated, and I just wanted it to be over. I
even opened my eyes because I thought it was over, and then
I heard you say, “Letting go of thoughts and emotions and
now paying attention to everything.”
Teacher: When did you first notice the irritation? (Returning the
participant to the overwhelm of irritation.)
Participant 1: Right from the very beginning.
Teacher: Practice can be really demanding and difficult.
(Normalizing and bringing compassion to the participant
experience.)
Participant 1: Yes.
Teacher: How was the irritation experienced? (The teacher is staying
focused on unpacking the way the emotion manifested for the
participant.)
Participant 1: I was tense all over and agitated. I didn’t want to sit
here. I wanted to get up and walk around.
 Teacher: It’s not easy to sit with irritation. (Highlighting that this is
common.) But you stayed. How did you work with that?
(Encouraging being with and self- efficacy.)
Participant 1: I knew it would be over eventually, and I think I
remembered about the breath sometimes. I did come back to
your voice when I could.
Teacher: So much of our practice is finding ways to sit with
sometimes challenging moments and doing the best we can,
by staying as present as possible. (Reinforcing persistence, a
present moment focus, and kindness.)
As this dialogue illustrates, the nature of mindfulness entails that
challenges may arise at any moment, and the practice of inquiry requires a
teacher to meet the participant where they are, regardless of where the
teacher thinks they should be with respect to the session or program. It is
essential that he is able to let go of his agenda, staying with what is current.

Home Practice Review

The teacher reviews the previous week’s home practice, including the
sitting meditation alternated with the body scan practice or the yoga
practice (standing or lying down), how people used mindfulness during
stressful moments (circle of awareness), and the difficult communications
calendar. It is important for the discussion about the difficult
communications calendar that the teacher have participants read from their
calendars, ensuring that they present the difficulty briefly and answer the
questions as they appear.
After the discussion of the home practice, the teacher engages the
group in a conversation about the upcoming all-day retreat, answering
questions, reducing anxiety, and letting people know what to expect. This
will include an overview of the day, logistics, what practices they will
engage in, what to bring, and how they should prepare for it. Please see the
section “The All-Day Retreat” for more details.

Difficult Communications Styles Exercise

 Expanding the practice of mindfulness from our individual experience
to our interactions with others is an important progression for dealing with
stress, as other people are so much a part of our lives. What is important, in
this part of the session, is that the teacher convey how habitual our
communication can be and the effects of this on ourselves and others,
verbally and nonverbally, including gesture, posture, tone, volume, and so
on. The focus continues to be experiential, addressing the verbal, physical,
and emotional expressions that are common to challenging conversations.
The exercise that follows allows both parties involved in the dialogue to
bring attention to their reactions. This subsequently highlights the
possibility of kinder, more empathetic ways of responding to others when
challenges arise.
There are a number of ways one might explore difficult
communications. While it is important to attend to mindful listening and
speaking, what is actually essential is that attention is brought to the
embodied experience of the interactions themselves. Below is an overview
of one such exercise.
The teacher explains to the participants that the following exercise is
an experiential way to explore some of the typical communication styles (or
roles) in which we may engage during difficult conversations. He asks the
participants to pay attention to which of the four roles (stating, of course,
that there are others) they might recognize and identify with and those that
might be unfamiliar to them.
To start, the teacher chooses a volunteer, one who is approximately his
size and shape. (Nonverbal cues can affect the way participants perceive the
interaction.) The teacher will speak to the volunteer, explaining the
exercises and their role and how the volunteer needs to begin the
conversation. It can be helpful for the teacher with the aid of the volunteer
to select a specific problem or topic to hold in mind to bring this exercise to
life. He will ask the volunteer to say something along the lines of, “Hi, I’ve
been looking for you. I’d really like to talk to you.” (This is the opening
statement of each conversation.) In addition, the teacher will explain to the
volunteer how the scenario will unfold.

1. Conversation 1: The teacher will set this up (and all subsequent

conversations) by saying that this is someone who wants to have a
conversation with him and has an agenda. The volunteer walks
 (does not run) toward him and when they are in front of him but not
too close, the teacher engages in the following dialogue that conveys
taking too much responsibility: “I’m so sorry. I know I messed up.
It’s my entire fault. I’ll do better next time. I just need a little bit
more time. I’ve been so busy this week.”
The teacher then turns toward the group and asks them, “What
did you see and hear? What are you experiencing now?” The
group popcorns out various responses that highlight their
perceptions of the interaction. The teacher includes the volunteer
in this dialogue. Before moving on to the next
scenario/conversation, the teacher has everyone take a few
breaths, noticing body sensations, thoughts, and emotions. This
debriefing takes place after each of the following scenarios.
2. Conversation 2: The volunteer walks toward the teacher and the
teacher steps aside when they get close, saying the words that
articulate avoidance: “I don’t have time right now. I have another
meeting to go to. I need to take care of something else.” And then he
walks away.
3. Conversation 3: (Prior to this conversation the teacher informs his
volunteer that during demonstration, he will not be moving out of
the way.) As the volunteer approaches, and when they are facing
each other, the teacher says the following words or similar ones to
articulate holding his ground, pushing back, irritation, or frustration:
“I am tired of you always blaming me. I don’t feel as though I have
your support. Whenever we are together, you are not taking
responsibility for your part in our difficulties.”
4. Conversation 4: The teacher arranges two chairs that are facing the
group. When the volunteer is quite close, the teacher engages them
in the following example of what one might say to articulate
openness, engagement, and compromise: “Oh, hi. I have been
looking for you. And I know you have wanted to speak to me. Is this
a good time for us to talk? Great, let’s sit down.” He and the
volunteer sit down on the chairs facing the participants. The
conversation continues with the volunteer joining in. “I am
wondering how we can sort this out. Do you have some ideas?”
 After completing all four “conversations,” the teacher instructs the
participants to engage in these roles for themselves, in dyads. They stop
after each one to discuss what they are experiencing and perhaps which
style or role they identify with. Everyone has the opportunity to experience
being in the role of the person who “wants something” and the role of the
person who is being approached. Following this, the participants return to
the large group to have a general conversation about the exercise, including
in what circumstances any of these ways of communicating might be
useful.

Brief Sitting Practice

The teacher takes the group through a short sitting meditation practice
with a focus on the breath to help them regulate their energy following this
stimulating exercise.

Assigning Home Practice

The home practice assignments for the coming week are:

Alternating days of the sitting meditation practice with the body scan
and/or yoga (standing or lying down) for six out of seven days using
audio to facilitate the practice.
Bringing awareness to our relationships with other people,
organizations, and systems and how they impact us and we them,
asking ourselves whether it is possible to bring kindness and
compassion to both our differences and our similarities.
Bringing attention to our world “diet”—what we take in from the
world—reading, technology, news, food, and so on, and our
relationship to these.
Additional handouts.
Home practice log.

The teacher closes the session with a brief breath practice, if there is
time, thanking the group for its participation and effort.
In Closing
In this session, participants continue to work with the skills that have been
learned to this point, but here the focus is primarily on the interpersonal.
Examples of difficult communications and the personal styles or roles we
bring to them are introduced through an experiential exercise. The
importance of ongoing attitudes of curiosity, kindness, and compassion are
stressed. The teacher reviews what to expect in the all-day retreat as a way
to prepare for this extended period of practice and to manage any anxiety.
Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 6 Agenda (short form)—2.5 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. He brings additional materials that include the
attendance sheet, pens, paper, and handouts.
Welcome to session (5 minutes)
Yoga (standing/lying) (20 minutes)
Sitting meditation practice (35 minutes)
Inquiry (20 minutes)
Home practice review and discussion of all-day retreat (20 minutes)
Difficult communications styles exercise (30 minutes)
Brief sitting meditation practice (10 minutes)
Home practice assignments (10 minutes)

Session 6 Agenda (long form)—2.5 hours

Welcome (5 minutes). Teacher welcomes the group, allowing it to
settle.
Standing/lying-down yoga practice (20 minutes). The teacher leads a
yoga practice, reminding participants to take care of themselves as
needed.
Sitting meditation practice (35 minutes). The teacher facilitates a
sitting meditation, focusing on the breath, body, sounds, thoughts,
emotions, and choiceless awareness, and then back to the breath.
Guidance needs to have extended periods of silence between the
different foci and instructions to bring attention to the breath or open
the eyes if the participants are overwhelmed.
Inquiry (20 minutes). Inquiry of the yoga and sitting practices
follows. The emphasis remains on normalizing the challenges
inherent in practice and fostering how they are working with and
relating to what is arising.
Home practice review (20 minutes). This is a general discussion that
reviews how the participants have engaged in the home practice
assignments. The teacher facilitates a discussion of the all-day retreat.
Difficult communication styles exercise (30 minutes). This
experiential activity demonstrates various communication styles and
roles that people engage in when faced with potentially conflictual
interpersonal interactions.
Brief sitting meditation practice (10 minutes). A short breath practice
follows the difficult communication styles exercise to settle the
group.
Home practice assignments and discussion (10 minutes). Over the
coming week, participants will alternate sitting meditation practice
with the body scan and/or yoga (standing or lying down) for six out of
seven days; practice bringing awareness to their relationships—
interpersonal, organizations, and systems; and practice bringing
attention to the diet they consume from the world—technology, news,
food, books, etc. The teacher distributes the home practice log and
any other handouts.
 THE ALL-DAY RETREAT

The All-Day Retreat

THEME
A day or half-day of extended silent mindfulness practice.

RATIONALE
Reinforces and deepens mindfulness-based skills through the
practice of mindfulness over a prolonged period.

INTENTION
To deliver the mindfulness practices that participants have
experienced in the previous weeks.
To cultivate a moment-to-moment attention to all experiences
regardless of whether they are perceived as pleasant, unpleasant, or
neutral.

PRACTICE SKILLS
Program Based: The container of silence; delivery of yoga practices (lying
down and standing); body scan; sitting meditation practices; walking
meditation; mindful eating practice; mountain or lake meditation; loving-
kindness meditation; closing exercise; instructions for going home.
Teacher Based: Harnessing the skills of mindfulness practice—focused
and open and receptive attention; moving from stillness to movement and
vice versa; de-centering from personal narratives; increasing empathy for
self and others; and bringing kindness and compassion to self.

Teaching as Practice: Anchoring the Teacher

Typically, the all-day retreat is held between the sixth and seventh sessions
and lasts for about six or seven hours. The intention for this retreat shapes
how the teacher prepares for this full day of practice. If facilitating a full
day of practice is not possible due to logistical issues, then offering a half-
day (e.g., four hours) is an option.
It is always helpful to find some time for one’s own practice before
teaching, as this encourages a present-oriented mind-set where we are able
to tap into our own mindfulness process. Practice for the teacher acts as a
reset, a reminder that regardless of what she is encountering, attitudes of
interest, kindness, and compassion will be central. In addition, it is helpful
for the teacher to review an outline of the practices that she plans to deliver,
along with the allotted times. This plan should take into account whether
she is teaching on her own or with a co-teacher. If she is teaching solo, she
must make sure that she pays attention to the pacing of the sequence of the
practices so as to manage the time and her own energy level. If she is co-
teaching, she and her co-teacher need to plan who is responsible for which
practices. The participants are held in silence until the very end, when the
teacher will transition the group out of formal practice to a discussion of
how the day unfolded. The teacher will provide the group with instructions
about going home and how to navigate this.

Facilitating the Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:

Yoga practices (standing and lying down)

Body scan practice
 Sitting meditation practices
Walking meditation practices
Eating meditation (informal) at the break if a half-day, or over lunch
if a full day
Mountain or lake meditation
Loving-kindness meditation
Transitioning out of the silence

What follows now is an overview of the all-day retreat that includes

logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room and make sure that she has
all the materials she needs for this session.

Opening the Session

The teacher invites everyone to find a place in the room, selecting a chair or
a cushion to sit on. She then welcomes everyone to the all-day retreat. It is
customary for MBSR teachers to make this day of practice available to
participants from previous MBSR programs at no charge. If past
participants are present, the teacher will make note of that in her opening
remarks. She explains the structure for the day and reminds participants to
take care of themselves as needed. She will have covered this in session 6,
but it is helpful to review the form for the day, as it includes any
participants from previous groups and any current group members who may
have been absent from session 6. She takes care of any housekeeping issues
at this time, particularly if the retreat is being held in a location that is
unfamiliar to the participants. For example, she may discuss such logistics
as parking, where the bathrooms are, and that there will be no formal
breaks, except for a break if a half-day of practice, and lunch, if a full day.
Participants are encouraged to take their own bathroom breaks as needed.
She reminds participants that the day is held in silence until the very end,
when they will have an opportunity to talk about the experience with each
other.
She (and a co-teacher, if present) lets the group know that she will be
leading the practices, and as the day progresses, will stress the importance
of self-care. This includes participants taking responsibility for working
within their safety parameters when engaged in the yoga practices and
adapting any of the poses when needed. She continues, acknowledging that
as the day unfolds, it is likely they will meet pleasant moments, challenging
ones, and periods of time when they are distracted or daydreaming. She
speaks to the normalcy of this movement of attention and that recognizing
this is as much a part of the practice as is returning to the present moment.
But she also notes that participants may move outside of their window of
tolerance (capacity to manage difficult emotional states), becoming
dysregulated. She discusses with the group how they can meet these states
should they occur. This may involve a number of strategies, such as
opening the eyes if they are closed, returning to a focus on the sensations of
breathing or the body (e.g., feet or hands) if overwhelmed, getting up and
walking around, drinking a glass of water, getting a blanket, or approaching
the teacher.
The teacher will offer the invitation that members of the group avoid
eye contact with each other and explain that this helps reduce external
stimulation and fosters internal awareness. Communication comes in many
forms, and the avoidance of eye contact releases them from the nonverbal
cues that trigger habitual social responses and etiquette. This enhances their
focus on their own experience. Other forms of communication include
texting, reading, and writing, and in the service of continual practice the
teacher asks the group to refrain from these activities.
She states that it will be important that they remain for the duration of
the day, but that if they need to leave, they must let her know. If she is
teaching solo, she makes sure that participants understand that if they need
to speak to her during the day, she is available at the break or during the
lunch period. If she has a co-facilitator, then one of them will be available
when the other is teaching. In closing, she requests participants to switch off
their cell phones for the day, including during breaks—again to ensure their
focus remains on their practice and on their internal experience.
 As there are suggested meditation scripts for the sitting meditation
practices, the body scan, and mindful movement practices in the
appendices, and since we have discussed the facilitation of these practices
in previous sessions, we will not be describing them here. Instead, we will
offer some guidance for the mountain, lake, and loving-kindness
meditations, and instructions for going home. These meditations differ in
some important ways from the other practices participants have experienced
in the class thus far. The mountain and lake instructions use a visual image
or metaphor that is designed to encourage an innate sense of steadiness,
depth, stability, expansiveness, and calm. These practices also highlight that
we are continually in process and embedded in something greater than
ourselves. Loving-kindness meditation is an invitation, through the use of
specific phrases, to bring an intention of friendliness, warmth, and kindness
to oneself and others.

The Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.

The Mountain Meditation

The teacher will settle participants by inviting them to come into a
comfortable sitting position. She offers instructions that bring her
participants to notice their body sensations and the contact the body is
making with the floor, the chair, or the cushion. Her guidance includes
finding a position that best conveys a sense of ease. She might say the
following: “Finding a position that conveys a sense of being awake, alert,
and as comfortable as is possible for you. Taking the next few moments to
make any adjustments that are needed. The spine is gently lifted, arms and
legs relaxed, and the head supported on the neck with the shoulders
released. Taking these moments to sense into body sensations that are
arising from inside the body as well as from the surface of the skin.” She
pauses for a few moments, allowing participants to experience what is
arising for them.
 She then asks them to close their eyes or to soften the gaze, continuing,
“As we pay attention to body sensations, we can become more aware of our
breathing. So taking a moment now to notice where you best sense the body
breathing, to notice the physical sensations, sensing the breath, the
inhalation followed by the exhalation, followed by another inhalation. No
need to change the breath in any way. Just resting attention on the
movement and rhythm of breathing.” She will pause here for a few
moments, allowing participants to have time to bring their attention to these
instructions and to sense into the movement and flow of breathing.
She continues, “As we sit here, holding the body in stillness, breathing
gently, with a sense of being present, bringing to mind an image of a
mountain. This may be a mountain you know well or one that you have
seen a photo of. Taking a few moments now to bring this image to mind.”
The teacher will pause here, allowing the participants to visualize this.
Continuing with her instructional focus, the teacher says, “Noticing the
base of the mountain, its rootedness into the earth, the shape of the slopes,
whether there are trees growing on the slopes or whether there are stony
outcrops, its peak and whether the peak is covered in snow or bare. Perhaps
there is more than one peak. There may be streams and waterfalls cascading
down the mountain or high mountain lakes caught along the ridges. Taking
these moments to be with this mountain, noticing its size, its outline, its
solidity.” The teacher now pauses for at least a couple of minutes.
She continues, “As we sit here, becoming familiar with this mountain,
can we sense that we, too, have qualities similar to a mountain?… A sense
of stillness, calmness, and dignity… That we, too, are rooted to the
ground… And with each breath a sense of being alive, grounded,
complete.” The teacher allows for a few moments to pass.
She continues, “As we continue to sit here, like the mountain, we will
experience the passage of time. How the warmth of the day is followed by
the coolness of the night. How the light changes, the movement of life on
the mountain, the animals, the birds, the waterfalls, the plants, the melting
snow. And through all this movement and change, the mountain is itself.
The seasons come and go, the weather fluctuates, sometimes hour by hour,
day by day. There is rain, snow, sun, wind, clouds.” Again the teacher
pauses.
 She continues, “In the fall, the slopes of the mountain may be covered
with the brilliant colors of red, yellow, orange, and green. The animals and
birds will be preparing for the winter to come. Some will be leaving for
warmer climates. In the winter, the slopes of the mountain will be bare, and
may be covered in snow. The peaks of the mountain may be shrouded in
mist or low-lying clouds. In the spring, activity returns to the mountain,
with animals and birds building nests, the plants and trees growing, the sun
warming the slopes, and the snow retreating up them. In the summer, the
days are longer and the winds are calmer. The animals and birds are
enjoying the fruits of the summer. There may be people, families visiting
the mountain, climbing its slopes, enjoying the forests and the waterfalls.
Some will be happy to be on the mountain; others may experience the
mountain in different ways, depending on the weather: that it is too cold,
cloudy, or rainy. Others may wish to be elsewhere and not at the mountain.”
The teacher allows time for her participants to experience these images.
She continues, “No matter what the weather is doing, what people are
saying, the mountain stays consistent. Grounded in its connection to the
earth, experiencing storms, snow, sleet, the changing seasons, it remains.
Through it all, the mountain is unaffected by what is happening on its
surface, by how it is being perceived, spoken about. It is fundamentally
itself during all the changes and movement. As we practice, we can also
embody a sense of steadiness, a sense of stillness in the face of all that
changes in our lives. In understanding the movement of change, we know
there will be times of difficulty, loss, and anxiety but equally times of joy
and ease. We will experience storms, maybe for extended periods of time,
along with periods of darkness. And there will be moments of relief and
warmth. Throughout all of this, there is a sense of the mountain within,
safely enduring, grounded.” The teacher leaves some silence for her
participants to experience this.
She ends the practice by asking them to let the image of the mountain
recede into the background, and to bring the attention to the breath in the
body and to the sensation of the body sitting.

The Lake Meditation

This meditation is done in a lying-down posture (supine) and if that is
not possible, then in a sitting position. The teacher begins by asking
participants to choose a position that allows them to be as comfortable as is
possible. She invites them to pay attention to the sensations arising from the
contact points that the body is making with the floor or the chair and
sensing the length and breadth of the body from the head to the toes. She
allows some time for participants to settle in.
She then continues, “And now, bringing attention to the breath, to the
physical sensations of breathing wherever you best sense them. Noticing the
movement of breathing, the inhalation followed by the exhalation. No need
to change the breath in any way; rather, resting attention on each in-breath
and out-breath. Nothing for you to do here, just this sense of being present
to the movement of breathing.” The teacher pauses.
She continues, “As you continue to breathe, taking a moment now to
bring an image to mind of a lake. Perhaps this is one you have visited or a
photo you have seen. Taking time to be with this image, noticing whether
this body of water is small or large, surrounded by trees or mountains or in
a valley…seeing how the lake is cradled by the earth. Having a sense of this
lake, even if there isn’t a clear image or no image at all.” The teacher once
again pauses for a few moments.
Continuing, she can offer the following instructions or ones that are
similar: “Noticing the color of the lake, whether it seems deep or shallow.
And on the surface of the lake, the images of the trees, the mountains, the
rocks, the sky, the sunlight, the clouds reflected on it. And knowing that
with the arrival of breezes, the wind, these reflections will shift, change,
and disappear. As day turns to night, the surface of the lake reflects the
moon, along with other shadows. And in winter, the lake may freeze, and
yet underneath the crust of ice, there is movement and life.” Again, the
teacher pauses.
She continues, “As you continue to breathe, recognizing that like the
lake, being held by the earth, so too are you connected to the earth.
Breathing as if you and the lake are one. Calm, still, deep, and receptive,
allowing for the movement of each moment and equally understanding that
there will be periods of disturbance when the surface becomes choppy and
stirred up by events. But underneath these moments of reactivity, the lake
itself is not significantly affected by what is happening on the surface. It
remains essentially stable. And that you, too, like the lake, can be aware,
observing the movement of the mind and the heart, the interplay of thoughts
and emotions, the stories, the memories, the worries, watching them come
and go just like the ripples and waves on the surface of the water. And
noticing the relationship you have to these movements of mind and heart.
Acknowledging them, sensing their coming and going. No matter how
ruffled the surface of the lake is, the depth of the water receives the energy,
gently moving back and forth, until all is stillness again. Can we, like the
lake, absorb the movement of events…that in the depths of our being know
that we bring equanimity and understanding even when disturbed?” The
teacher allows for several moments of silence to pass.
She brings the practice to a close by saying words to this effect: “In a
moment, we will be bringing this practice to an end. Letting go of the image
of the lake and letting the breath be in the forefront of attention. Attending
now to the rhythm of breathing, each in-breath followed by an out-breath…
And now opening the eyes, taking in the surroundings of the room and
moving the body in whatever way seems helpful.”

Loving-Kindness Meditation
This meditation uses specific phrases and images, setting an intention
to bring a sense of friendliness and loving-kindness to oneself and others.
The teacher repeats the phrases as a reminder of the intention. Traditionally,
these phrases are initially directed to oneself, and then move to include a
benefactor (someone who is dear to you, who supported you in some way),
then to a neutral person (someone you don’t know), and then to a difficult
person (someone who has presented challenges for you). Finally, the
practice expands to include all sentient beings, including yourself and the
other people you brought to mind during the practice.
If a teacher decides to offer this practice, she needs to be familiar with
it and have worked with it in her own practice. She will also need to
consider the fact that how she leads this practice will depend upon the
group with which she is working. This meditation can elicit strong thoughts
and emotions, ones that include a sense of sentimentality or that the activity
is contrived, or it can give rise to the opposite of loving-kindness—a sense
of unworthiness, distress, and anger. For these reasons, it is essential that
the teacher work to create the emotional context for this practice prior to
engaging with the actual phrases, directing the participants’ attention to
cultivate a sense of friendliness and warmth in body, mind, and heart. What
follows is an adaptation in which the rationale for each stage of the loving-
kindness practice is made clear, and provisions are made for elements of the
exercise that participants might find difficult.
The teacher invites participants to find a comfortable sitting position,
one that offers a relaxed posture, but where the spine is erect, the shoulders
are relaxed, and the head is held comfortably. The hands are supported in
the lap. She then says, “And now allowing the eyes to close, or to soften the
gaze, settling into an awareness of the body and the breath. Sensing the
movement of breathing, and a sense of the body sitting here.” She pauses.
She continues, “In this practice, we’ll be cultivating loving-kindness or
a sense of friendliness. We all have this capacity…and now, inviting a sense
of warmth, of friendship, of kindness that wishes happiness for ourselves
and for others. If this does not appear easily, that is not a problem; it is
enough to cultivate this intention. As we continue, you will be hearing some
phrases, which I will offer as guidance. You can use these phrases or ones
of your own.
So, now bringing to mind someone who is dear to you, a benefactor,
someone who has cared about you or someone you admire, alive or passed
on. Allowing your heart to open to their goodness and kindness. Let them
come and sit beside you, sensing their presence, offering them these words:
“May you be happy
May you be free from harm
May you accept yourself just as you are
May you be as well as you are able to be
May your life be one of balance and ease.
“Repeating these phrases quietly to yourself for this dear person, as
you continue to sit here, breathing easily.
“May you be happy
May you be free from harm
May you accept yourself just as you are
May you be as well as you are able to be
 May your life be one of balance and ease.”
The teacher repeats the phrases two or three times, allowing for a
couple of minutes of silence between them, which allows participants to
practice in this way.
She continues, “So, now allowing the image of that person to fade and
bringing yourself to mind, conveying a sense of warmth, of kindness, of
love to yourself. If this feels difficult, then it can be helpful to bring to mind
yourself as a young child, letting this image or memory sit beside you.
Feeling tenderness toward this child…allowing those feelings of love to be
present now… If this still feels uncomfortable, perhaps there was a pet you
loved very much and who loved you unconditionally and so allowing those
feelings of love to be present… Equally, you can remember a time when
you were kind or generous, experienced some moments of laughter and
happiness…or bringing to mind a friend who appreciates you for who you
are… As you experience these feelings of warmth, kindness, and love,
notice how the body feels. Maybe you are aware of a smile appearing, a
sense of openness, and a sense of ease. Just resting easily in these feelings if
this is possible.” The teacher pauses here for a few moments.
She continues, “And, now offering the phrases to yourself:
“May I be happy
May I be free from harm
May I accept myself just as I am
May I be as well as I am able to be
May my life be one of balance and ease.
“Repeating these phrases quietly to yourself.”
The teacher will repeat the phrases once more after a few moments.
She continues, “And now, allowing this image of yourself to fade and
extending the phrases to include everyone here in the room…some you
know and others you don’t know. Repeating the loving-kindness phrases…
“May we all be happy
May we all be free from harm
 May we all accept ourselves just as we are
May we all be as well as we are able to be
May our lives be one of balance and ease.”
She repeats the phrases one more time out loud.
She continues, “And now allow this awareness to include yourself,
everyone here, family and friends, all human beings and animals living on
this earth. Recognizing that all beings wish for happiness, to be safe,
healthy, and have ease.
“May all beings be happy
May all beings be free from harm
May all beings be as healthy as they are able to be
May all beings have balance and ease.”
The teacher will then bring the practice to a close by inviting
participants to extend the words of loving-kindness to themselves, followed
by returning to the breath before opening the eyes or widening the gaze.

Transition Out of Silence

At the end of the sequence of practices for the all-day retreat, the teacher
transitions participants out of the period of prolonged silence and back into
the rhythms of everyday life—a move that can be difficult without proper
transitioning.
The transition out of silence can take many forms. It is helpful that this
be facilitated gradually. To this end, participants can move into dyads or sit
shoulder to shoulder (beside each other, facing in opposite directions). They
are instructed to select one person to speak first, and the other person is
directed to be the listener without commenting. The speaker begins by
whispering as they talk about their experience of the day. The teacher tells
the group that she will monitor the time and tell them when to switch
speakers (after 5 minutes). At the end of these 10 minutes, they are given
another 5 minutes to debrief the experience in their pairs. Following this,
they return to the large group to debrief further.
Instructions for Going Home
This is the final component of the day and it is essential to discuss how to
negotiate the transition from a long period of silence to the busyness of
everyday life. Participants need to understand that they are currently in an
unusual state, one in which they may be slowed down, making their
reactions not as automatic or as quick as they are normally. They may find
they are hypersensitive to the stimulation of everyday life (sounds, sights,
etc.). They might consider how quickly they will resume their interactions
with technology, driving, or others. The teacher suggests that the group try
to minimize stimulation as much as possible. For example, for that evening
they might want to forgo alcohol, watching television, checking social
media, or being with a lot of people. This is because after such a prolonged
period of silence and internal awareness, they can feel bombarded by
external forces that require interaction.
Another area to address is to whom and how participants will talk
about the experience. It can be important to be sensitive to the fact that
other people in their lives won’t have had the same experience that they
have had. It may be completely foreign to them, and they may not actually
be interested in hearing about the day. Furthermore, the meditative
experience is difficult to describe because it is experiential and embodied
rather than a cognitive process that lends itself easily to a narrative. While it
is natural to want to share something about an experience that was
meaningful, especially with people who have made it possible for the
participant to attend the day, they may have had an extremely trying time
working, looking after children, caretaking, and more, and they may have
little patience for hearing about the retreat.

In Closing
The all-day retreat holds a significant place in MBSR. It provides an
extended period of practice in silence, allowing participants to meet the full
range of their experience by engaging in a variety of meditation practices
over the day. The teacher is creating a setting that allows the group to turn
inward and be with whatever they encounter physically, psychologically,
and emotionally. The duration of practice assists in the development and
deepening of mindfulness and what this has to offer to ourselves and others.
The new meditations of the mountain, lake, and loving-kindness also help
extend the practice beyond the self. This sets the stage for session 7, in
which the group learns to apply mindfulness to their interactions with the
world.
A suggested agenda follows. Visit
http://www.newharbinger.com/45601 to download a copy of this agenda.

MBSR All-Day Agenda (short form)—7 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. She brings additional materials, including the
attendance sheet, pens, paper, and handouts.
9:00 a.m.: Welcome and brief overview of the day—guidelines,
housekeeping, and safety parameters
9:15 a.m.: Sitting meditation—awareness of breathing
9:30 a.m.: Mindful movement ending with a brief body scan
10:30 a.m.: Sitting meditation—breath, body, sounds, thoughts,
emotions, choiceless awareness, and back to the breath
11:10 a.m.: Walking meditation
11:40 a.m.: Mountain or lake meditation
12:10 p.m.: Instructions for silent lunch and mindful eating practice.
The teacher offers the following guidance: to maintain silence;
continue to avoid eye contact; engage with the senses of sight, touch,
hearing, smell, taste, and awareness of thinking but allowing the
primary focus to be on the process of eating. Participants will be
asked to monitor their state of hunger and when it is satiated. Lastly,
they are reminded not to engage in reading or writing or to be on their
cell phones. The emphasis is on the silent lunch as part of the practice.
Following the completion of the meal, people are invited to check in
to see what would be conducive to self-care, such as a rest or gentle
movement.
1:10 p.m.: Mindful movement
2:10 p.m.: Loving-kindness meditation
2:40 p.m.: Walking meditation
3:10 p.m.: Transition out of silence—first in dyads as a mindfulness
speaking and listening exercise, and then a debrief in the large group
3:40 p.m.: Instructions for going home—negotiating external
stimulation, communication, and safety
4:00 p.m.: Home
 SESSION 7:

Interacting with the World, Skillful

Choices, and Self-Care

Session 7

THEME
Expanding the practice of mindfulness to everyday life by
exploring choices that promote self-care, wellness, and healthier
patterns of behavior.

RATIONALE
Integrating mindfulness practice beyond the intrapersonal to
include the interpersonal environment enhances its utility.

INTENTION
To generalize the practice of mindfulness to a wider context.
To continue to focus on personal markers of stress, coping styles, and
what is adaptive and maladaptive.
To increase awareness of stressors that can and can’t be changed and
how to work with these using mindfulness.
To nurture self-care, flexibility, and resilience.
 PRACTICE SKILLS
Program Based: Different chair exercise; yoga practice (participant-led);
sitting meditation practice, focusing on the breath, body, choiceless
awareness, and back to the breath; mindful inquiry; review of the all-day
retreat; home practice review of the sitting meditation practice, mindful
yoga, and body scan; interpersonal interactions through the lens of
mindfulness; discussion about environmental stressors, their impact, and
our relationship to them; increasing self-care and skillful and mindful
responding; and assigning home practice.

Teacher Based: Reinforcing the mindfulness skills of open awareness,

acceptance, and skillful responding (including adaptive coping);
generalizing the practice and use of mindfulness to a wider context for self-
care and interactions with others and the world; and embodying
adaptability, receptivity, acceptance, equanimity, compassion, and letting
go.

Teaching as Practice: Anchoring the Teacher

As in the other sessions, the teacher prepares for teaching by taking a few
moments to practice, intentionally supporting a present moment focus
(moving from “doing” mode to “being” mode). Contemplating the previous
week’s themes and the home practice assignments will help him set the
context for this session, which is focused on integrating mindfulness into a
wider frame of reference. The theme of this session addresses how we
respond to the many choices and stressors of the modern world.
Additionally, the teacher will spend a few moments reviewing where the
group is in its learning trajectory, recognizing that it is moving toward the
end of the program (the group stage of adjournment). The participants may
be anxious about this, and the teacher’s understanding and acceptance of the
impermanent nature of experience will be helpful here.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:
Different Chair Exercise: The teacher invites the participants to move
from the chair they usually occupy to a different one. This different
chair exercise allows participants to reflect on how quickly habitual
attachment occurs and how change can offer a new perspective.
Yoga Practice: The participants then move into a yoga practice. The
participants lead the practice and choose a favorite yoga pose to
demonstrate. The teacher can assist as needed. The emphasis is on
experiencing these poses as available and easily accessible at any
time—a way to incorporate these movements into everyday life.
Sitting Meditation Practice: The teacher moves participants into a
sitting meditation practice, directing their attention to the breath,
body, and open or choiceless awareness (the entirety of experience),
and ending with a focus on the breath. The teacher places an emphasis
on resting in an open and receptive stance as he moves the group
through the various foci of this practice. To this end, there will be less
use of descriptors, more silence, and less overt instruction to enable
participants to investigate specific sensations that may come to their
attention. The intention is to enhance their self-guidance, and to allow
them to witness the coming and going of experience along with how
they are relating to what is arising.
Inquiry: Inquiry follows the practices. This includes a discussion
about the yoga practice that the participants led. A review of the
sitting meditation places particular emphasis on how they are working
with open monitoring and what is arising. The teacher reinforces as
needed the group’s insights into the benefits of this open awareness as
it relates to cultivating equanimity and the “catch and release” of
stressful mind and mood states.
All-Day Retreat Review: The teacher reviews the all-day retreat with
the group, eliciting what was learned and its relevance to ongoing
practice.
Home Practice Review: The teacher facilitates a discussion about the
previous week’s home practice—the sitting meditation practice; yoga
practice (standing or lying down); the body scan; and how people
brought attention to the relationships they have to the diet they take in
from the world, such as technology, oppression, poverty, the news,
food, organizations, etc.
 Group Discussion: A wide-ranging discussion follows that
incorporates what has been learned and moves to include the
environmental stressors experienced on a daily basis. Participants
explore the role of mindfulness in supporting both healthier patterns
of relating to these stressors and adaptive behaviors.
Home Practice Assignment: The home practice for this week includes
engaging in self-guided meditation practices of the participants’
choosing. Additionally, they will work with bringing awareness to the
body and breath intermittently throughout the day, including upon
waking and before falling asleep. They are also asked to pay attention
to the environment and their activities (focused on the senses).
Closing: Closing the session can be done in a variety of ways to mark
the end of the session, following which the session handouts are given
out. He reminds the group that the following session will be their last.

What follows now is a comprehensive overview of session 7 that

includes logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room, ensuring that he has all the
required materials, such as the handouts for home practice.

Opening the Session

The teacher welcomes everyone to the session and moves into facilitating
the different chair exercise.

The Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.

Different Chair Exercise

 The teacher welcomes the group and invites the participants to take a
different seat than the one they usually sit in. Once they have changed seats,
he asks what they are noticing from this experience. Participants often
report preference and attachment to what is familiar and some dis-ease with
this. In addition, they might express how change can bring a different or
new perspective. This highlights how automaticity and preference may
narrow our view, shutting us down to new possibilities. This has a direct
relationship to how we often experience stress and our reactions to it.

Standing and Lying-Down Yoga Practice

The teacher invites the participants to choose a familiar or favorite
yoga pose that they will lead. Visit http://www.newharbinger.com/45601 to
download a pictorial guide to standing and lying-down yoga poses.

GUIDANCE
There are a number of ways that each participant can lead this, and the
teacher offers some helpful suggestions. He states that some of the
participants might decide to take the group through a standing body scan.
Equally, others might decide to lead a favorite or familiar movement pose
that has been helpful to them. The teacher is ready to assist if necessary. He
reminds them of the importance of self-care and of paying attention to the
body and to the breath.

Sitting Meditation Practice

This formal sitting practice focuses on the breath, body, and choiceless
awareness (open awareness), and closes with attention to the breath. The
instruction is minimal, allowing for long periods of silence. This allows
participants to be self-directed, supporting their exploration of direct
experience. The teacher will remind them to bring kindness and compassion
to what is being experienced.

GUIDANCE
 The teacher initiates the practice attending to posture and then moves
into the instruction that starts with a focus on the breath, then to an
awareness of the body, followed by choiceless awareness and ending with
focus on the breath. During the practice, he leaves extended periods of
silence to enable participants to have their own experiences without
interruption from his guidance. By engaging in longer periods of silence,
participants are increasingly working with self-guided practice.

Inquiry
Inquiry follows the practices. The teacher attends to participants’
experiences, with a particular interest in how they are relating to what arises
in the practices, and how they acknowledge and describe what is present.
The teacher will encourage descriptions that point to the sequential arc of
experiences (tracking), and how they meet challenging moments when they
appear. He will also listen for those moments when participants express
ease, insights, and equanimity resulting from practice. An important aspect
of the inquiry process is when the discussion reveals the key teaching points
of the session. These are elicited from the conversation itself, and not by the
teacher teaching them. As the eight-week program draws toward its
conclusion, the teacher will be particularly attentive to moments when
individual or group sharing reinforces the learning, and how the practice of
mindfulness is germane to working with stress.

Discussion of All-Day Retreat

It is helpful to have a review of the all-day retreat, as this gives the
participants another opportunity (in addition to when they did this at the end
of the retreat) to talk about their experience—the challenges, moments of
ease, insights, and general reflections from the day of extended silent
practice. The teacher engages participants in talking about the relevance of
the retreat day to their practice. He will also question how the transition and
reentry to home went. Having this discussion about the retreat experience is
useful not only for those who were able to attend, but also for those who
could not make the day. For these participants, hearing how the day went
enables them to be a part of the experience.
 Home Practice Review
The teacher facilitates a discussion about the previous week’s home
assignments: the sitting meditation alternated with the body scan practice or
the yoga practice (standing or lying down), and how people brought
awareness to what they take in from the world around them, such as their
relationship to technology, the news, music, food, and so on. He reinforces
the use of both formal and informal practice and the implication that
mindfulness is a way of being that can be applied to any situation.

Interacting with the World, Skillful Choices,

and Self-Care
The teacher facilitates a discussion on our interactions with the world
and their personal impact. This is an important exercise, as it extends the
relevance and application of mindfulness practice to a wider context.
He begins by asking participants to popcorn out a general list of
environmental and societal stressors that will cover a wide range of topics,
including technology, politics, climate change, racism, pollution, traffic,
finances, workload, family, housing, and more. As this was a part of the
previous week’s home assignments, participants already have a good sense
of these stressors. Participants are then invited to contemplate the ones that
they feel particularly affected by, and to pick one on which they would like
to focus. Frequently, technology is chosen by the group, given its
ubiquitous nature. Sometimes it can be helpful for the group’s learning if
everyone uses the same category of stressor, but this will be dependent upon
the constellation of the group and its needs.
The participants then move into small groups or dyads and discuss
how they are relating to this stressor and how they might bring mindfulness
skills to its management over the next week. This provides an opportunity
for participants to bring a variety of mindfulness practices and other
strategies to the targeted stressor. These may include a shift in attitude
toward it and an intentional behavioral change. Participants commit to a
concrete way of working with this stressor throughout the week as part of
home practice.
 Assigning Home Practice
The home practice assignments for the coming week are:

Participants choose a specific self-guided practice that can be a sitting

meditation practice, yoga, walking meditation, and/or body scan. The
teacher asks the group to stay with their chosen practice for the week.
This promotes autonomy for personal practice and the experience of
not being guided. For some, this will be a relief, while for others self-
guided practice can be quite difficult. Participants will have the option
of alternating their home practice with and without the audio
recordings, as a way to build toward self-led practice. The teacher
may suggest the use of a timer or digital bells as a way to mark the
end of practice.
Informal practice will include bringing awareness to the body and
breath for a few minutes upon waking and before sleeping, and
attending to the breath, environment, and activities (focused on the
senses) intermittently throughout the day as a way to extend
mindfulness into daily life.
Participants will work mindfully with the identified stressor from the
session and attend to its impact and how to manage it skillfully.
Additional handouts.
Home practice log.

The teacher closes the session with a brief breath practice, if there is
time, thanking the group for its participation and effort.

In Closing
This session widens the lens of mindfulness to include environmental and
societal stressors. As participants are nearing the end of the program, how
they incorporate mindfulness into their everyday lives and interactions will
be significant for their continuing practice and its ongoing relevance.
Mindfulness is an experiential practice (way of being) that has utility for
managing life stressors. This is emphasized by the exercise in which they
select specific stressors with which to work during the week using
mindfulness practices and behavioral strategies. The teacher supports the
group’s autonomy and competency through the invitation to engage in self-
guided practices of their choosing during the week. This session stresses the
relevance of practice to all aspects of life.
Two agendas follow. The first is brief and includes suggested times.
The second contains a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 7 Agenda (short form)—2.5 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. He brings additional materials that include the
attendance sheet, pens, paper, and handouts.
Welcome to session and different chair exercise (5 minutes)
Yoga (20 minutes)
Sitting meditation practice (35 minutes)
Inquiry (20 minutes)
Review of all-day retreat (10 minutes)
Home practice review (20 minutes)
Interacting with the world, skillful choices, exercise, and self-care (30
minutes)
Home practice assignments (10 minutes)

Session 7 Agenda (long form)—2.5 hours

Welcome and different chair exercise (5 minutes). The teacher
welcomes the group and leads them through the different chair
exercise to highlight attachment to the familiar and the reactions and
possibilities that a different perspective may bring.
Participant-led yoga (20 minutes). The participants facilitate a yoga
practice to enhance their autonomy and sense of competence. This
also increases the portability and accessibility of everyday movement.
Sitting meditation practice (35 minutes). The teacher facilitates a
sitting meditation practice with focus on the breath, body, choiceless
awareness, and back to the breath. Guidance uses extended periods of
silence.
Inquiry (20 minutes). Inquiry of the yoga and sitting practices
follows. The emphasis remains on normalizing the challenges
inherent in practice and fostering how participants are working with
and relating to what is arising.
Discussion of the all-day retreat (10 minutes). The teacher facilitates a
discussion of the retreat.
Home practice review (20 minutes). This is a general discussion that
reviews how the participants have engaged in the home practice
assignments. This includes alternating sitting meditation practice with
the body scan and/or yoga (standing or lying down) for six out of
seven days; bringing awareness to our relationships—interpersonal,
organizations, and systems; monitoring the diet we consume from the
world—technology, news, books, etc.; and any other handouts and
home practice log.
Interacting with the world, skillful choices, and self-care exercise (30
minutes). The teacher leads a discussion of environmental and
societal stressors and their impact on the participants. He elicits a list
of potential stressors and asks the participants to silently consider
some that are personally relevant. They discuss, in dyads, how they
might work with a stressor of their choosing for the coming week
using the practice of mindfulness and behavioral strategies. The group
then debriefs the exercise, discussing how each person will work with
their chosen stressor.
Home practice assignment (10 minutes). Over the coming week,
participants will alternate sitting meditation practice, yoga, walking
meditation, and/or the body scan without guidance for six out of
seven days; do informal practice of noticing the breath and body
throughout the day; bring awareness to the senses during activities
and when interacting with the environment; and work with a
personally relevant world stressor. The teacher distributes the home
practice log and any other handouts.
 SESSION 8:

Keeping the Practice Alive

Session 8

THEME
Endings and beginnings—managing the transition from the end of
the program to the integration of mindfulness and its relevance to
daily life.

RATIONALE
Endings can present challenges. Therefore, the teacher highlights
this process through the lens of mindfulness, presence,
impermanence, and letting go and reinforces the relevance of the
learning over the past eight weeks.

INTENTION
To process the adjournment of the program.
To review the learning over the course of the program.
To mark the ending with a celebration and/or ritual.
To allow participants to express what they learned and what they will
be taking away with them (concepts, attitudes, skills, and practices).
To reinforce the awareness of stressors, stress reactions, and self-care.
 PRACTICE SKILLS
Program Based: Body scan, yoga practice, sitting meditation, inquiry,
home practice review, discussion of what has been learned and takeaways,
choosing one formal and informal practice for the next few weeks, and
closing ceremony/ritual.

Teacher Based: Providing a context for appreciation of what has been

learned through individual and group review; managing endings and
supporting letting go; promoting participant autonomy and self-efficacy;
and embodying flexibility, acceptance, equanimity, compassion, and letting
go.

Teaching as Practice: Anchoring the Teacher

We all can have different relationships to endings. The teacher prepares
herself for the class with a brief sitting and reflects on the trajectory of the
group and her teaching over the past eight weeks. This will help her work
with participants’ expectations around and reactions to endings.
Contemplating and discussing the theme of keeping the practice alive helps
mark this transitional session in which participants must let go of the group
and the teacher. The participants will have a variety of thoughts and
emotions about this. The teacher’s awareness, acceptance, and management
of this process of termination are essential.

The Mindfulness-Based Practices

The teacher takes the participants through a variety of practices that include
the following:

Body Scan: The teacher invites the participants to move into a body
scan practice.
Yoga Practice: This is followed by a yoga practice guided by the
teacher or self-guided by the participants.
 Sitting Meditation Practice: The teacher then guides the group in a
sitting meditation practice (breath, body, open awareness, and back to
the breath) with very little guidance, to help participants increase their
familiarity with self-guidance.
Inquiry: Inquiry follows the three practices. She reminds the group
that the program began and ends with the body scan. She encourages
participants to reflect on their relationship to this practice and what
they have learned having engaged with it. The teacher also listens for
the group’s responses to the predominantly self-guided yoga (if that is
what she has provided) and the sitting meditation practice.
Program Review: There are many ways to review the participants’
initial expectations when they first began the program. The discussion
includes the joys, surprises, and challenges that arose during the eight
weeks. The teacher provides some time for participants to identify
what they will be taking with them to help them continue managing
stress.
Home Practice Review: The teacher facilitates a discussion about the
previous week’s home practice—what meditation practice they chose
—a self-guided meditation practice, self-guided yoga practice, or the
body scan; and the exercise on managing stressors from the world
(technology and other) and how people brought mindfulness practice
to these.
Home Practice Assignment: The home practice assignment will focus
on the coming weeks and will address what formal and informal
practices participants will use.
Closing Ceremony: This is an important ritual that marks the end of
the program, facilitating the participants’ process of letting go.

What follows now is a comprehensive overview of session 8 that

includes logistics, the protocol/curriculum, practices, and teaching skills.

Teacher Preparation
The teacher will check on the setup of the room, ensuring that she has all
the required materials (e.g., anything needed for the closing—yarn, a rock,
or other token for participants to take as a reminder of the program).
Opening the Session
The teacher welcomes everyone to the session and moves into facilitating
the body scan.

The Mindfulness-Based Practices

As a reminder, we have provided scripts for many of the meditation
practices in the appendices.

Body Scan
The teacher welcomes the group to this last session and invites the
participants to prepare for the body scan practice either by lying down on
yoga mats or sitting.

GUIDANCE
The teacher reminds participants that they are ending the program as
they began, with the body scan. She guides this meditation practice by
leaving longer periods of silence than previously to allow participants to
encounter and explore their own experience.

Yoga Practice
The teacher invites participants to guide themselves through a
sequence of yoga poses if they feel comfortable doing so. This enhances
and promotes self-efficacy. Alternatively, she may choose to guide them,
ensuring that she leaves longer pauses between instructions to reinforce
participants’ direct experience unmediated by her voice. Visit
http://www.newhar binger.com/45601 to download a pictorial guide to yoga
poses.

GUIDANCE
 Whether the teacher chooses to lead the participants in a yoga practice
or instructs them to self-lead will be dependent upon what she thinks will be
most useful for a particular group. If she chooses to let the group lead
themselves, she will remind them to maintain awareness of the other
members of the group for the purpose of self-care and appropriate
boundaries. Should she choose to lead the group, she will use minimal
guidance throughout the practice and longer periods between instructions,
allowing participants to facilitate their personal practice.

Sitting Meditation Practice

This meditation practice of focus on the breath, body, choiceless
awareness, and back to the breath enhances the facility to be open and
receptive to all experience. It continues the practice of being aware of our
relationship to what arises and how we respond in each moment, using
various anchors of attention.

Inquiry
Inquiry follows these three practices. With respect to the body scan,
the teacher is attentive to how the participants’ relationship to, and
experience of, the practice has changed over the program, if it has. This
continues conveying the message that how we meet experience initially or
repeatedly can be different through the application of mindful awareness.
This is important for cultivating an open view and flexibility to the
changing nature of sensations in the body scan. The teacher listens to the
responses from participants about the self-guidance from the yoga practice,
or the prolonged periods of silence, if she led it. It is common for
challenges to appear when we are guiding ourselves. She normalizes these,
should they be expressed, positively reinforcing participants’ efforts. With
respect to the sitting practice, choiceless awareness can also be a time when
difficulties, the pull of attention, or a sense of overwhelm occurs. The
teacher supports the continuation of practice in the face of these challenges,
by stressing that these are to be expected and explored, as part of this
ongoing journey of discovery.
 Guided Reflection and Discussion of the
Program
The teacher asks participants to move into dyads and then silently
contemplate the following questions as a way to review the expectations
and goals they had coming into the program and what they learned. Some
suggested questions to ask are:

Thinking back to when you first came to the program, why did you
originally sign up for the class?
Why did you stay?
What will you take away with you from this experience and how will
you support your mindfulness practice?
What are some of the joys, surprises, and challenges that arose during
the eight weeks?

The group is asked to record their reflections and then discuss these
with their partner. Following this exercise, the large group reviews what
was discussed. It can be helpful for the teacher to write on a whiteboard or
flip chart what participants plan to take away to help them continue to
practice, and which practices (formal and informal) they are going to
choose to work with over the next month. Using the whiteboard or flip chart
can be a useful learning cue, as it collects the group responses and
highlights a range of options for individual learning.
It is also helpful to discuss short (one month), medium (three months),
and long-term goals (the next year). This helps operationalize continued
practice. Another way of formalizing this is to ask participants to write a
letter to themselves about their experience of the program, what they have
learned, what they are going to take away, and which practices they are
going to use in the future.

Home Practice Review

The teacher facilitates a discussion about the previous week’s home
assignments. The emphasis is upon what they chose to practice with, and
whether they guided themselves or used the recordings. What came up is
explored. Self-guidance can be challenging and frequently raises a number
of questions for ongoing practice. The group also reviews the external
world stressor (e.g., technology) they chose to work with during the week.
The teacher elicits the specific mindfulness practice, behavior, or attitude
they identified and used. This reinforces the applicability and integration of
mindfulness into everyday life.

Assigning Home Practice

The home practice assignments are:

Participants identify a specific formal and informal practice they will

focus on over the coming weeks.
They are asked to bring awareness to the breath several times during
the day. This is a reconnection and a reminder to be present to the
unfolding nature of experience.
They are given handouts, a bibliography, and resources.

Closing Ceremony
The closing ceremony, or ritual, is a boundary-marking event signaling
the end of the program and the psychological transition that follows. There
are a number of ways to facilitate this. Endings may be very emotional for
some participants, and the teacher needs to be aware of this. The teacher
asks the group to form a circle where they are sitting close to each other.
Depending upon the form of the closing, she leads them through a process
where they briefly identify what has been meaningful about this program or
what they are experiencing in the moment.
One such example of a closing ceremony is for the teacher to take a
ball of yarn, holding on to one end. She then explains to the participants
that when someone is ready, to raise their hand, and she will throw the ball
to them or roll it along the floor toward them, while maintaining her hold on
the yarn. The person is asked to say three words that describe their
experience of the MBSR program. They are also given the choice not to say
anything if they would rather not speak. They too maintain a hold on part of
the yarn, passing the ball to another participant when they raise their hand.
In this way, each person comments on the experience until everyone has
had an opportunity to speak or to hold the ball in silence for a few seconds
before handing it on. The teacher speaks last and often provides words of
encouragement. The teacher then asks the group to stand and raise the
interconnecting threads of yarn, symbolizing interdependence and support.
They then cut the threads, symbolizing that everything ends while keeping a
piece of the yarn as a memento, either tying it on their wrist as a bracelet or
using it as a bookmark, luggage tag, or something else.
Other examples include the teacher handing out flowers, pebbles, or
colored stones with a word relating to mindfulness inscribed upon each.
People may also bring in their own meaningful objects that reflect the
importance of the program to them. Whatever the object participants bring
in, by making this a formal process, the teacher contains the emotional
content for the participants and reduces the likelihood of them engaging in a
long narrative.
It is not uncommon for participants to express the wish to continue
practicing with the teacher and with the same group. This is a desire to
continue with what has become familiar and important and speaks to the
difficulty of letting go. The teacher understands this is normative and
temporal and will have made a decision about what is possible to offer, if
anything. These efforts at continuation are usually short-lived unless they
are formalized in a specific way.
One approach to continuing practice with the teacher is through the use
of booster groups of weekly hour-and-a-half sessions that last four to six
weeks. This requires preregistration and can be successful particularly if
offered a couple of times per year. The success will be dependent upon the
volume of participants and number of programs taught over the year. What
can be less successful are drop-in groups that do not require preregistration
because the impetus to continue fades over time.

In Closing
This session marks the end of the eight-week program and ends as it began,
with a body scan practice. Discussions address reviewing what has been
learned, the selection of ongoing practices, and a closing ceremony or
ritual. It is essential for participants to have the opportunity to share what
the program has meant to them, what they have learned, and what they are
feeling about ending. For many participants, being a part of this group has
been a transformative experience. This is often expressed as a wish to
continue. The teacher will have decided how she will manage this. In
addition, the teacher identifies local resources that are available, such as
sitting groups and yoga classes, and includes supplementary information,
such as books, apps, or websites.
Two suggested agendas follow. The first is brief with suggested times
allocated. The second includes a summary of the session. Visit
http://www.newharbinger.com/45601 to download a copy of these agendas.

Session 8 Agenda (short form)—2.5 hours

Prior to the session, the teacher sets up the room with chairs, cushions (if
using), and yoga mats. She brings additional materials, including the
attendance sheet, pens, paper, handouts, and whatever she will use for the
closing ceremony.
Welcome (5 minutes)
Body scan (30 minutes)
Yoga practice (20 minutes)
Sitting meditation practice (15 minutes)
Inquiry (15 minutes)
Guided reflection and discussion of the program (20 minutes)
Home practice review (15 minutes)
Home practice assignments (5 minutes)
Closing Ceremony (25 minutes)

Session 8 Agenda (long form)—2.5 hours

Welcome (5 minutes). The teacher welcomes the group.
Body scan (30 minutes). The teacher leads participants through the
body scan.
Yoga practice (20 minutes). The teacher either leads the yoga practice
or invites participants to facilitate their own practice to continue
enhancing their autonomy and sense of competence.
Sitting meditation practice (15 minutes). The teacher facilitates a
sitting meditation practice with focus on the breath, body, choiceless
awareness, and back to the breath. Guidance uses extended periods of
silence.
Inquiry (15 minutes). An inquiry of the body scan, yoga practice, and
sitting meditation follows. The emphasis is on what is coming up for
participants when there are long pauses, or when they are guiding
themselves without external instruction.
Guided reflection and discussion of the program (20 minutes). The
teacher leads the group to reflect, record, and discuss what they have
learned, what has been meaningful, and what they will take away to
assist them in continuing their mindfulness practice.
Home practice review (15 minutes). A discussion ensues of practice
with or without audio recordings and how participants worked with
an external world stressor using mindfulness.
Home practice assignment (5 minutes). Participants choose a formal
and an informal practice for the next few weeks. They are invited to
attend to the present moment multiple times throughout the day using
the breath and/or body as an anchor. Handouts and resources are
provided.
Closing ceremony (25 minutes). The teacher leads the group through
a closing ceremony to formalize the end of the program.
 PART 3:

Beyond Curriculum/Protocol into the

Heart of Teaching

A major theme for this book is the necessity of having a

curriculum/protocol from which to teach, and that teaching a mindfulness-
based program requires that a teacher embody the practice of mindfulness.
In part 2, we described the curriculum/protocol of the MBSR program in
detail. In part 3, we will discuss what it is to embody mindfulness and its
interactive expression, inquiry. The curriculum/protocol provides a useful
(and essential) guide to teach MBSR, but to rely solely on this would be to
leave out a vital and dynamic ingredient: that of transmitting the richness of
the practice of mindfulness, its philosophy (the study of reality as
experienced, the nature of existence, and ethical attitudes), and psychology
(the study of mental factors, emotions, and behavior). Embodying
mindfulness is challenging because it asks that an MBSR teacher
authentically impart what he has come to understand from practicing
mindfulness. This predominantly experiential knowledge base must then be
translated and transmitted to others. It takes time to develop both the
language and the cognitive understanding to do so. This is in contrast to
teaching a curriculum/protocol that is learned in a conceptual manner.
 CHAPTER 4:

Presence, Form, and Process:

Embodiment

In this chapter and the next, we move beyond the MBSR

curriculum/protocol into an in-depth discussion of embodiment and inquiry,
of which presence, form, and process are dynamic aspects. A separation of
embodiment and inquiry into two distinct categories is a contrivance to
facilitate the discussion of these key components of teaching. We need to
remember that embodiment is integral to inquiry and vice versa. Teaching
MBSR requires an understanding and appreciation for the structure of and
modular approach to the program while relying on a teacher’s embodied
mindful presence to communicate the various practices and exercises.
While one could simply teach the content of the MBSR program,
facilitating mindfulness calls for the teacher to personify embodiment and
inquiry as a mindfulness practice.
Presence, form, and process are concepts we will use to assist the
discussion regarding the nature of embodiment and the inquiry process.
Presence is expressed as a dynamic and fluid attitude, demeanor, and
behavior that involves a quality of focused attending, active listening, and
the manifestation of mindfulness. Form consists of the structural elements
of the program, which contain the curriculum/protocol, guidance of the
formal meditation practices, various exercises, and method of inquiry.
While important, because of its organizing functions, form can become
restrictive when it overrides the teacher’s ability to maintain a present
moment focus and cognitive flexibility, and to stay in process during
guidance and inquiry. Process, then, is the unfolding movement of the
teacher’s and participants’ practice, fluid and contingent upon the context,
what is arising in the group, and the content of the sessions.
 Embodiment consists of a teacher’s embracing of a present moment
orientation that includes the ability to engage in and teach a continuous and
steady attention to various meditative foci (objects of interest, such as the
breath), open monitoring, and the discernment of skillful responding. These
are expressed through the attitudinal foundations of mindfulness. Inquiry,
which we discuss in chapter 5, is the interactive manifestation of
embodiment, the conversation that takes place between the teacher and the
group, about what has arisen during the mindfulness practices and
exercises.

Aspects of Mindful Embodiment

How a teacher develops mindful embodiment, a tangible quality of being
and a specific stance for teaching MBSR, is developmental and complex.
Because this is a process that takes time and may be expressed and
experienced in various ways by different teachers, a discussion of
embodiment requires reflection and sensitivity to its diverse manifestations.
However, the expression of embodiment is visible, both nonverbally
and verbally, through a teacher’s demeanor, behavior, body language,
spoken word, tone, and pacing. The culmination of these qualities we refer
to as the teacher’s presence. By embodying key aspects and attitudes of
mindfulness, a teacher is demonstrating and transmitting its core
characteristics and concepts. This has significance for participants’
experiential learning of the practice. The presence of a teacher and his
representation of mindfulness matter because they convey an ethical way of
being and behaving through a kind, curious, and compassionate stance.

Present Moment Orientation

A first step toward embodied mindful presence requires the
recognition of and intentionally attending to the present moment. While this
is an intention that we hold, we recognize that, in practice, this is not
continually sustainable. Inevitably, our attention will get pulled in a variety
of directions (into planning what comes next in the agenda or our own
reactions to what a participant has just said). However, over time, the ability
to attend in this way becomes increasingly available, leading to the facility
to spend more time in the present and less habitual time in the past or
future, engaged in repetitive thinking (Farb, Anderson, & Segal, 2012).
To this end, the teacher needs to learn to pay attention to his own
experience, as it is revealed, and at the same time stay attuned to how the
participants are expressing their experience. Attending to his own
experience allows him to recognize and understand how his own state and
reactions may interfere with his ability to be in the present, embody
mindfulness, and stay with what is happening in the group. Embracing this
inner awareness helps the novice teacher decrease the tendency for his
agenda to get in the way of the participants’ experience.
Developing this intra- and interpersonal wakefulness to the present
moment—again, embodying mindfulness—is a skill requiring practice.
Indeed, embodying mindfulness requires the teacher to understand the role
of cognitive appraisal, meta-cognition (awareness of awareness), and the
characteristics of steady attention, open monitoring, and discernment
(Woods, Rockman, & Collins, 2019).
Cognitive appraisal is a normal function of the mind to perceive,
interpret, and personalize a situation. Meta-cognition (knowing that you are
thinking) is part of various traditional forms of meditation. In mindfulness-
based programs, this process is intentionally developed as a skill and made
explicit. Meta-cognition is essential because it supports the ability to de-
center (gain perspective and loosen from a fixed sense of self), providing a
different relationship to and understanding of stress. This is an important
learning because it allows for flexibility and adaptability in meeting the
vicissitudes of life.

Steady Attention
Part of a teacher’s embodiment is cultivating a steady attention on an
intended object (e.g., the breath) that is a key factor of mindfulness practice.
A teacher will be aware of other aspects of experience, but they will be in
the background. Nurturing a steady, unwavering attention involves the
teacher’s awareness of his own experience, while at the same time actively
listening to participants’ questions, reflections, and insights, and their
integration of mindfulness practice into everyday life. When the teacher is
in the flow of this “intersubjective space,” he is deeply curious and able to
drop a personal agenda even though he is still holding the themes of the
session in the background, so that they are accessible when needed. He is
aware of how difficult it can be for people to slow down and stay present, to
learn to describe their direct experience, rather than habitually and
immediately move into an interpretation or narration (story) of it.
This steady attention is then translated into being able to track the
movement of sensations (thoughts, emotions, body sensations, sounds),
encouraging the process of de-centering from self. De-centering entails the
development of a sense of self as process rather than something fixed that is
in need of protection. This promotes a sense of self that is flexible, reducing
defensive reactions or being controlled by such mental activity as
comparative thinking, judgment, competition, thoughts of incompetence,
worry, caretaking, wanting an outcome, perfectionism, or needing certainty.
A teacher who embodies such flexibility and openness provides important
learning for participants by modeling a more adaptive approach to
managing stress.
Of course, we do need a view of self in order to function in the world,
but what we are addressing is how tightly we adhere to it. A fixed sense of
self results in a more limited view and choice in terms of how we respond
to the present moment. Such an attachment to self as an entity also limits a
teacher’s ability to embody mindfulness. This will also have the tendency to
pitch us into more traditional methods of teaching in which we are the
experts and the students are passive recipients of our wisdom.
What follows is an example of a teacher working with steady attention
to highlight the habitual nature of automatic pilot. The following dialogue is
taken from session 1 after participants have been guided through the raisin
exercise.
Teacher: We have just had the experience of being with this object—
the raisin—and I am wondering what showed up?
Participant 1: Apart from this being a weird experience, it made me
realize that I wouldn’t take this amount of time to be with a
raisin!
Participant 2: I don’t think I have ever smelled a raisin before!
(Laughter from the group members with the teacher smiling.)
 Participant 3: Listening to a raisin was kind of strange!
Participant 4: By bringing my attention to looking at the raisin, I
realized that it is easy to think you know something like a
raisin that is pretty familiar, but it was as if I had never seen
the raisin like this before.
Teacher: What did you notice?
Participant 4: Well, there was something about being given time to
look that allowed me to see the raisin in a different way—I
could see the ridges, the color; it was shiny and round. And I
was really concentrating on the raisin in those moments.
Participant 5: It was as though there was no rush. I was aware of
thinking things about the raisin, but your guidance was a
reminder that when we noticed we were thinking, that was
okay, and we could let go and bring our attention back to the
qualities of the raisin. Thinking sort of went into the
background.
Teacher: It’s interesting to notice that here when we took some time
to be present in this way, slowing things down, deliberately
paying attention in this way, we had the opportunity to see
things differently. How might this be relevant to reducing
stress?
Here the teacher is summarizing briefly what has been expressed by
the participants (a present moment attentional focus) and is also asking an
important question, which is what might be the relevance of this exercise
(the first in session 1) to reducing stress. By picking up on the themes of
attending to the raisin by utilizing the senses, taking the time to slow down,
the teacher highlights the practice of sustained attention, with being curious
about what is present rather than assuming one knows (automatic pilot).
These are important building blocks for future learning.

Open Monitoring
Open monitoring (also known as open awareness) is an embodied,
receptive way of being with experience and a distinguishing feature of
embodiment. The intention of open monitoring is to “enhance the capacity
to bear witness to experience as well as to how one is relating to it” (Woods,
Rockman, & Collins, 2019). While this refers to both teacher and
participant, our focus here is on the teacher. By maintaining an openness to
what is occurring intrapersonally and interpersonally as he guides the
formal meditation practices, exercises, and works with the group during
inquiry, the teacher imparts a curious, receptive, and clearly demonstrated
way of approaching and being with whatever is occurring. Over time, the
participants internalize this observer stance because it is being imparted by
the teacher, which enables them to increase their tolerance to stress, support
their access to the full range of experience (the joys and challenges), and
learn that everything passes. In this way, they can meet their lives with
more equanimity and choice. The following example of open monitoring in
action is taken from session 2 after the body scan meditation practice.
Participant 1: I had a really hard time listening to your voice during
that practice. I stopped listening to it.
Participant 2: Yeah, I had a hard time too. You kept saying the same
things over and over again.
This is not an uncommon occurrence during the second week and can
be challenging for a novice teacher (Teacher 1), who may personalize the
responses.
Teacher 1: I’m sorry my voice got in the way. (Here the teacher has made
the discussion self-referential and doesn’t address the
participant’s experience.)
A more seasoned teacher (Teacher 2) will pause before responding, in
order to recognize and accept any thoughts, emotions, body sensations, and
urges in reaction to these responses and maintain a curious and dis-
identified stance.
Teacher 2: Oh, can you tell me a little bit more about what was hard?
(This teacher keeps the focus on the participant’s experience,
maintaining a present moment orientation, curiosity, and
receptivity.)
Social etiquette often entails an apology if one person is having
difficulty with what is said by another. However, when teaching MBSR,
this can be counterproductive because it sidesteps the intention of open
monitoring, which is to be curious about participants’ experiences rather
than personalizing them. This example also illustrates how an experienced
teacher can skillfully demonstrate the process of open monitoring by
staying with participant responses, not taking them personally, and valuing
the investigation of experience rather than reacting to it.

Discernment
An additional aspect of embodiment is discernment. Discernment can
be thought of as the wisdom and maturity to know what is a skillful
response in any given situation. Part of mindfulness practice is to discover
the underlying causes of suffering, and by developing a different
relationship to those causes, create the conditions that contribute to our
well-being. The teacher frames this knowledge by holding attitudes of
kindness and compassion that include himself and others equally. By
attending to each moment with open awareness, and expressing this through
his interactions, the teacher creates an environment that encourages
experimentation with novel ways of meeting stress. This in turn changes the
participants’ relationship to challenging stressors. In this way, the capacity
to hold an experience regardless of its charge is enhanced, increasing
options around what to do next, if anything. With respect to stress,
sometimes actions are not required or even helpful, and it may be wise to
remove oneself from or intentionally avoid a situation. At other times, it
may be more helpful to simply allow an experience to be as it is or let it go,
if possible. These are key points of instruction that the teacher makes
throughout the program, highlighting discernment (insight) as part of
everyday mindfulness.
What follows is a demonstration of how to work with discernment
where the teacher is leading an exercise from session 7—interacting with
the world, skillful choices, and self-care. In this part of the session, the
teacher facilitates a general discussion about environmental/world stressors
that participants identify, with a focus on their relationship to them. In this
example, the teacher uses technology as the vehicle to explore the impact of
such stressors. After participants have had some time to discuss with each
other how they use technology and its effects upon them, they then examine
how they might bring the practice of mindfulness to their relationship to a
particular aspect of technology. This is then translated into a concrete
“behavior” that they commit to working with for the following week.
Behavior here refers to a skillful response, whatever that might be, which
will often be different for each person.
Teacher: I’d like to hear how you’ve chosen to work with
technology and how you are going to change your
relationship to it this coming week.
Participant 1: My issue is the number of emails that come in every
day and how often I check them. I recognize that I’m
constantly checking my email on my phone and this gets in
the way of whatever I’m doing and whoever I’m with.
Teacher: Great. How are you going to bring mindfulness to this, and
then how will you work with it?
Participant 1: I realize that as soon as I wake up, I check my phone
for emails! So, I am going to turn off my phone at night and
when I wake up, I’m going to do a mini body scan before I
turn it on. This will help interrupt my automatic need to
check my phone, bring a pause, and let me decide what I do
next. I may even wait until I get to work to look at it. That
would be a relief. It will be interesting to see whether I can
actually do it this coming week.
Teacher: I look forward to hearing how it went when we meet next
week.
Participant 2: I realize that I’m a news junkie, particularly while I’m
in bed at night, and then that affects my sleeping. I’m going
to stop and bring awareness to the craving to know what’s
happening even though I just checked the news earlier in the
evening. I’m going to attend to my breathing and notice what
I’m thinking, the emotions and body sensations that are
present. Then I’m going to turn out the light and go to sleep.
Teacher: By stopping and bringing attention to the urge to watch the
news and then focusing on your breathing, you are
intentionally avoiding what is usually a habitual behavior.
Sometimes avoidance can be a really good thing!
 These two examples show how discernment can be used to work
mindfully with chronic world stressors. One person used body awareness to
interrupt habitual behaviors. The second person used breath awareness of
internal experience, followed by avoiding the stressor. The importance of
bringing the practice of mindfulness into the “real” world cannot be stressed
enough. In this example, the teacher has chosen to focus on our ubiquitous
relationship to technology as a stressor, but equally the focus could
encompass other areas of interest to the group.
Central to the practice and teaching of mindfulness are specific
attitudinal foundations of mindfulness, as they play a significant role in the
development of the teacher’s presence and mindful embodiment. And it is
to these that we now turn.

Attitudinal Foundations of Mindfulness

Rooted in and informing the embodiment of mindfulness are attitudinal
foundations that include such qualities as patience, trust, beginner’s mind,
nonjudging, acceptance, non-striving, and letting go (Kabat-Zinn, 1990,
2013). To this list we would add two others: curiosity and compassion
(Woods, Rockman, & Collins, 2019). When one internalizes these qualities,
they become part of a lived and dynamic experience rather than solely an
intellectual pursuit. And it is through the expression of these attitudes that a
teacher brings life to the practice and teaching of MBSR. They influence
the presence of a teacher (authenticity, self-awareness, empathetic
attunement), impact the form of the teaching (the method, how he structures
his approach), and contribute to the process (the practice) of teaching. Of
course, these attitudinal foundations are not only applicable to teaching
MBSR but are also relevant to how we engage in everyday life.

Presence
Presence is a state, a trait, and an ongoing process that entails a teacher
being fully present (Farber, 2008). As Parker Palmer suggests in his book,
The Courage to Teach (2007, p. 1): “We teach who we are.” In MBSR,
teaching who we are (presence) means embodying one or several of the
attitudinal foundations in any given moment. Being fully present starts with
a present moment orientation. This anchors the teacher and the participants
in the here and now, promoting an intersubjective space (Buber, 1958),
which in this case is harnessing mindfulness.
For an MBSR teacher, this means embodying patience (it takes time
and effort to pay attention in this way) and imparting trust in the process as
a participant struggles with a practice, discovering what is to be learned. In
another moment, a teacher will emphasize acceptance (seeing things as they
are, and not as we might wish them to be) and letting go of the tendency to
hold on to something long after it has passed. A brief example of this
follows.
Participant: This practice was really hard. My mind was all over the
place. Even when I heard the words you said about noticing
when the attention wanders, to let go and come back to what
we were focusing on, I found it really hard to do that.
Teacher: It takes a lot of energy to pay attention in this way.
In this example, the teacher is being supportive without being overly
reassuring, reflecting patience, trust, and acceptance.

Form
When teaching is based on a curriculum/protocol, there is a method or
form for its delivery. This is important for quality assurance and useful for
training future teachers. It is therefore an asset and provides an organizing
principle and guidance for the teacher. But we can get too attached to form
itself. It becomes a “thing” to which we rigidly adhere. In MBSR, if a
teacher relies entirely on the structure of the program and loses sight of the
attitudinal foundations, he risks reducing his responsiveness to the needs of
the group and the teaching becoming reductive.
The MBSR curriculum/protocol is a living document. This means that
in any given moment, while a teacher is informed by the structure of the
session, he is also responsive to the participants, utilizing any number of the
attitudinal foundations when required. In this way, the teacher embodies
flexibility, adapting his responses when appropriate, rather than rigidly
adhering to a structured approach. He retools the form as needed, using it as
a conduit to express presence and process, but maintains the structure of the
program to minimize confusion and drift from MBSR’s central tenets. An
example follows from session 4. The teacher has taught a sitting meditation
practice where participants have had the opportunity to work with
challenging physical sensations.
Participant 1: I wasn’t uncomfortable in this practice! This is the
first time I haven’t had some kind of ache or pain!
Participant 2: I decided to lie down for this practice. That really
helped. I was more comfortable.
Participant 3: Focusing on the breath was really helpful. When I was
uncomfortable, it made it easier.
Participant 4: Were we supposed to be focusing on the breath?
Participant 5: I thought we were focusing on the body!
The novice teacher might well want to respond by reviewing the
instructions for this practice or addressing specific themes (the form). And
although that would be useful, it would not be in the spirit of embodying the
practice by responding to what participants are noticing, addressing their
confusion, or taking the opportunity to employ the attitudinal foundations.
Let’s see what an experienced teacher might offer.
Teacher: So, noticing there wasn’t discomfort this time, and making a
choice to lie down seemed to make a difference; focusing on the
breath as well as a focus on the body was also helpful. Lots to
look at here, which is great (acceptance and non-striving). This
is our practice; whatever shows up is of interest. I’d like to hear
more about this experience from you all (curiosity and
nonjudgment).
The teacher has let go of any need to review the practice or explicitly
discuss one of the themes for session 4 (working with challenging
components of stress—in this case, in the body). He is staying with what is
being presented (present moment orientation) and is indirectly expressing
several of the attitudinal foundations through his encouragement and
curiosity. He also keeps participants close to their direct experience of the
practice during the inquiry, implicitly addressing relevant themes.
 Process
The attitudinal foundations (and the practices of mindfulness) provide
a flexible underpinning for a teacher to attend to his interiority as well as
maintain awareness of the outer world. This awareness is receptive, curious,
compassionate, and adaptive, and it is this that is conveyed to participants.
It is a radical act of kindness to stop and turn toward oneself. By being
curious, nonjudgmental, and accepting of experience—acknowledging the
challenges, the self-criticism, and the anxiety—a process can unfold in
which we develop a sense of being an observer of (de-centering), rather
than the protagonist in our own story.
Understanding self as process is important for a teacher, as it allows
him to let the sessions unfold, rather than requiring that he control the
program or be too attached to his role as the teacher who maintains
ownership of “his” group, imparting his expertise. If we end up believing
the story of who we think we are, we are operating in a way antithetical to
the practice. Hence, there is a focus on everything as sensation. This
promotes a loosening from a fixed identity and enhances attention to
experience as an ongoing process, rather than something reified, already
known, and with a “right way.” It is in these moments where the attitudinal
foundations can be so helpful. An example follows from session 5 after the
sitting meditation practice.
Participant: This was hard. I found it really difficult to pay attention
for all of that time.
Teacher: What showed up in this practice? (Here, the teacher has
avoided the personalizing aspect of the comment and is
focused on the experience itself, reflecting curiosity.)
Participant: I think in the beginning it wasn’t too bad, but as it went
along my attention drifted and I got anxious.
Teacher: So, you noticed the attention shifted and anxiety? (The
teacher is checking in, emphasizing the emerging process,
naming it, and demonstrating trust, interest, and acceptance.)
Participant: I’m not very good at this.
 The participant has moved to narrative self-referencing and a judgment
about self, not uncommon when we believe we are not doing something
“right.”
Teacher: A bit of judgment has crept in here! Might I ask, how did
you know the attention shifted? (The teacher has simply
identified the judgment but is not fixated on it, which is key
to dis-identifying from a view of self as incompetent. He
returns to the experience itself without a fixed agenda and
reflects the attitude of non-striving.)
Participant: I noticed feeling anxious.
Teacher: Ah, where?
Participant: (Pauses) My breath was faster, and I had butterflies in
my stomach. I can sense it now.
Teacher: (Pauses) I wonder if it would be possible to bring attention
to these sensations in this moment? (The teacher models
turning toward, acceptance, and compassion.)
Participant: (Takes a few breaths and shifts position) It’s there; it’s
like a fluttering.
Teacher: That’s our practice. Noticing, acknowledging, being present
for.
The teacher has allowed the practice to reveal what was present for
this participant by staying with what was expressed and showing interest
and trust in what might emerge. There was no agenda, no desired outcome,
and by tracking the sensorial experience, the context was not personalized
(“I’m not very good at this”), but was instead about an unfolding process
worthy of attention. This lessens the attachment to a fixed sense of self
because it reveals the components of experience as fluid events, with
sensorial components, rather than as reinforcers of who we believe we are.
How a teacher orients and speaks to the present moment, delivers the
program, facilitates group process, manages individual learning, and relates
to participants as they engage with the material is very much a part of his
embodiment. Presence, a way of being, needs practice, requiring an
openness and vulnerability to self and other, one that offers teacher and
participant the opportunity to be more fully human. Form provides the
medium for transmitting mindfulness as a skill. Process is the moment-by-
moment practice of mindfulness.

In Closing
In this chapter, we have discussed embodiment using the concepts of
presence, form, and process to explore a present moment orientation, of
which we highlighted the components of steady or sustained attention, open
monitoring, and discernment. We included an exploration of the attitudinal
foundations that we see as critical to embodiment. We now turn our
attention to inquiry, the mindful dialogue between teacher and participants
that requires a teacher’s presence, has a form, and is also an emergent
process.
 CHAPTER 5:

Presence, Form, and Process: Inquiry

A book that addresses the heart of teaching in reference to mindfulness

would be incomplete without giving attention to inquiry. While there are a
number of definitions for inquiry in mindfulness-based programs (Crane et
al., 2008; Santorelli, 2016; Woods, Rockman, & Collins, 2016, 2019;
Brandsma, 2017), we see it as “a contemplative dialogue between teacher
and participant(s) that supports the investigation of experience arising from
the practice of mindfulness” (Woods, Rockman, & Collins, 2019, p. 124).
Contemplative dialogue here refers to an intentional process of
observation, exploration, and consideration of both internal and external
experience. As such, it can be viewed as having active and receptive
components. The active component consists of the MBSR teacher’s
guidance of the post-practice conversations. How participants internalize
these conversations is the receptive component.

Inquiry
As a contemplative dialogue, inquiry has a specific intention. Its main
objective is to assist participants in their exploration of mindfulness and in
the learning of certain concepts and skills. Inquiry is anchored in reflecting
on the experience of mindfulness practice and how that might relate to
helping people manage stress differently. As each weekly session builds on
the previous one, inquiry follows a similar trajectory. It provides an
important platform, where what is showing up as a result of mindfulness
practices can be articulated. In reflecting on this in the group setting, the
teacher explores with her participants the synthesis of experiential learning
with cognitive understanding. Although there may be specific topics that
get addressed in each session, there is considerable overlap between them
from session to session. This is helpful because it reinforces the learning.
Inquiry in the early sessions will tend to focus on the universality of
experience, with an emphasis on increasing participants’ ability to use
descriptive language for this. In the early sessions, a teacher directs
participants to use the anchors of the breath and the body to begin to
develop directed and steady attention, which promotes a present moment
focus. In the middle of the program, the teacher’s focus expands to helping
participants acknowledge how they are relating to and exploring
experience, highlighting and supporting the development of the participant-
observer stance (meta-cognition). The later sessions tend to reinforce
equanimity, stability of attention, and the applicability of mindfulness to
everyday life. This supports resilience, distress tolerance, and the
practicality of mindful awareness.
In order to unpack the inquiry process further, we will discuss how it
relates to the dynamic aspects of embodiment and teaching we have been
discussing: presence, form, and process.

Presence
Embodying inquiry is a practice of present moment orientation,
incorporating sustained attention, open monitoring, and discernment, and
entails that the teacher express the attitudinal foundations verbally and
nonverbally. Inquiry is an expression of the teacher’s embodied mindful
presence using the medium of speech. It will also be demonstrated through
body language that reflects an openness and ease with participants’
responses, whatever they are.
What’s more, along with a sustained attentive focus when conversing
with an individual, the teacher will have an awareness of the group as a
whole. And in her oral presentation to the group, a teacher demonstrates an
interactive and inductive process, where she helps the group deconstruct
experience following the specific mindfulness practices that include formal
and informal meditations and various exercises. Through this process of
examination, the teacher is acting as a guide, supporting and helping
participants to observe and investigate their own experiences as their
practice evolves. This is an awareness practice and a cultivated ability that
is ultimately generalized to everyday life. This is where participants learn to
use mindfulness for intrapersonal and interpersonal stress reduction,
increasing adaptive coping.

Form
There is an inherent tension in using the word “form” to describe the
inquiry process. If we believe—and we do—that inquiry is an organic,
dynamic engagement and exploration of the experience of mindfulness
practice, then by its very nature it does not rely on a structured approach.
We see inquiry as an ongoing investigation; as a dialogue that has been
defined in various ways; as a conversation, an exploration, or an
investigation into the experience of another that has been outlined
extensively elsewhere (Woods, Rockman, & Collins, 2019; Segal, Williams,
& Teasdale, 2013; Crane, 2008, 2017).
However, having a form or method can be valuable, particularly for the
novice teacher. Crane (2008, 2017) describes inquiry as consisting of three
layers. Each layer outlines specific categories, reflections, and intentions. In
the first layer, such questions as “What did you notice?” and “What showed
up in this practice we just did?” are asked. This points to the primacy of
attending to experience itself. It also supports the building of a descriptive
vocabulary about one’s experience where the content or story is de-
emphasized.
In the second layer, questions such as “How might this be different
from how we usually pay attention?” are asked. The teacher is suggesting
that paying attention mindfully is indeed different from how we attend
habitually and encourages evaluation of this tendency. This enables
participants to develop a different perspective about how they might
typically view experience. It also offers an alternative way of attending to
what is in awareness. This is important because when we meet challenging
moments, we are often subject to automatic judgments, self-critical
thoughts, doubt, anxiety, confusion, and impatience, of which we are often
not aware. If we add these habitual reactions (thoughts and emotions) to
difficult moments, we increase our suffering and stress. In this layer, the
teacher will also be interested in supporting participants to track the
sequential nature of their meditative experience. This is because it is easy to
get fixated on a particular body sensation, thought, or emotion. By tracking
experience, the teacher supports the participants’ recognition of it as a
process, with a transient nature, and that there exists the possibility of
letting go (impermanence).
In the third layer, the question “What might this have to do with
reducing stress?” points to the relevance of the practice to everyday life.
This is an essential question to ask, for without it, formal and informal
practices of paying attention to experience are not necessarily integrated
into daily life when they are needed. This question importantly creates a
bridge from the experiential nature of mindfulness practice to the applied
context of everyday living.
Embedded in the form of inquiry will be a teacher’s use of active
listening and speaking. “Active” in this sense implies attending to, without
needing to have a specific outcome. This is essential because without this,
the form becomes the end in itself rather than a vehicle of discovery. Using
simple and/or complex reflections to respond to participants’ observations,
reflections that acknowledge and validate, reinforces the skill of labeling
aspects of experience and conveys or clarifies relevant key teaching points
or themes that underpin the session or practice. What’s more, the teacher
does not lecture, but rather makes suggestions for participants to consider
that will reinforce learning. Her comments and open-ended questions
highlight the value of awareness and the de-emphasizing of narration,
explanation, and interpretation. This is because it is common for people,
particularly when in distress, to get stuck in repetitive thoughts or behaviors
that are ineffective problem-solving or stress-reduction strategies. Learning
to describe and hence observe one’s patterns of thinking, behavior, and so
on, rather than getting caught up in them, provides the opportunity to
potentially make healthier choices in responding to experience.

Process
We would suggest that inquiry is a developmental, scaffolded process
that builds as the MBSR program progresses. Again, from session 1 through
session 4, the teacher is focused primarily on helping participants recognize
the components of experience, to increase their awareness of what is
present (what is coming and going, or persisting), by predominantly using
the senses (including thinking and emotion) and body sensations, including
the breath, as anchors for attention. The teacher will emphasize noticing the
movement of attention as well as recognizing when one is caught in
challenging states or moments of avoidance. For example, in the following
excerpt, we see how the teacher engages with a participant following an
awareness of breath practice in session 3.
Teacher: We’ve just finished an awareness of breath practice and I’d
like to hear what you noticed? (The teacher asks an open-
ended question directed at eliciting description of the
experience.)
Participant: During the meditation, I kept thinking about an
argument I had at work today. I felt agitated and it was hard
to stay on track with the practice.
Teacher: How did you know you were agitated? (The teacher avoids
asking about the content of the thoughts but rather orients the
participant to his direct experience of the emotions and
senses.)
Participant: My brow was furrowed, and my stomach and jaw felt
tight.
Teacher: And when you noticed that, how did you work with that, if
you did? (She encourages further reflective observation and
exploration but does not probe the emotion.)
Participant: I realized I was caught in the thoughts and refocused on
my breath. And then I would start thinking again and would
notice and come back again. This happened a lot.
Teacher: So your mind would get caught up in thinking; you became
aware and intentionally brought your attention back to the
breath again and again. This is mindfulness training. It’s
simple, but not easy. (The teacher reflects back the
participant’s process, reinforcing his sequential tracking and
normalizing the experience for the whole group as part of the
practice of mindfulness.)
In this excerpt, the teacher is emphasizing what was noticed,
reinforcing the describing of experience rather than its narration, targeting
body sensations and breath as an anchor.
 In the second half of the MBSR program (sessions 5 to 8), the teacher
is focused primarily on helping the group work with stress reactivity and
how one can relate to stressors using mindfulness, by developing a different
relationship to them. The teacher continues to reinforce the skills of a
present moment orientation, paying attention (sustained attention), and the
tracking of sensations (experience), and includes the use of open monitoring
(the participant-observer stance) and the possibility of learning to be with
all experience. Accepting, and being with all experience, is not passive.
Skillful responding entails being able to safely endure stressful states, our
own and those that arise through interactions with others and the world.
Skillful responding also requires discernment of what is needed in any
given moment.
The teacher’s inquiry in these later sessions focuses on supporting
open awareness (the participant-observer), especially when challenging
moments arise, seeing their arising, shifting, and passing (impermanence).
Moments of difficulty are frequently met with habitual patterns of
avoidance, denial, and self-denigration. Maintaining awareness of these
moments leads to the next step, which is the possibility of exploring how
the practice of mindfulness can be used to work with these aspects of
suffering.
As sessions 5 to 8 unfold, the teacher clarifies for the participants that
while personal mindfulness is essential as a practice, it is equally important
that they learn to bring awareness to how they are relating interpersonally,
and with the environment. Her inquiry into the various practices and
exercises of these latter sessions continues to emphasize curiosity, the
acknowledgment, acceptance, and exploration of what is present, along
with kindness and compassion. This supports an open awareness to all
experiences, regardless of their charge, which includes a willingness to
observe and work with stressful moments/events. This awareness sheds
light on what might have previously been avoided or engaged with
unskillfully. This creates options for new choices.
What follows is an example of inquiry during the difficult
communications styles exercise (session 6), after the teacher has
demonstrated the third role of the person “holding their ground.” This part
of the exercise involves the teacher and participant engaging in a
conversation where both parties assert their point of view. The teacher’s
role is to resist the request for the conversation using an assertive style that
can border on aggressive.
Teacher: (Turning to the whole group) So what did you see and what
are you experiencing? (The teacher is asking the group to
bring awareness to and describe what comes up for them in
watching this scenario, such as body sensations, thoughts,
and emotions, reinforcing an experiential vocabulary. The
teacher is also asking participants to address how they are
relating to what they have seen.)
Participant 1: You were definitely not backing off. I felt sick when
you were talking.
Teacher: How did that show up—emotions, thoughts, body
sensations? (She asks the participant for more clarification
and to explore the experience further. What is implicit in the
teacher’s stance is acknowledgment, staying with, and
acceptance of discomfort.)
Participant 1: Yeah, I felt really uncomfortable, kind of mad. You
weren’t hearing her at all!
Teacher: There is a lot here that you’re aware of. (This is reinforcing
the value of paying attention to and expressing what has been
observed and experienced.) Others? What did you see and
what are you experiencing? (She conveys ongoing curiosity
about the group’s experience.)
Participant 2: I thought you were too aggressive. You didn’t give her
a chance to talk!
Teacher: What did you experience as you noticed or felt this?
Participant 2: I felt nervous and had “butterflies” in my stomach.
Participant 3: I thought your partner was cool—staying with you
when you were talking over her. But I did feel sorry for her.
Participant 4: Well, I felt sorry for you because she was so persistent
when you clearly didn’t want to talk about it.
 Teacher: It’s interesting how something like a role-play can produce
these moments of reactivity. Imagine what happens when
these situations occur in our lives. (The teacher normalizes
the range of reactions and generalizes these to everyday
interactions.)
This dialogue between the teacher and participants demonstrates the
acknowledgment and exploration of challenging interactions, bringing
awareness to and staying with them. In doing this, she is reinforcing the
value of witnessing one’s experience and in so doing, makes room for
observing experience rather than simply reacting to it. This is part of
developing the skill of de-centering (participant-observer) and is a crucial
element in working with stress mindfully.
At the end of this exercise, after the group has engaged in dyadic role-
plays, the teacher asks what the participants experienced, whether there
were any surprises or anything familiar, and invites them to turn inward and
monitor their reactions and relationship to these. What follows is a large
group discussion around the advantages and disadvantages of these styles of
communication and how participants might bring the practice of
mindfulness to them.
The teacher has helped the group identify the difference between
automatic reactivity and mindful attention, track the unfolding sequential
process of internal experience and interpersonal interactions, and reflect
upon the relevance to daily life of the insights that evolve out of this
discussion.
Inquiry is an expression of the teacher’s embodied mindful interaction
(presence) with her participants. The teacher supports them in learning to
pay attention in a particular way so that they learn to deconstruct experience
(form). As inquiry develops over the eight weeks (process), it assists
participants in the practice of developing a different relationship to stress,
along with an appreciation for the changing nature of experience
(impermanence). Through the skill of open awareness (meta-cognition),
participants become less attached to and identified with their stress. They
ultimately bring a new understanding and appreciation of the uncertainties
of life. The invitation, then, is that they willingly engage in perspective
taking to build stress tolerance, equanimity, and adaptive mindfulness skills
for intrapersonal and interpersonal stress reduction.
In Closing
In this chapter, we have discussed inquiry. Inquiry is a crucial expression of
mindful embodiment. We explored the three layers of inquiry that can help
ground beginning MBSR teachers in conducting the practice with
participants. We also explored inquiry using the concepts of presence, form,
and process as a way to highlight and contemplate some of its important
characteristics. Ultimately, however, the most illuminating way to come to
understand the process of inquiry is to practice it. This requires an openness
to not knowing what may come next, a humility and acceptance with
respect to our own messiness, and compassion when we inevitably make
mistakes.
 PART 4:

Adaptations of the
Curriculum/Protocol

In this part of the book, we explore how the original MBSR program has
been modified. We discuss a number of adaptations to such sectors as health
care, education, and the workplace and reaching out to diverse communities
and populations who have been historically underserved. In chapter 6, we
consider the scope and responsibility of teaching MBSR in health care
settings. In chapter 7, we address how MBSR and its adaptations are being
facilitated in education and the workplace. In chapter 8, we review
diversity, cultural relevance, and the sensitivity required to work with
underserved populations and different cultures. And in the final chapter of
this section, we discuss the research, limitations, and risks as these relate to
MBSR and other MBPs.
As we move into these chapters, we address a number of themes. This
involves a discussion of the essential elements to include when modifying
MBSR to clinical populations, educational settings, the workplace, and
diverse populations. We also examine the context in which MBSR is being
offered and by whom. Given that MBSR cuts across the private and public
sectors and is being modified and made available to a variety of people
from many backgrounds, these are important issues.
 Bringing awareness to these issues helps a teacher maintain fidelity to
what are thought to be essential aspects of mindfulness practices and
protocols. It is also important to recognize the culture and context in which
a teacher is embedded and how these may influence or bias his teaching. In
addition, a teacher is responsible for ensuring that participants are aware of
the scope and limits of the teacher’s occupation, and that the group is well
informed regarding what to expect from a mindfulness-based program in
terms of content, benefits, and potential risks.
 CHAPTER 6:

Applying MBSR to Clinical Populations

The adoption of MBSR and its adaptations to clinical settings are in large
part predicated upon the research to date that has established its utility. This
has provided legitimacy for the program and led to its acceptance into
mainstream health care. Kabat-Zinn, early on in the development of MBSR,
published studies on the approach, focused on chronic illness (Kabat-Zinn,
1982; Kabat-Zinn & Chapman-Waldrop, 1988). Over the subsequent years,
there has been an explosion of research into mindfulness in general, and
particularly MBSR. This will be addressed in depth in chapter 9.
In this chapter, we focus on MBSR and address specific issues that
arise from working with clinical populations. We also discuss who is
delivering it, for what medical and mental health conditions, and the
potential challenges that may arise. As we discussed in chapter 1, MBSR
began in a hospital setting, where it was offered by clinicians and non-
clinicians alike, to those identified primarily with physical medical
conditions, such as chronic pain and heart disease. As Kabat-Zinn saw it
and presented it to the referring physicians in the hospital, his stress
reduction clinic was envisioned to serve any patient with any condition or
complaint who was not being helped by traditional medical services (Kabat-
Zinn, 2011). He adopted the term “stress” as an overarching description of
these complaints, congruent at the time with the then-nascent field of
behavioral medicine. As such, MBSR was, and in many ways continues to
be, “transdiagnostic” (cutting across diagnosed conditions). Groups are
heterogeneous, in terms of what motivates people to seek mindfulness
training, as well as what drives clinical referrals.
Although Kabat-Zinn and colleagues (1992) published on a cohort
with anxiety disorders, for the most part, mental health as an identified
concern was not directly addressed. Rather, it was how stress was being
perceived and experienced regardless of the diagnosis. The practice of
mindfulness was seen as the agent that would provide participants with a
way to work through the perception of stress and its cognitive and
emotional correlates. And it was the application and utility of mindfulness
in everyday life that was viewed as a way to relate to and mitigate suffering
(stress) intentionally and skillfully. Suffering in this case is equated with,
perhaps euphemistically, stress, which Kabat-Zinn even cites as one
definition of the word dukkha (Pali for “suffering”) (Kabat-Zinn, 2011).

Mindfulness in Health Care

MBSR has grown in two distinct ways. Firstly, it has developed from a
transdiagnostic intervention used in heterogeneous populations, applied
with no or minimal adaptations, to an intervention used with more
homogeneous clinical populations with specific medical conditions (Jalali
et al., 2019). Secondly, it now includes adaptations of the original MBSR
curriculum to address specific populations or conditions, although not
limited to mental health concerns (e.g., mindfulness-based cognitive
therapy [MBCT], a program that combines MBSR with elements of CBT
for preventing depressive relapse). Some of the latter are recognized as
mindfulness-based empirically supported treatments (MB-ESTs) due to the
rigor of associated studies and accumulated evidence. They consist of
modalities that are grounded in the use of formal meditation practices as
well as some that use mindfulness more informally. Other mindfulness-
based approaches, while promising, do not meet these criteria to be
considered empirically supported.
The formal meditation-based modalities that are currently recognized
as MB-ESTs include MBSR itself and the following adaptations: MBCT
(Teasdale et al., 2000), mindfulness-based relapse prevention (Bowen et al.,
2009) for substance misuse, and mindfulness-based eating awareness
training (Kristeller, Wolever, & Sheets, 2014). The recognized informal
mindfulness-based modalities place less emphasis on formal meditation
practices but rather use cognitive exercises, metaphor, and poetry to convey
mindfulness concepts. These currently consist of dialectical behavior
therapy (DBT), developed by Marsha Linehan (1993a, 1993b), and
acceptance and commitment therapy (ACT), created by Steven Hayes
(2004) (Fielding, 2009; Kochamba, 2017). Other mindfulness-based
treatment modalities in use include mindfulness-based cancer recovery,
mindfulness-based chronic pain management (MBCPM), and mindfulness-
based relationship enhancement (Hofman & Gómez, 2017), to name a few.
MBSR, since its inception in 1979, therefore has been responsible for a
plethora of adaptations created for very specific conditions. With the advent
of one of these, MBCT (Segal et al., 2002), a well-researched, protocol-
based treatment developed for preventing depressive relapse, mindfulness-
based approaches moved into mainstream health care. MBCT took the
concept of suffering, identified in MBSR as normative or universal in that
everyone experiences it, and applied it to a discrete condition, a mental
disorder. This specificity and the rigor of the research associated with that
modality have also helped spawn numerous other studies, protocols, and
adaptations with varying levels of evidence to support them.
In our view, although MBSR is offered in hospital settings and to
people with chronic conditions, it does not necessarily need to be conceived
of as a treatment (although it is often viewed as such), but rather offers
meditation practices within a specific framework that promotes a way of
being for dealing with life, both the joys and the difficulties. Dobkin,
Hickman, and Monshat (2014) refer to the MBSR program as a “course”
and state, “It is not group therapy, nor is it a support group, but rather a
program intended to draw upon the group’s shared experiences to facilitate
the development of mindfulness in participants” (pp. 710–711). This is one
of the reasons why non-clinicians taught and continue to teach it.
The context in which, and populations to whom, it was originally
applied paved the way for the subsequent medicalization of mindfulness.
The explicitly clinical adaptation of MBSR in the form of MBCT to treat
depression made it, and many modalities that followed, targeted treatments
for pathology, to be delivered by clinicians. Those who encounter MBSR in
such contexts have described it as a “meditation therapy” that can be used
for chronic pain, depression, anxiety, cancer, diabetes, and other such
clinical conditions (Niazi & Niazi, 2011). Even the word “therapy” has
crept into the description of MBSR itself, where stress, which is not an
identified medical condition, would appear to have now become one.

Beyond Diagnoses
MBSR and its adaptations are therefore being absorbed as distinct
treatments consistent with the nosology (classification of diseases) of
physical medicine and psychiatry. Here they are being applied to everything
from organ transplantation to bipolar affective disorder and to people across
the life span. Do a PubMed or Google search of MBSR and you will find it
being used for a vast range of problems far beyond our scope to describe.
While there are many laudable reasons to explore and use mindfulness in
this way, there are also some potential concerns.
One of the central tenets of MBSR (and mindfulness in general) is its
holistic frame of reference. Therefore, the application and modification to
specific diagnoses risks reductionism and the potential loss of what may be
essential elements of its efficacy. Secondly, mindfulness is predicated upon
the experience of the practitioner, teacher, or participant, and is grounded in
phenomena (objects known through the senses). Therefore, a diagnostic
approach, particularly in mental health and addictions, may be deeply
problematic when it comes to MBSR, because it assumes that such
diagnoses are discrete identifiable entities with associated specific
treatments, which with respect to mental disorders they actually are not.
A diagnostic framework is but one way of approaching human
suffering when there is potential risk, severity, and duration of impairment.
In mental health and addictions, there is increasing interest in other
approaches that may be less categorical in their view of mental illness and
more dimensional, etiological, phenomenological, or some hybrid (Avasthi,
Sarkar, & Grover, 2014; Messas et al., 2018). This is important because
most psychological and pharmacological treatments in the area of mental
health are not specific to a disorder. The same approach can often be
utilized across them. Such transdiagnostic approaches are growing in
popularity as it becomes increasingly apparent that our mental health
nosology has serious limitations. MBSR is clearly such a transdiagnostic or
trans-phenomenological approach to suffering—a broad framework with
many discrete elements.
Perhaps a more helpful way to consider and apply MBSR to clinical
populations, regardless of diagnosis, would be to focus on stress as the
common problem: that is, to look at the common cognitive and emotional
difficulties that term entails, as they’re experienced by individuals and
groups. In addition, one might consider the areas of dysregulation
(thoughts, emotions, sensations, impulses), expressed symptoms of distress,
or impairment of function and behaviors to which mindfulness might be
applied and how best to do this. This could be a way to bring together what
appear to be distinct diagnoses and modalities, attending to what may be the
most relevant elements in the MBSR program.
According to Crane (2017), MBSR and other mindfulness-based
programs make formal and informal meditation practices central, while
mindfully informed programs, which share much in common with the
former, do not. In this opinion piece, the authors discuss what might be
essential to an MBP, but it remains the collective opinion of a select group
of experts in the field. The common features they outline include learning
which unhelpful habitual reactions and thoughts increase distress, training
in attention and emotion regulation, and decreasing experiential avoidance
within a context of experiential learning and inquiry. They describe the
essential features of the teacher to include appropriate training, embodiment
of mindfulness, and “participatory” learning with participants. However,
further research is needed as to whether these “essential” features are either
necessary or relevant to causation with respect to outcomes of mindfulness
training (Collins & Segal, 2020).

Common Elements Approach to Mindfulness

One current approach to psychotherapy that is garnering increasing
attention is the Unified Protocol (Unified Protocol Institute), developed by
Barlow et al. (2017). This transdiagnostic treatment for a range of
emotional and mental disorders (meaning the sufferer struggles with
managing difficult emotions) brings together aspects of mindfulness,
cognitive therapy, and behavior therapy, and addresses the emotion
dysregulation that underlies such problems as chronic low mood, worry,
and so on. Barlow and colleagues write, “By addressing shared mechanisms
… specifically, negative evaluation and avoidance of intense emotional
experience, this approach could simplify training efforts while also
addressing concerns about generalizability to routine care settings by
simultaneously accommodating co-morbid emotional disorders. Such an
approach may increase access to [evidence-based psychosocial treatments]
for the most common psychiatric disorders” (p. 3).
MBSR (and its adaptations) may be an ideal modality to deploy within
the common elements approach for a number of reasons. All of the
adaptations appear to use similar elements for teaching mindfulness and
target similar components of human experience, regardless of the disorder
being addressed. This is the case whether the problem is medical or
psychiatric because the identified disorder is not the target of mindfulness,
but rather the associated suffering, however that is being experienced.
If we are thinking about such an approach, then we must also look at
the variables that may either mediate (explain the relationship) or moderate
(affect the strength of the relationship) between an MBP and the person’s
response to it (Collins & Segal, 2020). For example, there is some early
evidence that negative thinking (e.g., rumination, worry) perpetuates
difficult emotional states and that de-centering is the mediator that reduces
depressive relapse in MBCT (Segal et al., 2019). For MBSR, Goldberg et
al. (2020) found that greater time in formal practice was the key mediator
associated with positive outcomes like self-report mindfulness traits and
improvement in psychological symptoms.
What is being explored is what elements might be most useful to
ameliorate targeted symptoms of distress or impairment. This could allow
us to explicitly focus on how much we might modify the MBSR program as
it was originally intended while still retaining the core aspects of
mindfulness (Fielding, 2009; Kochamba, 2017). This approach, while in its
infancy, could make mindfulness training more available and accessible,
reducing the need for individualized training protocols.
Another contribution to the common elements approach, as it relates to
MBSR, is the work of Baer et al. (2006). These authors have contributed to
this area with their development of the Five Facets of Mindfulness
Questionnaire, a self-report inventory that is an attempt to operationalize
mindfulness in order to concretely measure it. It includes the following
elements: observing, describing, acting with awareness, nonjudging of inner
experience, and nonreactivity to inner experience. These elements describe
what variables are present when a person is mindful, but not how
mindfulness works. The how may be better thought of as referring to
potential mechanisms, such as re-perceiving, meta-cognition, de-centering,
and interoceptive exposure, proposed by such researchers as Shapiro et al.
(2006), Bishop et al. (2004), Roemer & Orsillo (2003), and Farb et al.
(2018) to name a few.
 With respect to considering the development of a common elements
approach to MBSR and its adaptations, Fielding (2009) conducted a
qualitative content analysis to examine the central elements and specific
mindfulness practices of MB-ESTs. Her ultimate intention was to provide
clinicians with information and suggestions to think about when bringing
mindfulness into evidence-based practice. She identified too many common
elements and practices with respect to MBPs to enumerate here, but
summarizes her conclusions regarding the mindfulness-based clinician in
the following table (Table 7, p. 51):

Clinical Considerations Based on Common

Elements of MB-ESTs
The mindfulness-based clinician:

1. Balances acceptance with change strategies according to population

characteristics

2. Prioritizes optimizing mindfulness

3. Emphasizes experiential understanding of mindfulness

4. Models and practices mindful awareness and acceptance

5. Normalizes client experience and balances any power differential

6. Conceptualizes and practices from a holistic view

7. Elicits client commitment and personal responsibility for self-care

She also emphasizes that the two most significant elements of MB-
EST that overlap with CBT to consider are skills training and commitment
to home practice.
 Kochamba (2017) expanded on Fielding’s work and identified the
following common elements (some similar and some additional features) in
her qualitative study regarding the clinician/teacher (Table 1, p. 50):

Common Elements of MB-ESTs

The mindfulness-based clinician:

1. Balances acceptance and change

2. Elicits client commitment

3. Emphasizes experiential learning

4. Uses a holistic-contextual conceptualization

5. Normalizes client experience and balances power differential

6. Prioritizes optimization of skillfulness (more than the remediation of

pathology)

7. Promotes pattern recognition

Fielding (2009) states, “Studies have yet to elucidate which elements

are essential to effective outcomes. Thus the evidence base from which
clinicians might make important decisions about which elements to
integrate remains severely limited” (p. 10). However, teachers at any stage,
from early training to very experienced, might consider referring to the
above tables to ensure that they incorporate these elements when working
with an adaptation of MBSR as a way to maintain focus and consistency
with respect to what is being delivered and as teaching reminders. For
example, in the orientation session, the teacher can work with the group to
elicit its commitment to the program, home practice, and personal
responsibility for self-care. In this way, participants are encouraged to
develop intrinsic motivation and autonomy, which are key learnings for
individual members and the group as a whole.
Ultimately, while there is interest in the common elements of MBSR
and how they might be applied to different populations and adaptations,
what elements are actually necessary for positive outcomes as well as their
mechanisms are still to be confirmed. Given the number of programs being
developed both within the constraints of the available evidence and outside
it, increasing clarity around these elements, addressing the mechanisms by
which they work, and conducting continued research into their efficacy and
effectiveness will be necessary next steps for the field (Russell &
Siegmund, 2016).
This is an exciting area of investigation because it takes mindfulness
for clinical populations out of the realm of the single-diagnosis approach,
broadens who delivers it, and has the potential to make mindfulness
available and accessible to many populations worldwide without
necessarily creating whole new protocols.

Scope, Transparency, and Responsibility

Given the many contexts outside of the clinical in which MBSR is
practiced, it is imperative to discuss the matter of scope, transparency, and
responsibility with respect to teachers’ instruction. Again, MBSR programs
fall inside and outside of clinical settings and are taught by teachers from
many different professional backgrounds. And while there are universities
and community organizations that provide certification, a practitioner does
not, and never did, have to be a designated clinician to offer mindfulness
training to the public. Facilitating MBSR is not a regulated or controlled
act, and perhaps never will be.
Granted, stress is not owned by health care. And neither is MBSR.
That being said, while we can debate whether or not MBSR is a therapy, it
is, as we have said, therapeutic. So this raises the messy issue of who is
teaching it, and to whom. When it is offered within a clinical setting by a
registered or licensed clinician, that clinician is subject to some sort of
governance, with a clearly defined scope of practice and described
standards of care to optimize safety for those with whom he works.
Typically, this includes knowledge of and training in the indications;
contraindications; and relative, absolute, and potential risks of treatment.
This provides a safety net in that the clinician should know the limits of his
scope of practice, and recourse will be available for clients or patients along
with clear consequences for the clinician should he act outside of it.
Those who teach mindfulness outside of this context are often not
regulated. With the mainstreaming of mindfulness and its general
acceptance, increasing numbers of people are attending groups, and these
people may often be suffering from identified or unidentified mental health
problems. In addition, they may or may not be under the care of a
designated health care provider. This poses issues for the non-clinician and
adds risk for both teacher and participants.
For the teacher, you might not know when you are out of your depth;
you may not recognize when a participant is at risk or needs help (e.g.,
someone with a significant mental health history who is currently suffering
from acute symptoms that may be exacerbated by MBSR); you may not
know how to identify (or what to ask) whether or not a person is actually
suitable for the program (e.g., too emotionally dysregulated); and you may
not know what to do if someone exhibits an unusual state, is triggered, is
experiencing increasing difficulty with the practice, or has increased anxiety
or other adverse effects.
MBSR, as the words denote, is being offered to reduce stress. But
“stress” is a broad term, and what people may actually be coming for is help
with something else entirely. Furthermore, while the public can often self-
refer to MBSR programs, it is of note that health care providers may
intentionally refer people with significant mental health conditions to non-
clinicians offering MBSR. This, too, is problematic for the non-clinician
and raises another important issue. Those referring people to MBSR may
not be well versed about the program, what it provides, and its benefits and
risks. Therefore, teachers will need to screen potential participants to
increase their likelihood of being helped versus being harmed by the
program. To this end, a brief in-person or over-the-phone relevant
assessment (see the appendix) should be conducted that includes whether or
not the person has a health care provider. The required attendance, the
requisite home practice, and the participant’s motivation or ability to engage
in the group interactions should also be discussed.
 Particular risk factors identified as relative contraindications (although
not absolute) seem to revolve around such issues as active psychosis,
depersonalization, derealization, severe and acute depression and anxiety,
unprocessed trauma, severe eating disorders, extreme emotion or attention
dysregulation, and active substance misuse (Dobkin, Irving, & Amar, 2011;
Russel & Siegmund, 2016; Britton, 2019). We therefore need to remain
cognizant that mindfulness is not a panacea and is not helpful for everyone.
This applies to clinicians and non-clinicians alike who may be biased in
terms of its utility and positive effects.
Determining suitability can be particularly difficult for a teacher who
does not have mental health training and may not deem it appropriate
(depending upon the setting) to ask for private health information, such as a
mental health history. To this end, such teachers need to be explicit about
what they are teaching (e.g., a generic program or one targeted at specific
conditions or populations) and its limits, including their own, who and what
it is for, participant suitability, and the potential risks and benefits. Teachers
also need to ensure that their participants can provide informed consent
regarding MBSR, and that they understand what MBSR has to offer over
other programs for dealing with stress. Should the teacher think that a
participant is presenting with issues beyond the teacher’s knowledge and
skill, it shows wisdom and discernment if they are able to acknowledge this
and refer the participant to the appropriate sources for help, if available.
This also requires an understanding of the need for professional boundaries
between the teacher and participant(s). Teachers cannot be all things to all
people, yet the teacher without clinical training may be unaware of the
pitfalls of unclear boundaries. Finally, ensuring adequate documentation in
the form of informed consent, the limits, roles, and responsibilities of the
teacher, and a signed waiver by the participant covering teacher liability is a
way to increase the protection of both parties by making the terms of the
relationship during the MBSR program explicit.
The non-clinician may have participants who choose not to divulge
mental health diagnoses over concerns of being stigmatized. Or they may
be anti-medicine, or they may not believe that the medical or the mental
health world can assist them. Therefore, non-clinicians need to learn to
identify and work within their occupational limits, always prioritizing
safety for their participants and themselves. This will entail that the teacher
does not accept participants about whom they have doubts and/or who
belong to populations they haven’t had experience teaching.
This raises the essential issue of ongoing support and learning for the
mindfulness teacher regardless of his occupation. We suggest that a teacher
have a senior MBSR teacher as a mentor or supervisor and, if possible, a
community of practice consisting of other mindfulness instructors,
particularly when one is beginning to teach. A supervisor, mentor, or
community of practice can help a novice teacher with safety and risk
concerns, as well as provide authority through their experience around any
number of issues that can come up in a group. Keeping up-to-date with
respect to the scientific and other literature on mindfulness is a way to stay
informed of changes and emerging evidence in the field, as is engaging in
continuing professional development programs. The amount of data
available in this regard can quickly lead to overwhelm. To avoid this, it
helps to read about what one is specifically teaching, the challenges or
unusual events that come up in one’s group, or the questions the teacher has
related to his own personal practice and teaching.

In Closing
In this chapter, we have addressed the uptake of MBSR in health care and
beyond, and its application to specific conditions, predominantly with a
focus on identifying cognitive and emotional distress regardless of whether
the primary problem is physical or mental/emotional. We discussed some of
the problems associated with a diagnostic approach and elaborated on the
transdiagnostic nature of MBSR. This led to a discussion of the utility of
investigating the use of a common elements approach to the delivery of
mindfulness to those with physical and mental health concerns. Such an
approach may increase the accessibility of mindfulness to wider populations
and expand who can deliver it. Lastly, within this frame, we addressed the
increasing concerns that those who are not clinicians may have when
teaching mindfulness and how to approach these. Specific issues regarding
adapting MBSR to diverse contexts, cultures, and populations will be
discussed in chapter 8. We now turn to the increasing adoption of
mindfulness in educational settings and the workplace.
 CHAPTER 7:

Mindfulness in Education and in the

Workplace

In this chapter, we turn our attention to MBPs and adaptations of MBSR

that are being used in educational settings and the workplace. Schools,
colleges, universities, and business organizations are turning to mindfulness
to reduce stress, promote health and general well-being, cultivate resilience,
increase motivation, improve workplace functioning, and enhance
leadership skills. The past decade has seen considerable growth in MBPs
offered to youth and students K-12 and beyond. In grade school,
mindfulness skills are being implemented to support and develop social,
emotional, and academic learning. In colleges and universities, adaptations
of MBSR are being offered to manage stress, reduce anxiety and
depression, and promote resilience among students. And in the workplace,
mindfulness is being used to reduce stress, improve self-regulation and
resilience, increase job satisfaction, enhance creativity, promote
productivity, and strengthen self-confidence.
There is no uniform approach to teaching mindfulness in education,
nor indeed in bringing mindfulness to the world of work. Some educational
programs focus on integrating social-emotional learning (SEL) with
mindfulness practices, while others target improving academic
performance, reducing stress, strengthening resilience, and decreasing
anxiety and depression. Still other programs utilize formal mindfulness
practices while others don’t, and some require teachers to have a practice
while some do not. The question then becomes whether or not mindful
embodiment of the teacher is necessary, or can mindfulness be conveyed as
a skill simply by teaching its assumptions and principles?
In both profit and nonprofit sectors, organizations are looking to
mindfulness to reduce stress, increase general health, promote creativity,
strengthen leadership skills, manage anxiety, boost low morale, increase
motivation, and improve productivity. With the variation of programs using
different methodologies to teach mindfulness, this lack of consistency raises
issues for research around which variables are responsible for which
outcomes in these settings. Turning to the nascent research, we ultimately
want to explore the impact of mindfulness on promoting social and
emotional well-being, cognitive flexibility, enhanced academic
performance, and resilience. We also hypothesize an increase in positive
indicators for psychological, physical, and social health. The research thus
far, limited as it is, looks promising. In this chapter, we will explore all
these questions, starting with mindfulness in education.

Mindfulness in Educational Settings

Although the research is in its infancy, mindfulness-based skills do appear
to help students manage stress more effectively and increase general
resilience (Davidson et al., 2012). In a randomized control study, where
mindfulness practices were embedded in a SEL program (the MindUP
program), the students who received the program demonstrated
improvements in executive functioning and stress physiology, along with
greater empathy and optimism and decreases in self-reported symptoms of
depression. Their peers described them as more socially attuned and
accepting of others (Schonert-Reichl et al., 2015).
Mindfulness-based concepts are also being applied to and as a
framework for teaching and learning. The teachers promote and the students
develop a curious, open stance using a form of inquiry that shares some
elements with Socratic questioning. Where it differs is that inquiry
informed by mindfulness relies on direct experience and reflection to elicit
abstract concepts and their relevance to the subject being taught. Therefore,
traditional methods of teaching utilizing a cognitive (top-down) approach
are increasingly combined with inductive, bottom-up processes for learning.
Consequently, mindfulness as a foundation for learning may enhance
the acquisition of skills and knowledge by giving equal attention to
experience and reflective observations, integrated with insights, theory, and
abstract thinking in academic and applied contexts. Indeed, within the
educational field, dual-process learning theory fits nicely with a
mindfulness approach, as it utilizes both implicit (arising out of experience)
and explicit (application of concepts, reason, etc.) forms of thinking and
learning to acquire knowledge and skills (Sun, Slusarz, & Terry, 2005).
As we stated earlier, there is no universal approach to bringing
mindfulness into education, although there is a predisposition to embed
mindfulness into already existing curricula (K-12), in programs that offer
age-appropriate activities highlighting mindfulness principles and practices.
Many curricula in the primary and secondary school system include
mindfulness-based learning along with SEL strategies. In other school
systems, teachers attend the MBSR program as a way to reduce their stress
and to support increasing regulation of attention and emotion in the
classroom. In still other school-based programs, teachers are trained to offer
adapted forms of MBSR, which include delivering a variety of age-
appropriate mindfulness-based skills, and in some instances, teachers are
utilizing mindfulness-based approaches in the delivery of teaching
academic subjects.

Mindfulness and Social-Emotional Learning

Mindfulness and SEL have much in common. The Collaborative for
Academic, Social, and Emotional Learning (CASEL) defined SEL more
than twenty years ago. CASEL recognizes five central skills that constitute
SEL. These consist of self-awareness, self-management, social awareness,
relationship skills, and responsible decision making. They describe self-
awareness as the ability to know one’s strengths and limitations, confidence
in one’s knowledge, and an interest in continued learning. They define self-
management as coping with stress creatively and the capacity to establish
and realize goals successfully. Social awareness is described as the ability
to empathize and understand the perspective of others, including those who
hold different beliefs and come from different circumstances. Relationship
skills are understood to be the capacity to listen, communicate, and
cooperate with others; work effectively when there are differences; make
decisions for oneself; resist social pressure when needed; and offer and seek
help when necessary. Finally, responsible decision making includes making
constructive choices about how to behave and interact with others that are
grounded in cultural norms, specific values, and ethics, such as non-
harming (CASEL, 2020).
 SEL unpacks this list further in the following ways. For instance, for
promoting self-awareness, it is important to have an awareness of thoughts,
emotions, and behaviors; for strategies for self-management, it is important
to have the ability to self-regulate emotions, thoughts, and behaviors; and
for social/relational awareness, it is important to have the capacity to
connect authentically to self and to others with tolerance and acceptance of
differences. Looking at this list, we can see how well these skills
correspond with the broad intentions of MBSR and mindfulness generally.

Mindfulness-Based Programs and the

Research
Some of the mindfulness programs that offer specific curricula are
MindUP, .be, A Still Quiet Place, Learning to Breathe, Mindful Schools,
and Inner Kids. The MindUP curriculum (K-12) created in 2003 as part of
the Goldie Hawn Foundation, a not-for-profit organization, is a
mindfulness-based education SEL program that consists of twelve lessons
taught once a week, with each lesson lasting 40 to 50 minutes. The
mindfulness practices consist of focusing on one’s breathing; attentive
listening to a single sound; mindful awareness; and mindful listening,
seeing, smelling, tasting, and moving. The lessons promote self-regulation,
social-emotional understanding, and positive mood, and children are
encouraged to appreciate happy memories and express gratitude. In
addition, the curriculum involves performing acts of kindness for one
another and for the community at large. Teachers actively encourage
students to generalize the skills they are learning to support a positive
classroom experience and to use these throughout the day. A two-year,
randomized controlled study assessing the implementation of the MindUP
curriculum with a group of pre-kindergarten and kindergarten students
demonstrated superior vocabulary and reading scores in the MindUP
students (Thierry et al., 2016).
In another MBP, preschool students were taught a twelve-week
Kindness Curriculum. In a randomized controlled study, the sixty-eight
preschool children who were taught this program demonstrated enhanced
learning and increased health and social-emotional development when
compared with the control group (Flook et al., 2015). In a school-based
program where sixty-four second- and third-graders were instructed in
mindful awareness practices, those students who were less well-regulated
showed improvements in executive function, meta-cognition, and
behavioral regulation (Flook et al., 2010). In a 2005 article that reported the
results of a study where first-, second-, and third-graders were taken
through a twelve-week mindfulness training program (breathing exercises,
body scan, and sensorimotor awareness activities), the students in the group
who received the training showed improved outcomes on three attentional
measures compared to those who did not receive the training (Napoli,
Krech, & Holley, 2005). This is but a small sample of the range and variety
of MBPs being taught and studied.
Not only is mindfulness being used in the school system to increase
SEL and academic performance, but it is also being applied to physical and
mental health concerns. In November 2017, the National Institute of Mental
Health stated that the lifetime prevalence of any anxiety disorder for
females is 38.0 percent and for males 26.1 percent in thirteen- to eighteen-
year-olds (NIMH, 2020). This inevitably impacts learning, as well as
affecting both physical and mental health (Shonkoff et al., 2012).
The world of the twenty-first century has brought new pressures.
According to Common Sense Media, teens are online for an average of nine
hours per day (Common Sense Media, 2018). This is potentially
problematic; while research in this realm is not necessarily conclusive, the
relationship between this increased online time and recent demonstrable
increases in mental health issues in adolescents and young adults is a live
question. For example, in a large database review from 2005 to 2017, the
rate of major depression increased in adolescents by 52 percent and in
young adults by 63 percent (Twenge et al., 2019). The authors of the study
believe that cultural and social trends (e.g., the use of electronic
communication devices, the plethora of media platforms, and a general
decrease in sleep duration) could well be having a big impact on young
people.
For this population, there are signs that MBSR can help. When 102
adolescents who were diagnosed with a range of mental disorders and
attending an outpatient facility were taken through an MBSR program,
those in the MBSR group, compared to the treatment-as-usual group,
reported a reduction in anxiety, depression, and somatic distress with
increased self-esteem and improved sleep (Biegel et al., 2009). And in a
study where 120 seniors in a private school for girls participated in a
mindfulness-based curriculum, in comparison to the controls, the
participants reported increased emotion regulation; improved feelings of
calm, relaxation, and self-acceptance; and decreased negative affect. A
reduction in aches and pains and general tiredness were also reported
(Broderick & Metz, 2009).
Lastly, in 2014, a systematic review of twenty-four studies consisting
of a total of 1,348 students in grades 1 through 12 revealed that
mindfulness-based interventions demonstrated support for strengthening
resilience and improving cognitive functioning. However, the authors
offered caution, citing that many of the studies lacked power (due to small
sample size), did not use controls or other comparison groups, used self-
report versus objective measures, and encountered difficulty measuring
outcomes in school settings (Zenner, Herrnleben-Kurz, & Walach, 2014). In
an earlier study, Greenberg and Harris (2012) suggested that although there
was evidence to support contemplative interventions, the quality of the
research needed upgrading. Part of the difficulty facing researchers is the
lack of experimental control possible in the environments in which
mindfulness is being incorporated and the complexity of how it is being
adopted in education.
However, the current evidence, with respect to K-12 education, would
appear to support the ongoing investigation of mindfulness and its
application in this context.

Mindfulness and College Students

Attending college or university is a major transition in a young
person’s life, requiring significant adaptation. This is often a significant
stressor and can reduce academic performance and social functioning,
potentially leading to dropping out or failing. Learning mindfulness-based
skills can be helpful in managing such stress and the often attendant
anxiety, thereby increasing resilience and the development of other useful
coping skills (Warnecke et al., 2011). Mindfulness meditation has been
shown to decrease stress reactions and improve mood and academic
performance in both college and graduate students (Oman et al., 2008). In a
study aimed at promoting first-year students’ general health and well-being,
they were taught an adapted mindfulness-based curriculum. The results
showed a significant decrease in depression and anxiety symptoms and an
increase in life satisfaction (Dvoráková et al., 2017).
Koru mindfulness is a curriculum that has been designed specifically
for college students and emerging or young adults. “Emerging adulthood” is
the term used to address the age-group of eighteen- to twenty-nine-year-
olds. This is typically a time of developmental change and increased
pressures, such as parental expectations for academic excellence, student
perfectionism, social anxiety, and the financial burden of student loans. The
Koru program offers mindfulness practices (awareness of breath, body scan
meditation, guided imagery meditation, labeling thoughts and emotions
meditation, and meditation using the lines of a poem linked to the rhythm of
breathing) as stress management techniques. (See the appendix for more on
using poetry in MBSR.) It is highly structured, with a curriculum consisting
of an introductory course, an advanced class, and a half-day mindfulness
retreat, along with home assignments for practicing mindfulness. There are
four weekly introductory classes, 75 minutes in length. Shortening the
duration of the classes and their number was a way to accommodate the
busy lives of this target population. It is not uncommon to make these kinds
of modifications for programs delivered to children, youth, and emerging
adults (shortening practices and duration of classes and the program)
because it is believed that these changes make mindfulness more accessible
and acceptable to these populations. Koru groups tend to be small and
diverse. Participants who have taken the course report feeling calmer, more
rested, and greater self-compassion (Greeson et al., 2014).

Mindfulness for Schoolteachers

Teachers are facing increased stress in the classroom and in their work
environment as a whole. These stressors include increased workloads, time
pressures, lack of autonomy, exclusion from decision making, strained
relationships with colleagues, and poor support from administrators
(Antoniou, Ploumpi, & Ntalla, 2013). For example, in the US, a major
stressor is the advent of school violence. Although school shootings are
rare, they do happen. What is now increasingly common are lockdowns.
Schools rehearse lockdown procedures to save lives and so that students
and teachers alike are ready for a worst-case scenario: a shooter, a bomb, or
general threats of gun violence. Lockdowns are practiced in response not
only to imminent proximal danger—that is, when someone has gained entry
or has come to school armed—but also when some such event happens in
the school vicinity. Practicing these measures takes a psychological toll on
students and teachers.
Furthermore, teachers are faced with expanded work responsibilities.
These include an increase in class size and the task of integrating children
with learning disabilities, behavioral issues, and other needs. Therefore,
helping teachers manage their own stress is important for the classroom
environment as well as for their own health. In a study that looked at the
effectiveness of an adapted MBSR program, thirty-six high school teachers
either participated in the eight-week program or were on the waitlist
control. The results were encouraging. The participants in the MBSR
program showed increases in the mindfulness skills of observation,
nonjudgment, and reduced reactivity. They also reported enhanced quality
of sleep and improvements in self-regulation and self-compassion (Frank et
al., 2015).
Another study looked at burnout as a result of occupational stress in a
sample of 113 teachers in grade schools in the US and Canada. Teachers
were randomized to a mindfulness training program or to a waitlist. The
teachers in the mindfulness training displayed increases in mindfulness,
working memory, attentional focus, and self-compassion, and lower levels
of work-related stress (Roeser et al., 2013).

Mindfulness in the Workplace

As the pace of life has quickened, so have the demands of work increased.
The twenty-first century is a time of informational overload and accelerated
change. Businesses are finding they need to increase their organizational
responsiveness to the demands of markets in different time zones. Many of
us work excessive hours due to the demands of our employment, and work
no longer stops when we leave the office, regardless of whether we work at
a facility, at home, or remotely. At the same time, we also have the
responsibilities associated with home life. We are subject to incoming
emails, to-do lists, deadlines, and performance evaluations and are attached
to checking our cell phones frequently. Work becomes just another thing to
do on top of an already long list.
 The onslaught of all of this activation takes its toll intellectually,
physically, and psychologically. Many of us report feeling exhausted,
overwhelmed, anxious, depressed, and reactive. The American Psychiatric
Association (2018) reported a rise of 35 percent in anxiety across all age-
groups between 2016 and 2017. Stress is a significant problem in the
workplace, with about one-third of workers reporting high levels (Sauter et
al., 1999). Stress can be a factor in job turnover, absenteeism, and poor
performance, with depression being the largest single predictor of such
absences from the workplace. All of this comes at a significant financial
cost for society.
Understandably, organizations are turning to mindfulness and other
solutions to help their leaders and employees find ways to alleviate the
situation. The hope is that mindfulness training can address some of these
issues by promoting resilience and increasing creativity, performance, and
skillful decision making. However, incorporating mindfulness into the
world of business is not easy. There are many competing demands on a
leader and the employees’ time. Not all businesses are alike and therefore
will have different priorities, needs, and concerns. In addition, the capitalist
world is founded on a market that is driven by individualistic values and
competition for consumer resources. The values of business, then, are not
the values of mindfulness, even a mindfulness adapted to contemporary
culture. Indeed, a criticism of workplace mindfulness, especially in the
corporate sector, asks how much MBPs are being co-opted to create
workers who more effectively contribute to the bottom line without
questioning any of the ethical or cultural assumptions of the work they do.
An internet search reveals many variations on what to teach, how to
teach it, and what the program is targeting. Some concentrate on delivering
the MBSR program or an adapted form; others offer mindfulness meditation
classes alone or in combination with yoga classes. The intentions of these
programs are equally diverse. Some focus on reducing stress and improving
general health, while others aim to boost focus and productivity.
Increasingly, wellness programs provided by companies are including
mindfulness alongside more traditional methods of managing stress and
well-being (exercise classes, weight loss classes, massage, etc.).
In 2007, Google brought together a team of experts in mindfulness and
developed a course, Search Inside Yourself, for Google employees. In 2012,
the Search Inside Yourself Leadership Institute was founded to bring the
program to businesses, individuals, groups, and community-based
organizations. This program promotes mindfulness, enhances emotional
intelligence, and sets out to improve leadership skills. In their program
report, they surveyed 1,500 participants worldwide. Participants reported
decreased levels of stress, increased ability to manage change more easily
(resilience), increased levels of empathy and compassion, improved
collaboration with others, including during challenging conversations, and a
greater capacity to find solutions to difficult problems (Search Inside
Yourself Leadership Institute, 2019).
Google is not the only corporation that offers programs in mindfulness;
Apple, Aetna, General Mills, Green Mountain Coffee, and Eileen Fisher,
with corporate headquarters in the US, all offer some form of mindfulness
meditation. Aetna, the health insurance company, offers free yoga and
meditation classes to its employees, and General Mills provides meditation
rooms at its corporate campus. This is but a small sample of businesses
throughout the world adopting mindfulness in corporate settings.
The Forbes Coaches Council (2018) made fourteen recommendations
for encouraging mindfulness in the workplace. The list stresses the
importance of leading by example and therefore the necessity to practice
mindfulness for oneself, regardless of whether you are a leader or an
employee. It stresses the importance of the breath, being emotionally
present, taking pauses between meetings, slowing down, and creating
opportunities for unscheduled time and breaks. The paper offers a
suggestion about how to engage in mindfulness before a meeting by
spending a few moments paying attention to the breath before moving into
the substance of the meeting.
Perhaps one of the most significant issues facing the corporate sector is
the rate of change. Technology has accelerated the way corporations do
business, and we live in an age of obsolescence. Therefore, developing
ways to be flexible and adapt to the changing business climate is important
for organizations. Mindfulness has been shown to promote cognitive
flexibility and attentional and intentional focus, thus strengthening
awareness of what one is working on in the present moment (Zeidan et al.,
2010). It has been shown to increase short-term memory and the ability to
manage complex tasks. It also improves the ability to stay calm and open
(Goleman & Davidson, 2018). These combined traits offer employees and
leaders alike important skills for managing the volatility of world markets.
 However, this enthusiasm for mindfulness has the potential to produce
a backlash for a number of reasons. With the rapid entry of mindfulness into
the workplace, the degree of its adoption currently outstrips the available
evidence. There is a need for higher-quality studies. In addition, if
employers use mindfulness to unintentionally download the responsibility
for dealing with a stressful environment onto individuals without making
systemic changes in the workplace, it is bound to fail and result in cynicism
and resentment. We are perhaps at risk of mindfulness becoming mandated,
with organizations imposing a particular philosophy and practice on those
who would rather not engage in them. Mandating mindfulness is antithetical
to the values of the practice. So, it is important to find thoughtful ways of
introducing and integrating mindfulness into the workplace rather than
coercing leaders and employees to take these programs. Alternatively,
depending upon a company’s goals for reducing stress, improving
resilience, and increasing peak performance, there are other modalities an
organization could and perhaps should consider. How mindfulness is taught
in the corporate setting is also crucial. Having well-trained mindfulness
teachers who are a part of corporate culture will ultimately be essential if
mindfulness is to become a fixture there.

In Closing
In this chapter, we have discussed how mindfulness-based programs and
practices are being offered in educational settings and the workplace. In
both the field of education and in the world of business, what is being
delivered varies, although in many cases the common denominator is
adapting the MBSR program. However, at the time of writing, the
enthusiasm for these approaches has outstripped the current state of the
evidence. Over the next few years, it is likely that research will give us a
clearer understanding of the benefits and risks of mindfulness, and how to
optimally deliver it in the classroom and in the workplace. In our next
chapter, we explore another context for contemporary adaptations of
MBSR: bringing mindfulness practices to underserved communities.
 CHAPTER 8:

Diversity and Cultural Relevance:

Reaching Underserved Communities

Those who work in the field of mindfulness need to ensure culturally

relevant MBSR adaptations in order to reach out to diverse groups that do
not share the same history or culture of the dominant society. In this
chapter, we identify who is and who is not being served by current
applications of mindfulness. We discuss mindfulness’s applicability, utility
to diverse groups, and cultural relevance. We examine the ways in which
MBSR is being adapted, taught, and researched. Lastly, we address how
teachers can increase their cultural competence and adapt the program
where needed to enhance its accessibility to those diverse and/or
underserved communities that could benefit from MBSR.
So how do we understand diversity within the context of MBSR
specifically? Diversity includes all of those aspects that we think of as the
visible and invisible differences that make us unique. These include race,
age, gender identity, religion, sex, sexual orientation, physical or
intellectual ability, health issues, socioeconomic status, country of origin,
and more. Diversity, then, is about representation.
Inclusion, while tied to diversity, is often conflated with it, but is not
the same. Diversity commonly refers to the representation of the types of
people in a population; inclusion refers to the cultivation of social and
cultural norms and is predicated upon making people feel welcome, valued,
appreciated, and respected. Without paying attention to inclusion,
representation of the various groups embedded in any society is unlikely to
have an impact on the prejudice or stigma experienced by them
(Washington & Patrick, 2018). When people are included, they will be
much more likely to have a felt sense of belonging; they feel heard and that
can bring more social ease, psychological safety, trust, and acceptance.
 Given all the assumptions and principles inherent to mindfulness, it
would at first glance be a given that diversity and inclusion would be
addressed within it (Magee, 2016). The operational definition of
mindfulness we have used throughout this book stresses present moment
awareness and nonevaluative and directed attention. This would seem to
imply that with awareness, and a nonjudgmental stance, issues related to the
acknowledgment of cultural differences, diverse social mores, prejudice,
lack of diversity, socioeconomic status, exclusion, and social justice would
be irrelevant and therefore not in need of deliberate attention. And yet, we
know this not to be the case. And we also know that there is increasing
interest and impetus in the field to attend to these concerns (Hall et al.,
2011; Hsu, 2016; Le, Kinh, & Douang, 2019).

Mindfulness as Monoculture
Mindfulness in Western culture remains predominantly within the purview
of white people of European descent. Jon Kabat-Zinn, in creating MBSR,
took certain aspects of Buddhist psychology and practice and developed a
modality within health care and science that was congruent with Western
values, stripped of its Buddhist religiosity. As Funie Hsu (2016, p. 373)
writes, “Through MBSR both Buddhist mindfulness and the broader
teaching of Buddhism are expressed as universal traits”—the implication
being that what is taught in MBSR is relevant to anyone in any context
(Kirmayer, 2015). This view appears to be supported by the exploding
research and entry of mindfulness into so many sectors of society. It would
also seem to indicate that MBSR, and by association, Buddhist theory and
practice, are therefore apolitical, free from bias, cutting across all cultures
and communities. In fact, we should remember that the tradition of
Buddhism (which informs MBSR) is viewed by many—depending upon
how much of a traditionalist one is—as a truth and as a religion, and even
as the only path to enlightenment (Kirmayer, 2015). Hsu elaborates that
these “universal traits” expressed in MBSR and MBPs are located squarely
in secular and scientific mindfulness, distanced from their Asian origins
(comprised of South, East, and Southeast Asia), making them acceptable
and accessible primarily to Western white culture (Hsu, 2016).
It is therefore a complex and delicate process to extract elements of a
religion or psychology, and a therapeutic philosophy or way of life (and
Buddhism has been referred to as all of these) from another culture and to
translate it into a treatment or model of psychoeducation that is intended to
be for the many. Part of the history of mindfulness in the West, and MBSR,
is dominated by the migration of young, educated Western Europeans and
Americans who traveled to Asia and made contact and studied with
Buddhist teachers. Some of them returned to found meditation centers to
continue the teaching of Buddhist practices. A survey in the late 1990s
showed that the majority of converted Buddhists in the West were white,
upper middle class, and highly educated. This may be because Buddhism
can be viewed as a philosophy of life, a means of investigation of
experience without the trappings of a religion. The view of whether it is a
religion is likely dependent upon the definition one is using (Prebish,
Ponlop Rinpoche, & Sutherland, 2013). It is noteworthy that most modern-
day Dharma or mindfulness teachers and researchers are Caucasian,
underrepresenting those from diverse backgrounds. In addition, the subjects
of research are also predominantly white and from Western countries
(Amaro, 2014; Le, Kinh, & Douang, 2019).
There seems to be a similar lack of diversity in participant populations.
Most participants who attend MBSR and MBPs are white, middle-aged,
middle-class women who self-select and have access to health care. What’s
more, studies indicate women of European descent, with higher levels of
education, and in communities with greater social cohesion are more likely
to seek treatment than men, people of color, or those with less education
(Fleury et al., 2014; Morone, Moore, & Greco, 2017; Snowden & Yamada,
2005; Steele et al., 2007; Yamada & Brekke, 2008).
Ultimately, the takeaway is that MBSR and other MBPs, while
benefiting people physically and psychologically, still remain largely
embedded in the dominant culture. If we accept that mindfulness confers
benefits for mental and physical health, helps with managing life
challenges, improves interpersonal interactions, and cultivates compassion
for self and others, then it behooves us to include others beyond the white
middle class. To do this, we must first ask: Is mindfulness applicable and
helpful to more diverse populations? While this is not yet well studied,
there is some evidence that diverse groups benefit from MBSR and its
adaptations (Hall et al., 2011; Amaro, 2014; Le, Kinh, & Douang, 2019;
Woods-Giscombé & Gaylord, 2014). But there are also obstacles to this
potential dissemination.
Barriers to Disseminating Mindfulness to
Diverse Groups
Expanding the reach of mindfulness means addressing barriers that prevent
a wider dissemination. This entails examining the sociocultural norms of
populations that are typically slotted into the category of the minority, and
how those correspond with or differ from the norms of the majority. An
example of this relates to different self-conceptions and values between
groups. With the caveat that these are broad generalizations, people in
Western North American or European cultures value independence, a
unique sense of self, and self-reliance; African Americans alternate between
individualism and collectivism while consistently valuing family and
religious affiliation (Iheduru, 2006). Asian Americans have been shown to
value interdependence, harmony with others, and conformity (Kennedy et
al., 2007; Hall et al., 2011). Another example of this consists of the many
indigenous groups that place great value on harmony with nature and the
place of the individual within that landscape.
Other groups may experience a sense of discordance between their
religious beliefs and the tenets of MBSR. Furthermore, there may be a lack
of connection to or relevance of the themes and materials of the program to
the specific sociocultural environments of participants (Woods-Giscombé &
Gaylord, 2014). In addition, populations that have a history of
discrimination may feel unsafe in programs that don’t take this into account.
All of these issues will need to be sensitively addressed when adapting
MBSR to make it relevant to diverse populations. For the purpose of
continuing this discussion, we have divided these potential barriers into a
number of categories (knowing that they will overlap): logistics, culture,
content, interpersonal mindfulness, and the presence of the teacher.

Logistics
Some of the logistical barriers to participating in an MBSR group
consist of such factors as cost, location, and timing. For example,
depending upon where one lives, services for stress reduction or mental
health care may be less available or affordable to certain groups. Charging a
fee for the program may make the program inaccessible for some. Those
who have limited incomes, who border on the poverty line, or who are
below it will need to have the fee adjusted or waived. It is also likely that
additional assistance to encourage attendance will be necessary through
such incentives as bus tokens, the provision of food, or childcare.
The location may be another obstacle for certain groups. For example,
if programs are offered in a hospital or school setting that is perceived as
undesirable (unwelcoming, prejudicial, inconvenient), participants won’t
attend. In addition, some participants may need interpreters. Those suffering
from chronic pain or other physical disabilities will require additional
supports that may not be available. If the space is not physically accessible,
those with mobility limitations will be unable to participate.
The agenda and materials may also require modification depending on
the level of education or literacy, or neurodiversity, of the participants (e.g.,
shifting from text-based handouts to audio resources). With respect to the
agenda, practices may need to be shortened and discussion time lengthened
(Amaro, 2014). Finally, time of day may be an issue. If people are working,
then daytime groups may be a problem and will curtail attendance. If
adapting the program to work with people who have serious and persistent
mental illness or substance use issues, a group that is held too early in the
day may be an obstacle. Those who come from underresourced
communities or destabilized environments or who have executive
functioning problems may require incentives, supports, and frequent
reminders in order to attend and complete MBSR groups. By reflecting on
and addressing these issues, teachers can enhance recruitment, participation,
and completion of the MBSR program for participants who might normally
not consider attending.

Culture
MBSR and MBPs need to be structured so as to be culturally relevant
to the population with which they are working. Modalities such as MBSR
may not be acceptable or seem relevant to certain groups due to a multitude
of factors (Hall et al., 2011). Ladson-Billings (2006) coined the term
“culturally relevant teaching,” and although she is referring to education,
her work is also applicable to teaching MBSR. She highlights the
importance of being aware of the social context from which group members
come and how the teacher views them. This is often overlooked. Consistent
with mindfulness is her opinion that regardless of the students’/participants’
backgrounds, they are to be viewed as “capable and resilient” (ibid.., p. 31).
This stresses the importance of teachers adjusting the content of MBSR to
be culturally relevant as necessary, depending upon who is being taught.
It is vital that teachers recognize how their own privilege may get in
the way of their ability to do this. Lyubansky (2010), writing about white
privilege, talks about it as a willful ignorance or choice not to understand
significant cultural differences that is possible only for the dominant group.
We would argue that this is not really a choice, but rather such privilege
allows those from any dominant group to be blind to their own entitlement
and potential prejudices. Indeed, within our own culture, we may not even
be aware of racial or social differences. Waking up to this takes work and a
willingness to turn toward what may be cognitively and emotionally
difficult to see in ourselves.
Another barrier to attending MBSR is that diverse groups may have
cultural values, a sense of self, or religious beliefs that are discordant with
taking the program or accessing health services generally. There may even
be a stigma attached to attending. For example, Christian participants may
be wary of the Buddhist roots of MBSR. It will therefore be important to
stress the secular nature of MBSR. If teachers do reference the historical
foundations of MBSR, it will be necessary to make a link to other religious
traditions that include contemplative practices so as to make it clear that
rather than religion, the skills central to contemplative practice itself are the
focus of what is being taught. Discussing the specific health benefits of
MBSR to the demographic of the participants (e.g., African Americans have
an increased prevalence of diabetes and hypertension; South Asians,
particularly those from India, have a high proportion of cardiac disease)
may make the program more relevant to those who are otherwise on the
fence about the program’s personal applicability.
With respect to relevance, how the work is framed may enhance or
limit how applicable people think the work is to their own situation. Amaro
(2014) discusses that when she and Vallejo offered MBSR to a group of
African American women with substance use disorder, the participants did
not initially see mindfulness concepts specifically used to address stress as
inherently acceptable or meeting their perceived needs. But when
mindfulness was framed as a treatment with specific goals for substance
use, they could relate to this as personally relevant and were willing to
attend.
 Another potential barrier is the need for a teacher to be culturally
sensitive to language, watching for the tendency to preference the familiar
and to discount idioms and expressions with which he is unfamiliar. He will
need to check in or pay attention to whether people feel the need to use
“diction or references they wouldn’t otherwise use” (Washington & Patrick,
2018)—meaning that they change their words and phrases to match those of
the dominant group. With respect to language, another obstacle may be if
MBSR is being taught in a language other than English. An important
question to answer will revolve around whether or not direct translation of
concepts and materials is sufficient for teaching or whether further changes
will be needed to the way concepts are expressed so that they are both
understood and relevant to the recipients.
It will also be important when discussing key themes to use
appropriate cultural or socioeconomic-related references when considering
examples to be used in teaching. There may be certain exercises or practices
(e.g., difficult communications styles exercise) that could require adaptation
depending upon cultural norms around such factors as eye contact,
nonverbal communication, managing conflict, body language, power and
gender dynamics, and the management of trauma, to name a few.
A lack of cultural competence on the part of the teacher will also be an
obstacle to those of diverse backgrounds if the teacher is unaware of the
need for those participants “to recognize and honor their own cultural
beliefs and practices” (Ladson-Billings, 2006, p. 36). Therefore, this will
require that the teacher himself recognize that this is an issue. Ladson-
Billings states that “culturally relevant pedagogy is one of the ways of
‘being’ that will inform ways of ‘doing’” (p. 41). This is congruent with one
of the important intentions of MBSR, that of being present with others,
rather than impressing on another a particular view of doing.

Content
Any curriculum, and this applies equally to MBSR and other MBPs,
contains content that expresses particular values. For example, some of the
values of MBSR include spending time in formal meditative practice,
cultivating awareness, investigating one’s experience, developing a
nonjudgmental stance, turning toward life challenges, working with
reactivity, and supporting kindness and compassion. Attention to difference
is not a primary value in most MBPs; rather, sameness, interconnection, and
the similarity of experiences among participants are emphasized.
Unfortunately, this is a common perspective of white privilege (including in
the mindfulness field), and the disavowal of the difference inherent in
diversity can result in a discounting of the experience of others of different
races, cultures, and ages.
Another limitation to increasing the diversity of those who attend
MBSR groups is a lack of critical analysis around what is being taught, the
inherent biases of the content itself, and the biases of those teaching it.
Ladson-Billings (2006) writes that a curriculum is not “ideologically
neutral” and that it is important to both deconstruct and then reconstruct it
as needed. This means being able to bring a critical eye to the content of the
curriculum and examine its underlying assumptions and principles, what is
missing or covert in the key teaching points, and what is being valued and
what is not.
For example, teaching diverse groups necessitates the inclusion of
materials such as handouts written by authors from that culture or with deep
knowledge of that culture (e.g., if using poetry, stories, or metaphors). It
may also necessitate the use of other forms of information that convey the
messages of the program in culturally congruent ways. In addition, there
may be a need for more explicit discussion of the history of the work and its
benefits—discussion linking it to culturally diverse daily activities or
environments. It is likely that a discussion about the difference between
mindfulness and meditation will be helpful, as many groups have a tradition
of contemplative practice. Some groups may have a bias against meditation
but see mindfulness as more palatable. This means targeting “surface
structure” (cultural matching of messages and materials) and “deep
structure” (attending to the specific culture’s social and psychological
environment) (Woods-Giscombé & Gaylord, 2014). All of this requires
sensitivity and respecting, acknowledging, and celebrating differences
rather than inadvertently or advertently requiring assimilation. Such
attention to the range and specifics of participants’ cultural experience can
be established in the orientation or introductory session of MBSR, in which
the teacher shares his own social and cultural background—his place of
origin, his guiding principles, and his values—and encourages participants
to share theirs. This sets the stage for developing a sense of belonging for
the entire group, reducing the pressure for marginalized participants to fit
in.
The way that MBSR and other MBPs have been developed (as with
most psychotherapies) is to focus primarily on individual suffering. “Thus
the primary therapeutic mission in Western acceptance-based (including
mindfulness) approaches remains the affirmation of the individual self in a
nonjudgmental, accommodating way” (Hall et al., 2011, p. 7), and does not
in any deliberate way attend to the norms that govern interdependent
communities where there is less importance placed upon the self.

Interpersonal Mindfulness
MBSR and other adaptations do not directly address a lessening of an
attachment to a sense of self (Kirmayer, 2015) and spend little time on “the
relational dimensions of, or interpersonal, mindfulness” (Magee, 2018).
This focus on the individual to be aware, kind, and compassionate is deeply
personal and is combined with the implicit idea that compassion for others
will follow. But does it? We may be able to easily bring mindfulness and a
kind and curious stance to ourselves, and to those who are similar to us. It is
a big leap to move it beyond the culture or subculture in which we are
embedded to wider communities with which we have limited contact and
perhaps know nothing about (Hall et al., 2011). “If our lens stays within our
privileged circumstances, then we turn our compassion only toward things
that are personal and interpersonal. Rarely does that lens focus on systemic
problems, because the personal need to do that doesn’t exist” (Salzberg &
Williams, 2019, p. 6).
This adoption of mindfulness with a predominantly individual slant is
very congruent with Western norms and values regarding the rights,
freedoms, and power of the individual. In sessions 4, 5, and 7 of the MBSR
program, there is some time spent on the effects of such societal problems
as racism, ageism, and poverty, but the focus tends to remain on how these
larger societal issues affect the individual and how participants can respond
to them from this perspective. The sessions do not, to any great degree,
address how we ourselves may be contributing stressors to others or how
we might have a constructive impact on them beyond our mindful attention
or individual actions.
 For mindfulness to move beyond the self and to truly be inclusive, the
teaching needs to address relevant systemic and structural problems and be
transmitted or elicited in a way that can be taken up by the target audience
to make it applicable to a multicultural society. Depending upon the
context, how the content is delivered and in what form will need to be
adjusted to enhance its acceptability. This also means that a teacher will
need to reflect on how he may be (or is) maintaining the status quo, both
personally (through unrecognized bias) and systemically (by not addressing
these issues of diversity).

Presence of the Teacher

The teacher is a key factor in making MBSR and its adaptations
culturally sensitive, and therefore accessible to wider populations. A crucial
characteristic for teachers to embody is humility and receptivity to being
informed by participants. This will increase a teacher’s understanding about
their participants’ backgrounds. Furthermore, a teacher must also be
cognizant that the needs and goals expressed in the MBSR program may be
different between members from culturally diverse backgrounds.
Transparency about a teacher’s lack of knowledge of the cultures of those
he may be teaching, along with openness to being educated and a desire to
know, will go a long way to creating an inclusive and respectful
environment. Amaro (2014) also speaks of the need “to identify specific
areas of incongruity between [the MBSR program itself] and the needs of
[the] clients” (p. 612). Additionally, a teacher’s understanding and
awareness of his own culture, beliefs, values, and biases will help him not
impose these on others who may not share them (Yamada & Brekke, 2008).
When a teacher considers adapting MBSR or teaching the protocol to a
group with which he is unfamiliar, having a co-facilitator or advisors from
that background will be helpful. Teachers representative of the populations
being taught will enhance the mutual understanding of the lived experience
of that group. As well, they may potentially bring knowledge acquired from
previous experience working with that community. Familiarity with the
issues participants may bring and the social context in which they are
located will help increase understanding and relevance of the material and
the accessibility and effectiveness of the program. In these ways,
participants will hopefully feel valued, engage with the material, and be
accepting of the process (Amaro, 2014).
An aspect of increasing the accessibility of MBSR to diverse
populations will mean training teachers from a variety of racial, cultural,
and economic backgrounds. This will require an in-depth look at the
requirements of admission to training, how this training is paid for, and how
to make it financially viable for teacher trainees.
Critical self-reflection, sociopolitical awareness, and the ability to
recognize and examine one’s own cognitive biases and prejudices toward
race, gender, age, or socioeconomic status are necessary next steps if
mindfulness is to become truly universal and enhance a sense of
interconnectedness. This will necessitate instructors consciously addressing
these issues in teacher training programs and making prospective teachers
aware of them if they are not already. This process will also require the
need to think about how to integrate personal mindfulness and teaching
with issues of social justice. This is a critical step for all practitioners and
researchers in the field. Many people and some organizations are actively
involved in this process. For example, the Center for Contemplative Mind
in Society has produced the tool kit The Activist’s Ally: Contemplative
Tools for Social Change and other tool kits that are freely available from
http://www.contemplativemind.org (Edwards et al., 2007, 2017). To truly
step outside of ourselves and work with diverse groups will require turning
toward these difficult issues, actively engaging, and embracing difference.

In Closing
In this chapter, we have discussed the necessity for MBSR and other MBPs
to be more conscious of diversity, issues of inclusion, and the need to
increase a sense of belonging for all participants. This requires cultural
sensitivity, whether one is working with a specific group or with group
members from diverse backgrounds. We have outlined some areas of
consideration and some ways of adapting MBSR to help reduce oppression
and racism and to enhance accessibility, relevance, and sociocultural fit to
diverse groups. Like it or not, there will be no expansion of accessibility
without acknowledging difference and turning toward it. Yes, we are all
human and interconnected, but we come from diverse cultures,
perspectives, socioeconomic strata, and backgrounds that shape our views
of ourselves, others, and the world. Without waking up to this, mindfulness
will remain the purview of the dominant group.
 CHAPTER 9:

Research, Limitations, and Risks

In this chapter, we take a look at the research on mindfulness and what it

currently has to tell us. The past two decades have seen a significant
increase in both the quantity and the kind of research published on
mindfulness and MBPs. Broadly speaking, researchers have been interested
in the efficacy of mindfulness programs and, more recently, in the potential
mediators and moderators that may be contributors to enhanced well-being
and relief of physical and mental suffering. You might think on reviewing
the literature that the research on mindfulness provides strong evidence that
it is beneficial for many things, but on closer examination, a number of
concerns are revealed. These concerns seem to revolve around three broad
areas.
Firstly, there is no consensus around the definition of mindfulness as it
is employed in contemporary settings. This has a number of major
implications. At the very least, a common operational (concrete,
observable) definition about what is being investigated is crucial for
comparing and interpreting outcomes between studies. This also matters
because we need to be sure we are investigating what we think we are,
avoid other explanations for our results (confounding variables), and
determine whether we can generalize findings or repeat them. If we see a
particular outcome in only one study, but not when we repeat it, the results
are meaningless with respect to their utility and generalizability beyond that
study. And in fact, such outcomes may be spurious. Even when a researcher
is investigating an application of mindfulness such as MBSR, there is
variability in the MBSR programs being offered between studies and
sometimes even within studies. Few studies measure fidelity to a
standardized curriculum or, as we will explore in this chapter, detail how
they adapt MBSR to accommodate the specific population or condition(s)
being studied.
 Secondly, the quality of the research is varied (Dimidjian & Segal,
2015). Some of this is due to the nascent nature of the field. Some of it is
due to the diversity of medical conditions targeted for research purposes
and the differing mindfulness practices used between studies, thus making
direct comparisons difficult.
Thirdly, the studies often use different measures to evaluate outcomes.
This makes it hard to know how to interpret results, as well as to know
which results can be reasonably or confidently ascribed to mindfulness
training and to MBSR specifically.
Furthermore, because of the enormous interest in and uptake of
mindfulness into many settings, what is being imputed to it has outstripped
the evidence. This has led, in some cases, to misinforming and
overpromising the public, potentially putting participants at risk. What is
promising, however, is that the field of mindfulness is bringing attention to
these concerns and taking positive steps to remedy them.
We now turn our attention to the difficult issue of characterizing or
defining mindfulness, a necessary step for ongoing research. To do this, we
need to briefly trace its antecedents.

Describing Mindfulness
Mindfulness is one of the translations for the Pali word sati, which has also
been understood to mean “to remember” or “to bear in mind.” The concept
of mindfulness has roots in Buddhist philosophy and practice, particularly
as a kind of awareness that is the product of meditation practice. However,
within Buddhism, there are distinct traditions that offer different approaches
to the practice of mindfulness, and these have also been subject to change
over time due to specific cultural conditions (Dunne, 2015). If the
traditional forms of mindfulness lack cohesion as to what mindfulness is
and how one observes it, then researchers face a dilemma, as this raises
questions about what constitutes mindfulness and its practices and how to
best evaluate outcomes and measure its impact. Furthermore, an additional
level of complexity is that Buddhist psychology and the original intentions
of mindfulness practice itself are not centered on ameliorating or
investigating specific clinical conditions using the scientific method. That
is, there is a fundamental mismatch between mindfulness as originally
conceived and mindfulness as expressed in MBSR.
In relation to the MBSR program, Kabat-Zinn (2003, p. 145) uses the
following operational working definition for mindfulness: “the awareness
that emerges through paying attention on purpose, in the present moment,
and nonjudgmentally to the unfolding of experience moment by moment.”
In this definition, Kabat-Zinn is using mindfulness and awareness
synonymously. The practice of mindfulness is a training that deliberately
develops an attentional skill that has a present moment focus; observing and
participating in a present moment orientation includes an attitude of
nonjudgment that utilizes both curiosity about and acceptance of whatever
is occurring. In his definition, Kabat-Zinn is referring to a “state,” that is, a
distinct condition of mind resulting from meditation practice, which tends
to be short-lived; however, mindfulness has also been described as a “trait”
(a more stable and enduring quality), where the learning gained from
practicing mindfulness informs one’s interactions in everyday life. This
requires memory and evaluation, and also for mindfulness to eventually
become a way of being. When we understand mindfulness as a trait, the
ultimate intention of its practice is essentially to wake up to the reality of
being human.
Research assessing trait mindfulness uses self-report questionnaires,
such as the Five Facet Mindfulness Questionnaire (FFMQ) (Baer et al.,
2006). Such questionnaires are often administered before and after the
experience of a program. Assessing state mindfulness is more challenging,
as it requires measuring mindfulness in the moment. Therefore brain-
imaging techniques such as EEGs and functional MRIs (fMRIs) are being
used in an attempt to objectively measure and map state mindfulness. There
is an ongoing discussion about the utility of using both of these instruments
together to further understand the workings of the brain (Mulert, 2013).
However, using fMRI is extremely expensive as compared with EEG. Also,
new findings from neuroimaging should be acknowledged with caution as
to how they might impact the ongoing development of MBPs, as there is
inconsistency in the research, partly because it appears that broad networks
rather than specific areas in the brain are altered by meditation (Van Dam et
al., 2018).
Mechanisms, Intentions, and Processes of
Mindfulness
In an early attempt to describe the mechanisms of action underlying MBPs,
and indeed for mindfulness, Shapiro et al. (2006) proposed a model for
studying mindfulness. These mechanisms (axioms) consist of intention,
attention, and attitude, which are seen as “interwoven aspects of a single
cyclic process [that] occur simultaneously” (ibid., p. 375). Employing
Kabat-Zinn’s definition of mindfulness (2003), the authors see “on
purpose” as requiring intention; “paying attention” as attention, and “in a
particular way” as attitude, which encompasses mindfulness qualities. The
authors go on to state that intention will be subject to change as a
participant continues to practice, leading first to “self-regulation, then to
self-exploration, and finally to self-liberation” (de-centering from a fixed
sense of self). Attention is seen as the ability to observe one’s internal and
external experience moment by moment. And attitude refers to the qualities
of how one is attending, such as acceptance, patience, nonjudging,
beginner’s mind, trust, non-striving, and letting go (Kabat-Zinn, 1990,
2013).
From this model, Shapiro and colleagues (2006) suggest that the three
axioms of intention, attention, and attitude (IAA) are underlying
mechanisms that directly or indirectly account for “the variance in the
transformations that are observed in mindfulness practice” (ibid., p. 377).
The authors go on to suggest that intentionally attending (IA), with
openness and nonjudgment (A), leads to a shift in perspective, which they
label as a “re-perceiving.” Re-perceiving is seen as a meta-mechanism of
action, which influences change and positive outcomes. In addition, self-
regulation, values clarification, exposure, and cognitive, emotional, and
behavioral flexibility are seen as variables related to other psychological
outcomes of mindfulness practice.
For a different view of the intentions of mindfulness meditation, found
within a traditional context, contemporary Vipassana teacher Gil Fronsdal
(2016) describes three objectives of mindfulness meditation as “knowing
the mind, training the mind, and freeing the mind.” Fronsdal states that by
knowing the mind, we are learning to notice and explore the contents of the
mind and underlying tendencies. This requires training so that we come to
“see” what activities of the mind (thoughts, emotions, body sensations,
behaviors) are beneficial and which are unhelpful. With practice,
understanding grows, recognizing that being caught in certain mind states is
problematic, leading to increased misery. Learning to let go of (too much)
wanting is a key aspect of freeing the mind.
In another attempt to develop an approach to understanding the
underlying processes of mindfulness, Lutz and colleagues (2015) described
it as a spectrum or a “continuum of practices involving states and
processes” rather than as a discrete, single entity. This allows for the
inclusion of differences and greater clarity regarding the quality or type of
attention under investigation when studying MBPs. For example, in MBSR,
focused attention and open monitoring (attentional skills occurring along a
spectrum) are emphasized at different points during the program, although
they are seen as equally important practices. The first training of attention is
to maintain focus on a particular object, and when the attention moves away
from the object, to note that and then to return to the original intended
focus. The second fosters an all-inclusive open awareness (meta-awareness)
of all experience as sensations.
However, while each of these many descriptions is useful in its own
way, a standardized approach to research methods is necessary for
comparing studies, gathering information, making observations, interpreting
findings, testing hypotheses, and measuring outcomes. If there is no agreed-
upon description or definition of mindfulness, or indeed consensus about
what is being observed and measured, then it is difficult to generalize from
the results, or in fact to know what it is we are investigating. Researchers
are left to choose from a variety of accounts of mindfulness to apply to their
particular areas of study.
This lack of a single description or definition produces additional
problems for researchers when deciding which mindfulness practices to use
and to what ends. If different practices are used in various studies,
determining which ones are resulting in which outcomes becomes
challenging. Furthermore, many of these studies are also attempting to
address such questions as how long practices should be; which practices are
beneficial for which conditions; what the general benefits, limitations, and
risks are; and even whether practice (or an amount of practice) is correlated
with the development of mindfulness. Most importantly, teasing out which
specific variables (or elements) underlying mindfulness practice are
responsible for cognitive, emotional, and behavioral change, and how they
work, is a current and challenging exercise for the field. However, engaging
in the scientific investigation of mindfulness, within its contemporary
setting, is crucial for understanding its use as a therapeutic approach.

Current Research in Health Care

Before we move into a discussion on the specific research of mindfulness in
health care, a brief review of the scientific method may provide a useful
foundation for understanding what is happening in the field. Research
allows us to ask questions that foster exploration and provide explanations
by investigating hypotheses using the scientific method. The value of any
research will be predicated on the methods used, its lack of bias, its
reliability (ability to be replicated), and its validity, both internal (how
confident you can be that the findings are true and not a result of another
cause) and external (the results of a study can be applied to the real world
and are therefore meaningful).
The most extensive research into mindfulness and MBSR is in health
care. For that reason, we made the decision to focus on what is being
studied in this area, as it illustrates and clarifies some of the issues the field
is facing. To try and get a snapshot of how MBSR has spread and the many
ways it is being used and studied, we conducted a literature search using
PubMed, the online search engine of the US National Library of Medicine
at the National Institutes of Health. Using the terms “MBSR” and
“mindfulness-based stress reduction,” we examined all articles published in
2019 alone. There were 187 citations identified, representing articles
researching the science and implementation of mindfulness-based
interventions; studies of association examining the correlates and
mechanisms of mindfulness; articles describing the measurement and
methodology of mindfulness; and reviews, which attempted to survey
content areas or systematically review the use of mindfulness in its various
forms in a specific condition or population. Finally, a number of studies of
mindfulness were identified that cited MBSR in their introduction or
discussion but were not studies of MBSR or its adaptations per se.
Of the studies that investigated MBSR, or an MBSR-derived program,
there were fourteen individual studies on various forms of chronic pain.
There were also two reviews of mindfulness in chronic pain, which
included studies of MBSR and specific adaptations, such as mindfulness-
based chronic pain management (MBCPM). Eight studies were specifically
directed toward cancer, including four for breast cancer. There were also
four review studies of mindfulness and cancer that would have captured
both MBSR and cancer-specific adaptations. Another eighteen individual
studies and four reviews targeted various other medical conditions,
including cardiovascular disease, multiple sclerosis, and stroke, and
included five studies in women’s health (infertility, urinary incontinence
among women, and menopause). Of the studies in other medical conditions,
three were of diabetes and three were of obesity or disordered eating; four
of these other studies cited adaptations to the curriculum to include eating
and weight management as part of the intervention, and one was app based.
In 2019, with respect to mental health, there were twelve individual
studies and three reviews of MBSR. Two looked at general mental health
populations and the rest focused on specific mental health conditions, such
as geriatric depression, mild cognitive disorder, social anxiety, and
traumatic brain injury. It should be noted that the majority of studies in
non–mental health conditions still included depression, anxiety, and stress
as outcome measures. There were only two studies on substance use
disorders, and neither specified whether they were using MBSR or an
adapted protocol for substance use.
There were twenty-six studies and nine general reviews looking at the
use of MBSR with specific populations, including eight individual studies
of health care workers, from nurses to medical residents to emergency
medical services technicians. Among twenty-two of the studies that
addressed specific populations, there were six of parents and family
caregivers of dependent relatives, including caregivers of Alzheimer
patients, parents of children with autism or developmental delay, and
parents of children in the neonatal ICU. Among these studies were a
smattering of other populations, including tennis athletes, schoolteachers,
and inmates. Of these studies, four were online or app based in various
populations. There were six studies that were in heterogeneous populations
of the general public, and most of these were association or mechanism
studies.
This summary represents a cross-sectional view of how MBSR, and its
adaptations, are being utilized in myriad ways. If nothing else, it is stunning
to see the variety of conditions and populations to which mindfulness is
being applied, further demonstrating its growing popularity and move into
mainstream medicine. A key finding is that, surprisingly, few studies
actually discussed their curriculum or specified whether and how they had
modified it to accommodate the clinical condition or population they were
researching. Another key point, even in non–mental health conditions such
as diabetes or cancer, is that it is not a change in the physical condition
itself that is the usual outcome measure, but rather stress, depression, and
anxiety associated with the physical ailment.
We can deduce from this limited review that MBSR is being adapted to
different target audiences but not how it is being altered, if it is, from the
original curriculum. These are critical points because we are not yet sure
which elements of MBSR are necessary for positive outcomes. In fact, there
are few dismantling studies of psychotherapy, and mindfulness in particular
(Fielding, 2009), that look at mechanisms or common elements.
Dismantling studies allow for the discovery of the essential aspects of a
psychotherapy that act as agents of change or add to its impact. This is an
important discussion for therapeutic mindfulness and for ongoing research,
where it is often espoused that it is necessary to use the entirety of a
mindfulness curriculum or manualized treatment in order to consider it
mindfulness-based and for it to be effective. This is problematic for the
integration of mindfulness into a variety of sectors given the number of
applications, diverse contexts for its use, and varying degrees of acceptance
into organizations.
Adaptations without this clarity make it challenging to determine what
is actually being investigated or which elements are responsible for benefits
seen. One limitation of our review of the literature is that it is taken from
published medical research cataloged in PubMed. It may therefore bear
little resemblance to how MBSR is being offered in the general health care
system or wider community. However, what is most relevant for our
purpose is that it does show that MBSR has extended beyond its
transdiagnostic origins to encompass a wide diversity of targeted
applications and adaptations.
With that in mind, we turn our attention to the clinical benefits of
mindfulness, as we currently understand them.

Clinical Benefits of Mindfulness

Discussing the clinical benefits of mindfulness requires reviewing one of
the most researched adaptations of MBSR, MBCT. MBCT, derived from
MBSR (and CBT), has been methodically and rigorously studied for the
prevention of depression relapse and treatment-resistant depression
(Eisendrath et al., 2014, 2016; Kuyken et al., 2015; Collins & Segal, 2020),
as well as more recently using randomized controlled trials for people
experiencing depressive symptoms (Chiesa et al., 2015; Collins & Segal,
2020). Recent MBCT studies have provided early evidence that the skill of
cognitive de-centering and that of increased distress tolerance are important
elements for the outcomes associated with mindfulness practice. The
findings of two recent studies suggested that de-centering (meta-cognitive
awareness) helped participants manage distressing thoughts and emotions
and was a significant mediator for reducing relapse in depression (Farb et
al., 2018; Segal et al., 2019).
Fluctuation of low mood is a normal part of daily living, but in patients
with a mood disorder, low mood can lead to the activation of negative
thinking patterns (rumination) experienced when depressed. In the Segal
(2019) study, improved distress tolerance was an additional regulatory skill
for those with a history of depression. Indeed, reduction of maladaptive
rumination appears to be a critical mediator in the clinical benefits of
mindfulness (Heeren & Philippot, 2011). In a meta-analysis of mediation
studies, there was evidence for mindfulness, rumination, and worry as
underlying processes, and as significant mediators of clinical outcomes (Gu
et al., 2015). Given that these were studies of both MBSR and MBCT, the
findings suggest that these mechanisms are at work in both modalities.
MBSR has been shown to reduce stress, anxiety, and depression
(Khoury et al., 2013) and increase positive mood and compassion (Khoury
et al., 2015). In the largest systematic review and meta-analysis to date
(Goldberg et al., 2018), comprising 142 studies, the majority being of
MBSR and MBCT, the most consistent evidence was found for depression,
pain, smoking, and addictions. There has been extensive research in the
area of chronic pain demonstrating the value of mindfulness in reducing the
perception of pain by reducing its associated emotional and cognitive
aspects (Veehof et al., 2016). Other studies have demonstrated
improvements in working memory (Jha et al., 2010), although these
findings are mixed (Chiesa, Calati, & Serretti, 2011). Mindfulness
meditation practice appears to be associated directly with cognitive
flexibility (Siegel, 2007). There is also early evidence that practicing
mindfulness produces measurable effects on the brain (Tang, Hölzel, &
Posner, 2015). While MBPs are now seen as credible and viable
psychosocial treatments for a number of primary or secondary mental
health problems, the research is still far from complete or consistent with
respect to its outcomes or how it is being conducted.

Risks and Limitations

We have briefly outlined some of the fundamental issues that are inherent to
the research, as well as demonstrated the increasing interest science is
showing for the study of the potential benefit of mindfulness and
mindfulness-based programs. Mindfulness practices hold great promise in a
variety of settings, both inside and outside of health care for the reduction
of suffering, but it is also important to understand the potential limitations
and risks, particularly as this relates to teachers of MBSR and MBPs in
general. As of yet, there is very little research investigating the adverse
effects of mindfulness meditation practice, although there is increasing
interest in this area.
In traditional Buddhist circles, the appearance of challenging
psychological and physiological effects from practice are seen as part of the
spiritual path and therefore are not unexpected when they occur
(Buddhaghosa, 1999; Dalai Lama, 2011). But MBSR offers contemplative
practices that sit squarely in contemporary culture; therefore, when adverse
effects present themselves, teachers need to be conversant about them and
know how to offer appropriate support when needed.
Qualitative and quantitative research into mindfulness indicates that
people do face difficulties and challenges with their practice (Malpass et al.,
2012), and that meditation can be correlated with adverse effects such as
increased anxiety (Cebolla et al., 2017). In a study with experienced
meditators, strong emotional content included feelings of panic, anxiety,
fear, paranoia, depression, and grief (Lindahl et al., 2017). Unpleasant and
challenging states, as a result of meditation practice, can be harmful if they
produce long-lasting effects, make symptoms worse, or cause deterioration
in mood or function that put people at risk. This is an important area of
study and one about which we have little information. To date, the evidence
is retrospective, based on self-report and uncontrolled for bias.
 The burgeoning interest and excitement in investigating, using, and
adapting MBPs as a treatment modality has meant that researchers have
been focused primarily on what mindfulness is doing and how it may work.
This may have resulted in a positivity bias, with the subsequent neglect of
attention to negative outcomes. MBSR, as we have stated, is not a panacea
and its specific mechanisms or psychological effects are not well
understood. While we are using it to increase well-being and mitigate
distress, we need to be cognizant of and continue to examine its underlying
mechanisms, for whom it is most suitable and when, and the potential
adverse outcomes and how to manage these (Dobkin, Irving, & Amar,
2011).
Therefore, requiring screening criteria as an integral part of an
orientation session is crucial. How much screening a teacher will be able to
do will be dependent on the setting in which she is teaching, as well as the
boundaries of her professional designation. During this initial evaluation,
clearly explaining the potential risks and benefits in taking MBSR will go a
long way toward educating and protecting the consumer. Indeed,
preliminary research suggests that where the criteria for participation was
well delineated and the mindfulness teachers were well trained, there
appeared to be no evidence of harm (Kuyken et al., 2016).
Participants with identified mental health conditions may be best
served by clinicians. An example of such conditions might include a history
of repeated depressive episodes, severe anxiety, unprocessed trauma, active
substance use, active suicidal ideation, or a history of or current psychosis.
Furthermore, health care providers who have expertise in working with
these populations should know the limits of their scope and be able to
recognize and manage adverse effects resulting from participating in the
program.
It helps to know that the MBSR program has been adapted to support
those with a history of trauma and teachers have learned how to adjust their
teaching so that they are sensitive and knowledgeable in this area (Kelly &
Garland, 2016; Treleaven, 2018). MBCT as cited above is delivered
primarily by clinicians because it was specifically designed for patients who
have had several episodes of depression and targets relapse prevention.
There is good evidence for its efficacy (Kuyken et al., 2016; Shallcross et
al., 2018).
 Dimidjian and Segal (2015) address some of the important gaps and
limitations in the existing evidence and suggest a number of
recommendations to further an integrated process to fundamental research
questions. These include specifying intervention targets and populations,
not conflating promise with efficacy, addressing clinician training, and
delineating the specific effects of MBPs. They also propose improving the
methodological quality of individual studies. Using a National Institutes of
Health stage model (Onken et al., 2014), which is a behavioral intervention
model consisting of six stages, they analyzed the current evidence. By
mapping the MBP evidence base onto the six stages, they concluded that
the existing evidence is heavily skewed toward stage 0, basic research, and
stage I, intervention generation and refinement (e.g., pilot studies with the
majority using inferior control arms such as waitlist controls and treatment
as usual, versus active controls). Some research was evidenced in stages 0
and II (efficacy in research clinics with and without rigorous control arms),
but very little research was done in stage III (efficacy in community
clinics), stage IV (effectiveness), and stage V (implementation and
dissemination). Their analysis demonstrated where the gaps in the research
exist and where it could be most useful to direct future efforts, rather than
continuing to focus on the type of studies to date. This would further
contribute to our understanding of the utility and effectiveness of MBSR
and other MBPs.
We have clearly passed the period of early adoption of innovation with
respect to MBSR and MBPs. Differences and similarities between
mindfulness and other treatment modalities are being identified.
Mindfulness has been shown to be equivalent to medication under certain
circumstances and therefore is a viable alternative, particularly for those
who would prefer not to take medication (Kuyken et al., 2015). Still other
research is showing that MBPs are equivalent to other psychotherapies
(Goldberg et al., 2018). Increasing the rigor of the research in this field and
engaging in community effectiveness trials are necessary next steps to
understand the real-world impact of MBPs on the ground.

In Closing
There is no question that the amount of published research available on
mindfulness and MBSR is overwhelming. In this chapter, we discussed
some of the issues that the field is facing in the study of mindfulness and
MBSR. Because MBSR originated in a hospital setting, we decided to focus
on the research in the health care domain. The research there, although still
early, is extensive and has made inroads into uncovering the potential
benefits of mindfulness approaches. However, it has only just begun to
examine which variables are contributing to these outcomes. Due to a
variety of methodological limitations, many of the studies show mixed
results. Outside of health care, in other settings where MBSR has been
adopted, there is even less research, and what exists often has even more
significant limitations. It would seem that developing specific objective
measures founded on a clear definition and description of mindfulness
could assist in mitigating some of these concerns.
 PART 5:

The Professionalization of MBSR:

Maintaining Competence

A book on training people to deliver MBSR would be incomplete without a

chapter on the professionalization of the field, given the current evolution
of MBPs into various domains of Western culture. In this chapter we
discuss standards of training, development and maintenance of competence,
the relevance of personal practice, and the regulation or lack thereof of
mindfulness-based teachers. We see mentorship as a critical component to
the development of competent teachers. We also discuss future directions,
the integration of technology, and cost-effectiveness to make the training of
future teachers more accessible.
 CHAPTER 10:

Training and Professional Development

The rapid dissemination of MBSR and its adaptations into mainstream

society have brought with them an inherent tension for the training of future
teachers. With the spread of MBSR globally, training centers are quite
naturally influenced by national and regional mores, particularly as these
relate to the professionalization of any occupation. This would include any
required standards for professional development inside and outside of
professional training programs (e.g., social work, law, teachers,
psychologists, physicians). In several major mindfulness training centers
(predominantly in North America, Europe, and Australasia), there is
implicit agreement about how to go about training future teachers, but not
consensus. Indeed, it should be remembered that MBSR is not regulated
and therefore those teaching it, unless already members of a designated
profession, are not subject to any form of governance except public law.
What is common to these training programs is that they target the
development of specific skills (e.g., the delivery of core practices) through
experiential and didactic methods, maintain adherence to a curriculum (with
a range of flexibility), and stipulate that an MBSR teacher have a personal
mindfulness practice. To this end, many of them require attendance at silent
or hybrid retreats.
What constitutes a training program after that, and the time required
for the development of core teaching skills and best practices, is neither
well known nor widely studied. Indeed, the research to date has focused
primarily on the efficacy of MBSR rather than the competence of the
teacher delivering the program and the relationship of this to the
effectiveness of MBSR in the real world. Added to these issues, MBSR
teachers as an occupation are not regulated and therefore neither is their
training. They are often not required to meet specific standards related to
teaching competencies by any external body. This means that anyone
(individually or as part of an organization) can teach the MBSR program
without any training (as long as they are meeting certain requirements
necessary to call what they are teaching MBSR). This potentially places the
public at risk. Furthermore, anyone developing a training program for
teachers inside or outside of an academic institution can do so.
The development of the formalized training of future MBSR teachers
was created by and large by separate but associated events in the early
1990s. The first was the publication of Jon Kabat-Zinn’s Full Catastrophe
Living (1990), and the second was the airing of the documentary Healing
and the Mind with Bill Moyers, broadcast in 1993. With the publication of
Jon Kabat-Zinn’s book about the work of the stress reduction clinic at the
University of Massachusetts Memorial Medical Center and the publicizing
of the television documentary, the MBSR program reached a much bigger
audience. The upshot was a significant increase in interest about the MBSR
program and people applying to the clinic, wanting to be trained as MBSR
teachers. Ultimately, this led to the creation of a professional certification
pathway at the clinic and the founding of the Center for Mindfulness in
Medicine, Health Care, and Society (CFM) at the University of
Massachusetts.
The creation of the training program at the CFM was an organic
process that developed over time and resulted in a number of iterations.
However, it never wavered from the requirement that teachers needed to
have a personal mindfulness meditation practice and attend silent teacher-
led retreats. The CFM became the dominant influencer and de facto leader
for MBSR training worldwide. Ultimately, there are always challenges
when there is a monopoly. Such a stance, which is related to both control
and quality assurance, can also create an insular perspective. As MBSR
became more widely disseminated, the CFM found it increasingly difficult
to meet the needs of teachers wanting to be trained. Eventually, this led to
other centers worldwide developing their training pathways, some under the
auspices of the CFM and others independently, inside and outside of
educational institutions.
We now turn our attention to common assumptions that many training
centers make about the important training modules to be included in
training pathways. On examination of the current MBSR training programs
in North America and Europe, we see some common threads. First, there is
the assumption that the teaching of MBSR will only be as good as the
teacher and his understanding of two variables—that teaching is imbued by
the strength of his personal mindfulness practice and that this understanding
will influence and determine the way in which the various modules of each
session are taught (McCown, Reibel, & Micozzi, 2010). Additionally, a
teacher needs to learn about the various components to be taught that are
embedded in the program, develop specific skills of facilitation, and take
into account the context in which he is teaching (Crane et al., 2012).
So how does a training program attend to the trajectory of a teacher’s
personal practice? This is an unusual requirement for a teacher and stands
outside customary requirements for delivering an educational or therapeutic
program. It is easier to measure adherence to a curriculum/protocol than to
concretely measure a teacher’s embodiment of mindfulness practice. How
can this be assessed? And does the embodiment of mindfulness predicated
on personal practice actually affect outcomes? In other words, does
personal practice really matter?
As a way to emphasize the importance of a teacher’s personal
mindfulness practice, many training centers embed the need to attend silent
teacher-led meditation retreats prior to entry into a training program and
annually for the duration of the training. There is also an expectation that
once training is completed, a teacher will continue to attend these retreats
on a regular basis. A number of training centers also include mentorship or
supervision during the course of a teacher’s training. These senior
teacher/trainers have many years of personal practice, attendance at retreats,
and teaching the MBSR program. It is expected that mentorship addresses
skill development with respect to program delivery and attends to the
teacher’s personal practice and the embodiment of mindfulness as it relates
to teaching.
Of these two identified aspects for the training of MBSR teachers,
training to a curriculum/protocol is the easier of the two. The curriculum
serves as a safety net for quality assurance and increases the likelihood that
teachers maintain fidelity to the MBSR modules. However, MBSR does not
have a written curriculum per se. Full Catastrophe Living does provide a
description of the program, and the book has served the function of a
written curriculum for many until recently. In 2017, an “authorized”
curriculum guide was published on the CFM website. However, the authors
of this guide caution the teacher about conceiving of it as a manualized
protocol, the rationale being that there is an inherent risk in viewing a
protocol as providing the totality of what it means to teach MBSR. In their
view, this would be to downplay the contribution of an “intelligence” that
arises from a personal practice and just needs to be remembered. This
acquired intelligence is, they maintain, accrued via practice through
repetition and the development of skills honed over time. Our concern,
already expressed previously in chapter 2, is that building the skills of an
embodied mindful presence will take time, but having a
curriculum/protocol prepares the necessary ground for what to teach and
when. Adhering to a clearly defined structure is relatively easy. Once this is
learned, more time can be given to the development of a mindful approach
to teaching. Indeed, we could be in danger of conflating two things here.
Developing a mindful approach and understanding what that entails is one
thing; it is a lifetime’s work to support one’s own meditation practice.
This is where we need to digress for a moment and trace some of the
early history of how MBSR teachers were originally trained at the CFM.
The initial teacher trainers were in direct contact with the founder of MBSR
and his colleagues teaching in the stress reduction clinic. We can call these
trainers the first generation. Later on, the training process employed
second-generation trainers who had had access to the first generation. In
some ways, this process mimics how the practice of meditation is passed on
—through direct access to the teaching of respected teachers and founded in
an oral tradition. It is, for all intents and purposes, an apprenticeship model
based primarily on experiential learning and feedback from a mentor.
The difficulty with this trajectory and structure is that it (1) places a
great burden on a few well-regarded and experienced trainers, and hence is
impossible to scale; and (2) does not build capacity in the field. MBSR is
being taught across the public sector in health care, education, and the
workplace. With MBSR and its many adaptations being rapidly adopted, we
need to look at not only how to meet the needs of those future teachers who
work in different sectors and represent different cultures and ethnicities but
also how to foster the development of diverse future trainers.
As the need for training programs increases, there is concern around
the possibility of compromising the quality and integrity of teacher training.
Part of this issue is related to the growing evidence for the efficacy of
mindfulness-based programs and the additional pressure exerted on training
programs to produce teachers promptly. To some extent, part of this
integrity of purpose is being addressed by concentrating on specialized
adaptations of MBSR requiring specific training (e.g., mindfulness-based
cognitive therapy, mindfulness-based relapse prevention).
On the other hand, as we discussed in chapter 6, a common elements
approach to the various programs offering adaptations of MBSR might be
useful for training future teachers, as there is an increasing need to pay
attention to scalability, cost-effectiveness, and time constraints of potential
trainees. The most researched adapted versions of MBPs seem to contain
the same components or elements and also address what are perceived to be
universal mediators, moderators, and mechanisms related to the acquisition
of mindfulness skills to alleviate distress. This also relates to the targeted
population, irrespective of whether the issues are medical, psychiatric,
social, educational, or occupational, because problem specificity is actually
not the target of mindfulness. Rather, the focus is the associated suffering,
how it is being experienced, and how one relates to or manages it regardless
of its origins. Therefore, we might suggest that by using a common
elements approach, mindfulness training would be more generic, less
specific, and thus more cost-effective and efficient while achieving the
same general aims, only adapted when necessary.
In an attempt to promote intervention integrity and provide an
assessment tool measuring adherence to the MBSR program structure and
evaluate a teacher’s competence, including embodying mindfulness, Dr.
Rebecca Crane, PhD, and associates in the UK developed the Mindfulness-
Based Interventions: Teaching Assessment Criteria (MBI:TAC, 2018). In
the design of the MBI:TAC, the developers considered three areas of
interest that are important for intervention integrity: adherence,
differentiation, and competence. Adherence ensures that all the components
of the program are present, differentiation makes certain that no
components are added that shouldn’t be there, and competence denotes the
skill level of the teacher. All three are observable measures that quantify the
presence or absence of specific prescribed teaching elements and behaviors.
The MBI:TAC also considers six domains. These are coverage, pacing,
and organization of session curriculum; relational skills; embodiment of
mindfulness; guiding mindfulness practices; conveying course themes
through interactive inquiry and didactic teaching; and holding the group-
learning environment. Each domain contains a number of key features. The
authors state that currently they are not sure which competencies are
predictive of participant outcomes, but that each of the domains appears to
be essential to the whole process of teaching. In measuring the skill of the
teacher, the MBI:TAC uses a numeric value on a scale of 1 to 6, with 1
being incompetent and 6 being advanced. While there are a number of
issues associated with the MBI:TAC, including how the domains are
operationalized, their internal and external validity, interrater reliability, and
the use of such a rating scale as incompetent to advanced, rather than
novice to expert (MacPherson, 2020), it is the first comprehensive attempt
to develop a tool to assess the performance of mindfulness teacher trainees.
Research into measuring teacher competence and how that relates to
outcomes is in its infancy. In a study that utilized the MBI:TAC, the results
indicated that teacher competence was not significantly associated with the
number of MBCT sessions attended (adherence) or change mechanisms
such as rumination, mindfulness, cognitive reactivity, and self-compassion
(Huijbers et al., 2017). Indeed, teacher competence was not significantly
related to some key outcomes for depressive relapse during the fifteen-
month follow-up. The authors posit that this may be related to the MBCT
standardized protocol, the focus on participant self-reliance as an important
learning tool, other participant-related factors, and difficulties in the
assessment of teacher competence. Clearly, there is much work to be done
in this area, particularly as it relates to teacher competence, how to assess it,
and its relationship to client outcomes.
While we have spoken to the lack of regulation in the field with
respect to those delivering MBSR and some of the organizations that train
MBSR teachers, the issue of who is teaching trainees, who is being taught,
what is being taught, the criteria for admission to training programs, and
their duration and cost are also ongoing concerns. There is great complexity
around the issue of training precisely because of the broad reach of MBSR
into many sectors, both public and private, and the confusion around what
exactly MBSR is, as discussed in chapter 1 and chapter 9. Is it a therapy, an
education, a skill, a way of being, a spiritual path, or a combination of all of
these? Who is delivering it and who should be, what level of education
should be required, how much personal practice a teacher needs, and what
sector should they come from (education, health care, business, etc.) are a
few of the questions to be addressed in this rapidly evolving field. In
addition, as discussed earlier, participant diversity and how to train people
from diverse backgrounds are key issues to be addressed.
 Relevant to diversity is the cost of these training programs and the
length of time it takes to become an MBSR teacher. On review of a
selection of training centers in North America and the UK, the cost ranges
from reasonable to prohibitive depending upon who is delivering the
training and the context in which it is taking place. The time to completion
of training varies widely because it isn’t standardized or regulated. The cost
and the time commitment are often not sustainable or viable for many
people, and very few programs have scholarships available.

Future Directions
Perhaps the time is ripe for an overhaul of the way in which the training of
MBSR teachers has been conducted to date. Without sacrificing the
development of core competencies and best practices, can we develop
alternative methods of training? We have already seen that current training
is expensive and therefore has limited accessibility. Many educational
institutions are employing technology by putting training online to offer a
less expensive alternative and increase access as well as capacity. Teachers
in grade schools, colleges, and universities are utilizing both low-tech
methods such as experiential learning (learning by doing) and high-tech
methods using synchronous and asynchronous means. Some MBSR training
centers have started to offer distance learning through the use of technology,
but the majority are still overly reliant on the physical presence and in-
person interaction between the trainer and the trainees as fundamental to
learning.
Another issue is the inherent assumption that has been prevalent in the
field that it takes years to hone the skills of an MBSR teacher. While we
agree that training takes time, we see the acquisition of skills as
developmental and that can be taught to a level of proficiency that need not
take years when adequate support is provided to the trainee. Our experience
has been that if a trainee is given access to a senior teacher for mentorship
as soon as they begin teaching an eight-week program, the timely
acquisition of specific teaching skills, competency, and best practices is
enhanced.
Working with a senior MBSR teacher is an intense process.
Mentorship or supervision consists of meeting on a weekly basis with the
trainee while he is running the program and reviewing audio or video
recordings of the teaching. For the purpose of developing competence and
best practices, it is encouraged that the trainee review these recordings for
the purposes of self-assessment, and it is also required that the mentor
provide ongoing feedback. Competence can be understood as skills
combined with knowledge and ability. Best practices represent what are
viewed as being most effective for delivery and for protecting the consumer.
These are based on research, standards of care, expert consensus, opinion
leaders in the field, and current theoretical perspectives.
We see the use of technology as key to making MBSR training cost-
effective and providing increased access to training. The core components
of the MBSR program, currently taught face to face in intensive trainings of
varying lengths, could be offered using synchronous and asynchronous
videoconferencing platforms, including a shorter period of in-person
training. This makes it possible for trainees and trainers to be in different
locations and saves the trainee travel and accommodation costs.
What follows is a suggested description for training future teachers in
nonacademic settings. We do realize that some countries teaching MBSR or
MBCT do so within the context of the university setting, providing students
with an academic degree (usually at the master’s level) or certificate.
Additionally, already in limited fashion, but more likely in the future,
teaching MBSR or other MBPs will be part of the curriculum for a
professional or advanced degree. However, not everyone has the financial
means or the time to enter a degree program.
We believe it is essential to have a nondegree (diploma, certificate,
certification) pathway that pays attention to accessibility, building capacity,
and training in best practices. For those who study MBSR or other MBPs,
this training falls within the domain of continuing education or continuing
professional development. We propose an example of one model for such
training that has three phases.
The first stage, focused predominantly on cognitive or conceptual
learning, would teach core MBSR concepts that utilize online learning
strategies. In this phase, the student is offered a variety of modules or
courses to cover the breadth of the MBSR program, the underlying
assumptions and principles, the evidence base, and how to establish
scientific literacy. Students engage in and experience key meditation
practices and the conceptual or cognitive exercises. The second phase
moves the trainees to work together in person with a trainer, where these
core concepts and key teaching modules (formal and informal practices,
cognitive exercises, and inquiry) are practiced by the trainees under
supervision and with structured feedback. This initiates the process of
moving from a novice toward a competent teacher by including
performance-based assessments and supervision. The final phase would
require the trainees to teach a minimum of two eight-week MBSR programs
that include audio and video content of the trainee that is used for self-
assessment and assessment by the mentor. This supervision could be done
in a group or individually depending upon the needs of the trainee. During
the process of the training, attendance at a minimum of two five- to seven-
day teacher-led meditation retreats is required. Once the trainee has met the
requirements of the program, certification is provided.
Once competency has been attained, maintaining one’s skills is
supported through attending professional development programs, including
regular attendance at silent or hybrid teacher-led meditation retreats. Other
requirements include staying up-to-date with the latest research and changes
in the field and having a community of practice consisting of other MBSR
teachers who can provide support and act as a resource. Indeed, it would be
helpful to have a means of overseeing maintenance of certification. An
association or governing body could serve this function.
The field of MBSR is professionalizing. Professionalization can be
defined in a variety of ways. In this context, we are referring to the
occupation’s mandate to control its own work and to enhance its status and
credibility by increasing the duration of training. This would include
oversight of teachers (whether this is by a self-governing body or other
organization) to ensure standards of care, competency regarding skills and
knowledge, maintenance of continuing education, and management of
complaints by the public.
The question must be asked: Can MBSR teachers cause harm? If the
answer is yes, then regulating this occupation becomes an important
direction for the field and for training programs in order to protect the
public. How this will be determined remains to be seen.

In Closing
Those training future MBSR teachers have consistently maintained that
such training must include the acquisition of specific skills embedded in the
MBSR program, but also that the teacher’s capacity to embody the
mindfulness practice is an essential aspect of being an MBSR teacher.
Predominantly due to this latter requirement for embodiment of the teacher,
training programs have tended to be at least two years in length and often
more. The duration of these programs demands a significant financial and
time commitment. We have proposed that it is perhaps time to review the
training process and incorporate the use of new technologies into training
programs to make them more efficient and cost-effective. We have given a
brief outline for one such pathway. What has been a thoughtfully created
and accepted way of training MBSR teachers may no longer be meeting the
needs of the field in the twenty-first century. Indeed, studies examining
whether current trainings produce competent teachers are lacking, as are
studies assessing the relationship between competency, how it is defined,
and how it affects participant outcomes. The field has begun to identify this
as an area in need of attention. MBSR is an evidenced-based program. Our
training programs are in need of similar confirmation that we are indeed
training the next generation of teachers to a level of competency that
correlates with effective delivery of the MBSR program.
 ACKNOWLEDGMENTS

We would like to thank our long-suffering partners, Andrew Woods and

Bryan Moran, for their love, support, and understanding while we wrote
this book. We would also like to thank M. Lee Freedman, a mindfulness
teacher, for her work on the yoga figures. With her longstanding practice of
mindfulness and yoga, as well as being a child and adolescent psychiatrist
and visual artist, she was a perfect choice to do the drawings. Ferris Buck
Urbanowski was an early advocate of and curriculum developer for training
future MBSR and MBCT teachers. Her embodiment of mindfulness, and
the heartfelt and dynamic presence she brought to trainings, was a powerful
influence for Susan and all those Ferris trained. Evan Collins, a dear friend
and colleague to both Susan and Pat, significantly contributed to this book
through his willingness to listen and edit the manuscript. We would like to
thank Tim Blair, who contributed to the intake form with useful
suggestions. We are grateful to Rose Mina Munjee for her reading and edits
of the chapter on diversity and to Rhea Plosker for contributing to the
appendix on online teaching and allowing us to use her Window of
Tolerance figure. All of these people have made the book richer for their
contributions.
Most importantly, it is with heartfelt appreciation and respect that we
wish to acknowledge the work of Jon Kabat-Zinn, PhD. It is because of his
original vision that we have the mindfulness-based stress reduction (MBSR)
program. It is through his foresight that the teachings of the Buddha
Dharma are offered in a contemporary form that does not sacrifice their
profound message. Instead, the MBSR program offers a path that is
ostensibly for the reduction of stress—but has the potential to offer so much
more—and the Dharma, in its most universal sense, as a path of liberation.
Lastly, but by no means least, our deep gratitude to all of our MBSR
participants—you were our teachers. And to all of the people who attended
our professional trainings, a deep bow to you for trusting us to do our best
to try to impart the joy, love, and mystery of what it means to be an MBSR
teacher. Thank you.
 APPENDICES

In this section of the book, we offer examples of the following: an

intake/assessment form, a consent form, a waiver of responsibility,
confidentiality agreements, and a consent to use electronic communications.
Visit http://www.newharbinger.com/45601 to download copies of these
forms. We suggest you use these as an outline and modify them to fit your
needs. We have also included suggested scripts on guiding the meditation
practices, and there is a brief piece about yoga practice along with some
illustrative figures. The scripts and additional illustrative yoga figures can
also be downloaded from the site. Again, these scripts are examples and
should not be taken literally or used to read from when you teach. Finally,
we have suggestions for a midcourse check-in, a brief piece on the use of
poetry, and some reflections about teaching MBSR using an online
platform.

Intake/Assessment Form
What follows is an intake form for teachers whose occupation falls outside
of health care. For health care clinicians, the intake will include all relevant
details of a medical, mental health, and addictions assessment. Teachers
designated as clinicians will be required to collect and securely store private
health information in line with requirements of their governing body and
state and federal regulations. Non-clinicians, while not mandated to do this,
should treat all information acquired from their participants with utmost
care, endorsing confidentiality. This will necessitate transparency on the
part of the teacher, explaining the rationale for any collection of information
and how it will be stored.
The intake/assessment form is an important aspect of determining a
participant’s suitability for attending the MBSR program. The extent of
both the interview and the written intake form will be dependent on the
occupation of the MBSR teacher.
 It can be helpful to include pre- and post-inventories or scales during
the intake process to establish a baseline of the participant’s mood and
functional status. Such scales also allow the teacher to evaluate any changes
that occur upon completion of the program. An example of these
instruments that are in the public domain are PHQ-9 for depression, GAD-7
for anxiety, PSS for stress, and the WHO-5 Well-Being Index. These can be
used to assess participant outcomes from the program.

Sample MBSR Intake/Assessment Form

Name:

DOB:

Email:

Address:

What pronoun do you use to refer to yourself?

Home phone number: Office or cell number:

Is it all right to leave a message? Yes: No:

Name of contact person and phone number in the case of an emergency:

How did you hear about the program?

What is your occupation and work status?

What is your relationship status? (Circle one)

Single Partnership Married Divorced Widowed

Are there any events that might affect your participation in this program (for
example, recent loss of a relationship or death of a loved one)?

Name of primary care physician and phone number:

Are you currently under medical treatment? Yes: No:

If yes, please explain, including any relevant medications:

Please list any allergies:

Please list any mobility issues:

What is the quality and duration of your sleep?

What kind of exercise do you manage to do each week and what is the
frequency?

Cigarettes per day: Caffeinated drinks per day:

What is your alcohol and recreational drug use and frequency?

History of substance misuse (if relevant):

Are you currently undergoing therapy for mental health reasons?

Yes: No:

What are your main reasons for attending the program?

1.

2.

3.

What are your current stressors?

1.

2.
3.

What are your greatest anxieties?

1.

2.

3.

If you have experienced or are currently suffering from major depression,

severe anxiety, hallucinations, severe emotional dysregulation, thoughts of
harming yourself or someone else, trauma, or serious substance use (drugs
or alcohol), you should know that this program may not be suitable for you
at this time.

Is there anything else that you might want me to know about you?

Thank you for taking the time to fill in this form.

Note for non-clinicians: If you are an MBSR teacher from a background

other than health care, please be sure to make this explicit to your MBSR
participants at the time of this intake. This means that you clearly state the
limits of what you are responsible for and what the MBSR program can
offer. You need to take into consideration state and federal mandates that
you are responsible for reporting risk to self or others.
 The following problems will necessitate you considering the potential
participant’s suitability for the group:

Currently experiencing significantly low mood

Severe anxiety
Emotional reactivity and dysregulation that would interfere with
participation
Hallucinations (auditory or visual)
Suicidal or homicidal thoughts or actions
Current effects of trauma (e.g., flashbacks)
Significant substance use (drugs or alcohol)

If any of these are present, you should suggest that this is not a good
time for them to take the program. Make explicit to the participant that you
are unable to meet their needs, and that this would be a time to seek help
from a health care provider.

Consent to Participate and Waiver of

Responsibility
The risks, benefits, and potential side effects of MBSR, which is an
educational and experiential program, have been fully explained to me.
MBSR is taught in a group format. I fully understand that the program
consists of learning meditation practices and movements based on yoga that
require gentle stretching.
I understand that I am committing to attend eight (8) weekly classes and
one (1) full-day retreat and that there will be assigned home practices
requiring at least 45 minutes of practice each day between the weekly
sessions.
I understand that participating in the MBSR program may involve some
physical risk and may increase a sense of vulnerability or at times result in
challenging emotional states. MBSR is not intended to replace medical or
psychological treatment.
I understand that if I have concerns about my physical or mental health, it is
my responsibility when necessary to seek appropriate treatment. If my
MBSR teacher is a mental health professional, I may be directed to seek
assistance from a health care provider or even discontinue the course.
I take full responsibility and assume all risks for any physical, mental, or
emotional consequences of participating in this MBSR program.
I have read, understand, and accept the above conditions for
participating in the MBSR program.

Participant name (print):

Participant signature:

Date:

Confidentiality Agreements
My MBSR teacher acknowledges that my privacy will be maintained to the
full extent possible. All communications between the MBSR teacher
(whether or not he/she is a health care provider) and the participant are
confidential, excepting actions or intent, that fall outside these limits. There
are circumstances in which a provider of MBSR is required by law to
breach participant/provider-teacher confidentiality and these are as follows,
the extent of which is dependent upon professional designation (and
state/province/federal law):

Client expresses risk of harm to self and/or others

Client is at risk of harming a child through acts of omission or
commission (e.g., neglect, abuse)
Client is at risk when driving (e.g., dementia, substance induced)
Client reports being sexually abused

All of the above may involve mandatory reporting or referral to the

appropriate authorities or other health care providers.
 I have read and understand that under the above circumstances it is
mandatory that the MBSR teacher will take the appropriate action(s)
outlined.

Participant name (print):

Participant signature:

Date:

Client Acknowledgment and Agreement

I understand the limits of confidentiality and that the MBSR teacher will do
the utmost to maintain confidentiality of any personal health information
collected from me for assessing my suitability prior to and during my
participation in the program.
I agree to the collection and storage of personal health information.

Participant name (print):

Participant signature:

Date:

Consent to Use Electronic Communications

(when there is no encryption)
I, , consent to using email communications with my MBSR
teacher for the duration of the program (e.g., Hotmail, Gmail, or Outlook)
as needed. I understand that these delivery systems may not be secure for
personal health information. They may be accessed by others, accidentally
forwarded, or exist indefinitely. I further understand that email should not
be used for the purpose of communicating time-sensitive or emergency
information. I understand that should I decline to communicate via email
that this will not affect the care provided to me by my MBSR teacher in any
way, and that all communications will be done either in person or by
telephone.

Consent Do Not Consent

Participant name (print):

Participant signature:

Date:

Witness signature:

Date:

Midcourse Check-In
Having a midcourse check-in handout to give to your participants is useful.
This is a way for your participants to reflect on how the program is going
for them, both what has been helpful and what they are finding challenging.
It also gives the teacher the opportunity to hear from participants who may
not be particularly vocal in class. Typically, this handout is given out in the
fourth session, either to fill in during the session or as part of the home
assignments for that week. Participants are then asked to bring the
completed form to the next session.
Here are some suggestions about what to ask after they have entered
their name and the date on the form.
 1. What is your overall experience of the program so far?
2. What are you learning and discovering from practicing the body
scan, the mindful movement practices, and the sitting meditations?
The insights? The challenges?
3. Are you finding time to practice? If so, do you have a specific time
that you practice?
4. What are you learning and discovering from the informal practices?
The insights? The challenges?
5. Have you had any unusual experiences from doing the practices?
6. Do you have any other comments or concerns?

Meditation Scripts
One of the key features for teaching MBSR is that a teacher is able to guide
the meditation practices without reading from a script. This is because
facilitating any of the practices invites the teacher to be in practice,
embodying mindfulness. As she guides, she can call upon her own
experience. In addition, it is essential that she monitors the group.
Therefore, the following meditation scripts are simply a guide. It is
important that you find your own voice, the foundation of which is your
practice. A useful method for this is to record your guidance and review it.
This will help you develop the language for instruction. Important
considerations for language are volume, tone, pacing, and the use of silence.
The words should be simple, invitational, concrete versus abstract (minimal
use of metaphors), use present participles, and contain few personal
pronouns. Tone should be conversational rather than trying to generate a
special state of mind in your participants. A teacher needs to understand and
convey the intention and form of the meditations while she is guiding the
practices. It is essential to leave extended periods of silence (these are
identified in the scripts that follow) so that participants gain access to their
own experiences. As you move through the MBSR program, these periods
of silence increase in length.
Body Scan Meditation
What follows is an example of how to lead the body scan meditation
practice. It should be viewed as a description of fundamental components to
address. The instructions should be simple and easily heard. Pacing and
choice of words are key. You are supporting your participants in a practice
that involves paying attention in a particular way, exploring sensations in
various regions of the body, and then releasing attention before moving to
another part of the body.
Typically, the body scan is practiced lying down on the floor.
However, if and when adaptations are necessary, the teacher can suggest
sitting in a chair or the use of props to support the body lying down. If
participants choose to lie down, having a blanket or yoga mat to rest on is
helpful, as is having something to cover the body as needed.
Teaching any of the meditation practices invites the teacher to be in
practice. As she facilitates the practice, she can call upon the sensations in
her own body, using them as a guide. At the same time, she is maintaining
awareness of her participants.

Note: The body scan in session 1 will have more guidance and fewer
periods of silence than the instruction given in session 8.
In this script, we start the practice at the feet and move through the body,
ending at the head. Where you start is less important than making sure that
you move the attention around the body systematically.
Finding a comfortable position either on the floor or sitting in
a chair and taking a few moments to settle in, closing the
eyes or softening the gaze. Allowing the body to be
supported by the floor or the chair. Noticing sensations in the
body or from the surface of the skin. This time is an
opportunity to be fully present and awake to sensations in the
body, however they are in any given moment. In this way, we
are accessing our own sources of wisdom and healing.
Some sensations may be experienced as pleasant or
unpleasant…or even strong. In some areas of the body, there
may be no awareness of sensation. As best you can, staying
with each sensation moment to moment, noticing the actual
sensations themselves. You may be noticing a preference for
some sensations, wanting them to remain, and equally, you
may want others to be gone or lessen. Learning to notice
this, knowing there is no right way to be with the various
sensations, discovering a way to accept whatever is arising,
safely holding the experience, and acknowledging what is
present.
(Pause for 25 seconds)
In paying attention to the body in this way, it is likely that you
may become aware of the breath moving in and out of the
body.
(Pause for 10 seconds)
Bringing attention to the breath, wherever you best sense the
body breathing. This may be at the nostrils, the mouth, the
throat, or in the movement of the ribs and chest or at the
abdomen as the belly expands and releases. Sensing what
the breath does quite naturally. Allowing the attention to rest
here, on the rhythm of breathing.
(Pause for 10 seconds)
And now, bringing the attention to the abdomen and noticing
the sensations of breathing here.
(Pause for 25 seconds)
And gathering the attention from this focus of breathing at the
belly and moving it down the left leg, traveling down the full
length of the leg, down the thigh, the knee, the lower leg, the
ankle, to the toes of the left foot, and becoming aware of any
sensations that might be arising in the toes and foot.
(Pause for 10 seconds)
These sensations might be of heat or cold, moisture or
dryness, perhaps tingling, a sense of the toes themselves,
the nails, the nailbeds, and sensations arising from the
surface of the skin. Be with the experience of whatever is
arising from this part of the body, whether there are
sensations or none.
(Pause for 10 seconds)
On the out-breath, releasing the attention from the toes and
moving it along to the sole of the left foot, including the heel.
Sensing this area and what might be arising in this moment
from this part of the body.
(Pause for 10 seconds)
On an out-breath, gently releasing the attention from the sole
and heel of the left foot and on an inhalation bringing
attention to the whole of the foot, the top surface, the heel,
the sole of the foot, and the toes. Gently exploring what might
be present as you continue to breathe.
(Pause for 10 seconds)
On an out-breath, shifting the attention from the foot and on
an inhalation bringing attention to the ankle. Noticing what
might be present. Sensing the front of the joint, the back and
sides, and deep into the ankle itself.
(Pause for 10 seconds)
Now, on the out-breath, letting go of the left ankle, bringing
the attention on the in-breath to the left lower leg, the area
between the knee and the ankle. Becoming aware of
whatever sensations are here. Sensing the length of the
lower leg. The calf muscles, the shin. Perhaps the calf is in
contact with the floor and noticing pressure if there is
pressure. Noticing sensations that may be arising from the
surface of the skin … sensations of heaviness, lightness,
heat or cold, dampness, dryness. Gently investigating
whatever may be arising in this moment.
(Pause for 20 seconds)
On the out-breath, letting go of the left lower leg, and bringing
the attention along with the in-breath to become aware of the
left knee. Sensing the front of the knee, the kneecap, the
sides, the back, and then deep into the knee joint itself.
Sensing heaviness, relaxation, tenseness, ease. Whatever is
present. Being attentive to this part of your body as you rest
here, breathing.
You may have noticed that the attention has moved to
thinking. A story, a worry, a memory. If this has happened,
noticing that this is where the attention has moved,
recognizing this is a moment of waking up. This is something
that will happen many times. Once you’ve noticed that this
has happened, seeing if it’s possible to bring attention back
to the knee and the physical sensations that may be arising.
In this way, we are learning to steady attention using the
physical sensations of the body as an anchor to the present
moment.
(Pause for 20 seconds)
Now, letting go of attending to the left knee, as you bring
attention along with the in-breath to the left thigh. So, noticing
what is arising in this area, softening into its length. Perhaps
there is a sense of heaviness, lightness, warmth, coolness,
tingling. Noticing what sensations are present from the skin…
and from deep inside.
Developing this gentle, open curiosity and awareness to
whatever is present or absent. And if there is not much
arising in this moment, bringing attention to that. Sometimes
as we maintain this attention to the body, we can become
aware of a painful region, or an ache. If this is so, gently
noticing this and then seeing if it’s possible to return to being
with the physical sensations arising from the left thigh.
(Pause for 10 seconds)
On that next out-breath, releasing attention from the left
thigh, and now gently moving the attention along with the in-
breath across the lower belly and down the entire right leg to
the toes of the right foot. Taking time to become aware of this
part of the body. Sensing all five toes from the big toe to the
smallest one. Just being present. Noticing the nails and the
nailbeds, the space between the toes, or perhaps the toes
touching each other.
(Pause for 20 seconds)
On an out-breath, releasing awareness of the toes as you
bring attention with an in-breath to the sole and heel of the
right foot. Again, being curious about any sensations that
may be arising from this part of the body. Just paying
attention as best you can in this moment.
(Pause for 20 seconds)
Now on that next out-breath letting go of the sole and heel of
the right foot as you bring your attention to the full length and
width of the foot resting here. Noticing any sensations and
exploring them.
(Pause for 20 seconds)
Letting go of the right foot as you bring attention to the right
ankle on an inhalation. Noticing the front of the ankle, the
sides, the back, and deep into the joint. Allowing for all
sensations and noticing if thoughts are present. Often as the
body quiets, thoughts arise. If that happens, our practice is to
recognize the thoughts and then return the attention to the
part of the body that we are holding in awareness. In this
way, we are slowly learning over time to let go of getting
caught up in the stories of the mind.
We are allowing for the experience to be just as it is and
letting the body and a sense of the breath be an anchor, a
way to return to this moment.
(Pause for 10 seconds)
On the out-breath, releasing the right ankle, moving the
attention along with the breath to the lower leg. Noticing the
length of this part of the body: the shin, the sides, and the
calf. Holding this part of the body in gentle awareness and
allowing for all sensations or the absence of sensations.
(Pause for 10 seconds)
On the out-breath, letting go of the right lower leg as you
bring attention along with the breath to the right knee,
including the kneecap. Noticing any sensations from the skin
or from deep inside the knee. Just observing without
judgment.
(Pause for 20 seconds)
On an out-breath, releasing the knee, as you bring your
attention with the in-breath to the right thigh. Sensing its
length, and any sensations arising from the skin or from deep
inside the thigh, sensations of relaxation, lightness,
heaviness, tenseness, softness, whatever is arising we can
be present for.
(Pause for 10 seconds)
Letting go of the right thigh, and now bringing awareness
along with the breath to the area of the pelvis and the lower
abdomen. Feeling where the buttocks are making contact
with the floor or the chair. Noticing the right hip and the left
hip. This is an area of the body that contains the organs of
reproduction and elimination.
Being with the lower abdomen, the entirety of the pelvis as it
cradles this area. Gently breathing in and out and releasing
into any sensations that may be arising here.
Sometimes there can be strong sensations that arise from
this area, and if that happens, knowing you can return your
attention to the breath as a way of anchoring to the present.
And then when ready, gently returning your attention to being
present for the sensations that may be arising from the lower
abdomen and pelvis.
(Pause for 25 seconds)
Now letting go of the lower abdomen and the pelvis and
bringing attention to the lower back. You may sense an arch
in the lower back, or perhaps it has some contact with the
floor or the chair. For some people, the lower back is an area
that can hold tension, so being present as best you can with
whatever is arising and gently releasing with each out-breath.
(Pause for 25 seconds)
On the out-breath, letting go of the lower back and bringing
attention to the whole length of the spine as you rest here,
breathing in and out. Noticing any areas of tenseness, ease,
pain, comfort, vibration. Releasing as best you can with each
out-breath.
(Pause for 10 seconds)
And now letting go of paying attention to the sensations
arising from the spine and bringing attention with an in-breath
to the belly, to the region of the abdomen. Pausing here a
moment or two and noticing the rise and fall of the belly, as
you breath in and out. Steadying attention, being present for
the physical sensations arising here, as you rest, aware and
awake.
(Pause for 15 seconds)
Now, gently moving your attention and your breathing up into
the chest, where you may become aware of the beating of
your heart and the movement of the ribs. Not going
anywhere, or doing anything, developing an openness to all
that is arising here. Noticing the entire torso and the chest
moving as you breathe. Taking a moment here to be present.
(Pause for 20 seconds)
Sometimes as we hold the body in stillness, we become
acutely aware of a region that may be painful in some way. If
that is so, bringing attention to that area, breathing into it, and
breathing out from it, softening, and letting go as best you
can. You might choose to pay attention to the sensations in
this area. Sometimes it can be helpful to intentionally move,
paying attention to the movements, and then when you feel
ready return to your original position. In this way, you are
working wisely with what is possible.
And now on the out-breath, letting go of the torso and chest
as you move the focus along with the in-breath up into the
left shoulder, and down the length of the left arm, bringing
attention into the fingers of the left hand. Taking a moment
here to notice any sensations that may be arising in this
moment from this part of the body.
(Pause for 10 seconds)
Letting go of the fingers of the left hand, as you bring
attention to the back of the hand and the palm of the left
hand, including the left wrist. Taking a moment here, being
curious, gently exploring sensations, regardless of whether
they are pleasant, unpleasant, or neutral.
(Pause for 10 seconds)
Letting go of the back, the palm of the hand, and the left
wrist, and on an in-breath bringing attention up into the
forearm and the left elbow. Taking a moment here, exploring
sensations that may be appearing. Steadying attention in this
way.
(Pause for 10 seconds)
On an out-breath, letting go of the left forearm and left elbow,
bringing attention along with an in-breath up into the upper
arm and left shoulder. Steadying attention as you continue to
breathe, becoming aware of any sensations that are arising.
Noticing the length of the upper arm, the weight, any
sensations arising from the surface of skin, and bringing
attention to the left shoulder, the front, the back, and the side,
including the armpit.
(Pause for 20 seconds)
On an out-breath letting go of the left upper arm and
shoulder, bringing attention across the upper chest to the
right shoulder and down the full length of the right arm into
the fingers of the right hand. Steadying attention here,
noticing, becoming aware. A gentle and kind curiosity for
what may be arising as you attend in this way. Noticing if
thinking has appeared, and letting that go, and returning to
exploring sensation arising from the fingers of the right hand.
(Pause for 10 seconds)
On an out-breath letting go of the fingers of the right hand,
bringing attention with an in-breath to the back of the hand,
the palm, and the wrist. Taking a moment here to notice, and
to become aware of any sensations that may be arising.
(Pause for 10 seconds)
Now moving the attention from the back of the hand, the
palm, and the wrist of the right hand, up into the right
forearm, including the right elbow. Taking a moment here,
noticing.
(Pause for 10 seconds)
On an out-breath, letting go of the right forearm and elbow as
you bring attention into the right upper arm and right
shoulder. Taking these next few moments to notice
sensation, resting quietly, awake, and aware. Holding a
gentle and openhearted awareness as you pay attention and
breathe.
(Pause for 15 seconds)
On an out-breath, releasing the right shoulder as you bring
attention into both shoulders, and the shoulder blades.
Noticing what may be arising, as you lie here, gently
breathing and paying attention.
(Pause for 10 seconds)
On the out-breath, letting go of the shoulders and shoulder
blades, bringing attention to the throat and neck. Softening
and releasing as best you can, noticing any sensations of
tension, sensations of softness, warmth, coolness. Just being
present.
(Pause for 12 seconds)
And now on the out-breath, letting go of the area of the throat
and neck as you move awareness with the breath into the
face and head. Sensing the jaw, the chin, the lips, the mouth,
the teeth, the tongue, the roof of the mouth, the floor and
sides of the mouth, the cheeks, the nose and nostrils, the
eyes, the eyelids, the eye sockets, the eyebrows and the
space between the eyebrows, the forehead, the sides of the
head, the ears.
We use the muscles of the face many times during the day to
express emotions and thoughts. This is an opportunity to
release any tension and to be present.
(Pause for 12 seconds)
And now on an out-breath, choosing to gently release the
attention and awareness of the sensations arising from the
face, as you move attention with the breath to the back of the
head, the scalp, and the roots of the hair. Perhaps becoming
aware of the weight of the head and contact that the back of
the head is making with the floor.
(Pause for 10 seconds)
And now, bringing awareness to the full length and breadth of
the body lying here. From the head, all the way down to the
toes, including the arms. Noticing the weight of the body and
the points of contact.
Feeling the body and the movement of the breath, aware as
you lie or sit here. Feeling complete and whole just as you
are and allowing this being present to deepen, existing in this
place of quiet.
A state of relaxed awareness and openness to things as they
are. Knowing this acceptance and stillness can itself be
healing, as you lie or sit here, awake.
(Pause for 15 seconds)
Remembering that this state of clarity and open awareness is
available to you at any time by simply bringing your attention
to your breath and a sense of the body in any moment, no
matter what is happening in your day. For you can allow the
breath and the body to be a source of strength, balance, and
well-being.
(Pause for 10 seconds)
As we come to the end of this body scan meditation, allow
the next few breaths to be a little deeper, and then if your
eyes have been closed, allowing them to open, or if you
chose to soften the gaze, widening the gaze. Taking in the
surroundings of the room. Moving the body in whatever way
feels comfortable, stretching the arms, legs, wiggling the
fingers and toes.
 When you feel ready, rolling over onto your right-hand side
and taking a moment here.
Then moving into a sitting position if you have been lying on
the floor. Noticing this moving as part of the practice of
paying attention to sensations as you transition into the next
few moments of your day.

Sitting Meditation—Awareness of Breathing

This meditation introduces participants to a short sitting practice of between
10 and 15 minutes in session 2. As this is one of the early practices in the
MBSR program, there will be more instruction from the teacher than in
meditation practices later on. This is because participants need more verbal
support as a way to understand the intention of the practice. The teacher’s
voice also helps participants anchor attention. It is important to emphasize
the need to adopt a comfortable sitting position.
Taking a few moments to find a comfortable position on a
chair, cushion, or bench.
Chair instructions: Moving toward the front of the chair,
allowing the spine to be supported rather than relying on the
back of the chair; pubic bone descending, legs uncrossed,
knees hip-distance apart, and feet firmly planted on the floor.
Cushion instructions: If using a cushion, you need to elevate
the buttocks so that the knees are lower than the hips.
Crossing the legs, so that the knees are resting on the floor
and the pelvis is tilted slightly forward. If the knees don’t
touch the floor, placing a blanket or cushion underneath them
for support.
Bench instructions: Have a blanket or mat under the bench
so that when you tuck your knees under it they are not
resting directly on the floor.
Adopting a posture that can best support this intention to be
awake and relaxed. Closing the eyes or taking a soft gaze,
looking down toward the floor in front of you. The spine is
straight but not stiff. Taking the next few moments to check in
with the body sensations. You may become aware of areas of
tightness, so making any adjustments, as necessary. Settling
into this posture. The head is supported by the neck, and the
shoulders are released as much as possible. Letting go of
any tension as best you can. Softening the muscles of the
face.
Arms resting comfortably by your sides and the hands
supported on the thighs or in the lap. Adopting a dignified
posture, one that best supports the possibility of being awake
and present, along with an attitude of gentleness and
curiosity.
Sitting in this seated posture, becoming aware of body
sensations … heat, coolness, tingling, vibration, ease,
tension…aware of the length and breadth of the body sitting
here, the contact points the body is making with the chair, the
cushion, the bench, the floor itself.
(Pause for 20 seconds)
As we sit here paying attention in this way, becoming aware
of the sensations of breathing. Noticing where you best
sense the body breathing. This may be where the breath
comes into the nostrils…noticing the sensations of the in-
breath and the movement of the out-breath. Taking your time,
attending to the breath at the nostrils. Being present with the
sensations of breathing moment by moment.
(Pause for 2 minutes allowing participants to have their own
experience)
Attending to the movement of breathing…allowing the breath
to breathe itself, no need to change or alter anything.
(Pause for 2 minutes)
You may be noticing that the attention has moved away from
the sensations of breathing. When you become aware of this,
gently returning the attention back to the movement of the
breath. There is no need to judge this movement of attention;
recognizing this habit of mind is a part of the practice. Waking
 up to this is a moment of mindfulness and the choice for now
is to return attention to the anchor, which is the breath.
(Pause for 2 minutes)
Continuing to adopt a sense of kindness as we continue to
practice in this way. Recognizing when the attention has
moved to a different object of interest, like thinking—worry,
boredom, agitation, stories—becoming aware of this natural
tendency, letting this recede by intentionally returning to this
awareness of breathing.
(Pause for 1 minute)
In a moment or two we will be coming to the end of this sitting
meditation practice. If you have closed the eyes, allowing
them to open, or if you have softened the gaze, widening it
and taking in the surroundings of the room, bringing this
awareness to your next few moments.

Sitting Meditation—Awareness of Breath and

Body
The instructions that follow are an example of how you might lead a breath
and body awareness meditation. They are not to be considered as a script
for teaching this meditation, but rather a description of key elements to
include. As this sitting meditation is taught in the early sessions of the
MBSR program, it is helpful to remind participants about the importance of
finding a comfortable seated posture, and to repeat instructions about how
to adopt such a posture.
Inviting you now to adopt an erect, dignified, and comfortable
posture. The chest and spine are gently lifted and relaxed
with the neck long and the chin in line with the navel. The
head is supported by the neck, shoulders are relaxed. The
hands are resting comfortably on the thighs or folded in the
lap. Now, closing the eyes or softening the gaze, looking
down toward the floor a few feet in front of you. Releasing the
muscles of the face. Adopting a dignified posture, one that
best supports the possibility of being awake and present,
along with an attitude of gentleness and curiosity.
(Pause for 10 seconds)
Taking these next few moments to get comfortable, noticing
any areas of tension and making any adjustments necessary.
(Pause for 15 seconds)
Now, bringing your attention to the physical sensations of the
body by focusing on where the body is in contact with the
floor, the contact the buttocks are making with the chair,
cushion, or bench, and if the hands are in contact with each
other. Spending a few moments noticing these sensations.
(Pause for 10 seconds)
As you sit here in this seated posture, now bringing attention
to the breath at the nostrils and to the sensations of
breathing. Taking the next few moments to notice these
sensations. There is no hurry. Sensing the breath—some
coolness on the in-breath and warmth on the out-breath as
the breath leaves the body. Sensing the movement of
breathing and being present with the sensations of breathing
moment by moment.
(Pause for 2 minutes)
Continuing to notice the full length of each in-breath and out-
breath. There is no need to change or alter the breath.
Allowing the breath to breathe quite naturally. Resting
attention on those sensations.
(Pause for 2 minutes)
Bringing an attitude of openness, of curiosity. Becoming
aware of the changing nature of breathing.
(Pause for 2 minutes)
As we practice in this way, you may notice the attention has
moved to some other object of interest. It might be thinking, a
story, a worry. This is quite normal. Our attention becomes
distracted. When we notice this has happened, we simply
make a note of it and, letting go of this, escort the attention
gently back to the breath, a fresh opportunity to continue
practicing. There is no need to pass judgment on yourself
when this happens. The movement of attention is quite
natural. Instead, bringing a quality of kindness to your
awareness, and returning to sensing the breath.
(Pause for 1 minute)
As we continue to pay attention in this way, we are learning
to let the breath be an anchor, reconnecting us to each
moment as it arises. When the attention wanders, which it
will, we recognize that has happened. And this awareness is
a moment of waking up, a moment of mindfulness. And then
we have this choice, to reconnect to the breath, letting these
sensations be an anchor, grounding us in the present.
(Pause for 1 minute)
And now on an out-breath, letting go of this attention on the
breath and the exploration of the sensations of breathing at
the nostrils, and on an in-breath, expanding the awareness to
include the length and breadth of the body sitting here.
Allowing the breath to be present but in the background.
Adopting an open and receptive stance to the physical
sensations presenting themselves, wherever they are in the
body.
(Pause for 2 minutes)
When a physical sensation calls your attention, whether from
inside the body or from the surface of the skin, bringing
curiosity to it and exploring it. Really attending to these
sensations as best you can, noticing if they change. And
when they no longer hold your attention, returning to being
with the totality of the body, sitting here. Attending to the
movement of physical sensations, letting the body be an
object of interest and an anchor.
(Pause for 2 minutes)
When you notice that the attention has been drawn to
thoughts, stories, or sounds, this is a moment of mindfulness
 and an opportunity to choose to return to the original focus of
attending to body sensations.
(Pause for 2 minutes)
And now, on an out-breath, letting go of attending to the
body, allowing the physical sensations to be present in the
background. Returning the attention to the breath at the
nostrils and allowing the movement of breathing to be the
anchor.
(Pause for 1 minute)
And when the attention moves, which it naturally does,
simply escorting it back to the breath gently, without rigidity,
with a sense of intention and starting again. Remembering
that coming back to the breath is a part of mindfulness just as
is focusing on the breath itself.
(Pause for 40 seconds)
Maintaining a steady focus on breathing as you sit here. The
breath is always with you, always present, an anchor to
current experience.
(Pause for 40 seconds)
And now as we bring this practice to a close, opening the
eyes or widening the gaze and moving the body in whatever
way is needed.

Mindful Yoga
Mindful yoga is a key practice of the MBSR program. As such, it provides
participants an additional approach for exploring their relationship to the
body and to the mind. Unlike a regular yoga class, which tends to be
focused on a specific form, in the MBSR program, the teacher offers
instruction very much in keeping with the intentions of the other formal
practices (the body scan and sitting meditation). These intentions include
focusing attention, acknowledging, and exploring sensations, and
developing the capacity to return attention when it has moved and to have a
vocabulary to describe these experiences. During the yoga practice, as with
the other practices, the participant maintains a focus on the breath along
with body sensations arising from adopting and moving through the various
positions.
Stretching into the poses is about investigating the limits of a stretch,
sensing whether there is some leeway in moving further into the position, or
whether it is prudent to stay where you are, or indeed to come out of the
pose a little as an act of self-care. The aim is to explore the poses, accepting
the body as it is. Before each mindful yoga practice, the teacher reminds her
participants to be attentive to their own bodies, as they follow her
instructions. If at any time they feel uncomfortable with a particular
position, she reminds them to adapt it. For some groups, a teacher will need
to amend the poses, making them suitable for the group she is teaching. She
reminds them that the practice is not about pushing oneself or striving, but
more about listening to one’s own body, inviting a sense of being mindful,
present, rather than doing something.
The movement practice is not about teaching your participants how to
be yoga experts. If you are not a yoga teacher, say so; if you are, then
remember that you are not teaching a yoga class. Even though you, the
teacher, do need to have familiarity with the poses and have your own
practice, this is no different from insisting that you need to have a
mindfulness meditation practice. The poses are representations of an
intention to be cultivated on the part of the teacher and the participants.
They are much less about a final goal and much more about the exploration
of experience and what is possible. The poses are a vehicle for this, just like
sitting meditation practice.
This is meditation in action, an unfolding process with the emphasis on
the body in motion. Your instructions will include connecting movement
with the noticing of breathing. Pace is important, but not so slow that your
participants find it difficult to maintain interest and stay with the unfolding
nature of the practice. Make sure you demonstrate the postures, practicing
with your participants as you guide them, leaving silence and time between
poses and when exploring each pose for participants to experience what
they are feeling.
There is much we could say about teaching this mindful yoga practice.
One of the efficient ways to assist your learning to teach movement is to
video record yourself teaching and to review it. Subsequently, it is very
helpful to ask others to watch the video and provide feedback on language,
tone, volume, clarity of instruction, use of silence, and how you move your
own body to convey what you are hoping to demonstrate. What is important
is that the movements flow from one to the other and that the instructions
you give your participants are clear and concise.
The MBSR program offers a range of different standing and lying-
down poses. We have created a series of chair poses to help you adapt this
mindful movement to participants with mobility concerns. We have also
included these and others as an online resource to assist you in the delivery
of yoga instruction. What follows is a visual guide to how you might lead a
lying-down yoga (mindful movement) sequence. Feel free to use these or
create your own sequence of postures.
In these figures, you will see that diversity is key. We wanted to reflect
the reality of our world and of MBSR. You will have many ethnicities,
races, and cultures participating in your programs. We also wanted to de-
emphasize anatomically correct figures, preferring to produce images that
are less about personification and more about the positioning of the pose
and the shape or ethnicity of the person doing it. The de-highlighting of
facial features and the clothing the figures are wearing is deliberate and a
way of tying the images together because these are consistent features. In
addition, the faces lack a lot of definition as a way to convey more
neutrality. Ultimately, we were interested in conveying inclusivity and our
common humanity. Visit http://www.newharbinger.com/45601 to download
a copy of this yoga sequence.
Poetry
Using poetry in the MBSR program needs to be thoughtfully considered.
Poetry can be a powerful medium for eliciting many mindfulness-based
principles and, at the same time, participants will have a variety of
interpretations, ascribe different meanings, and have varied responses to
what is read. For these reasons, any poetry that is used by a teacher should
reflect the major themes of the session in which it is being used. If using
poetry, it behooves the teacher to have a number of poems available to meet
the specific needs of the group in that moment. Poetry is an invitation to
participants and therefore the teacher needs to convey this in her
introduction to reading the poem. Not every participant appreciates poetry
and may not be receptive to it. If the teacher reads a poem, she needs to
discuss it during inquiry in order to gauge the group’s response to it as well
as to elicit relevant themes.

Teaching MBSR Online: Considerations

Online teaching and learning are now available across many disciplines,
including education, business, and the workplace. While most eight-week
MBSR programs are taught face to face, they are increasingly being offered
online synchronously (live) and asynchronously (recorded). While there is
only early evidence to support the effectiveness of teaching MBSR
virtually, nevertheless there is no reason to doubt that the online medium
will be more commonly used as a delivery platform for both convenience
and access. However, this raises several issues, not least of which revolve
around risk to both participants and teachers, professional liability, and the
difference between delivering mindfulness instruction in person and online.
When teaching in person, there is greater immediacy and ease in terms of
how a teacher can respond to her participants in the face of risk or safety
concerns. Those occupations that operate under a license to practice will
need to investigate liability and insurance coverage regarding teaching
online. Teachers who come from occupations that are unregulated will need
to explore issues related to liability, risk, and safety.
When thinking about teaching MBSR online, there are a number of
factors to take into account. These include technical logistics and support,
issues of privacy, consent, group guidelines, and safety in the online space.
One essential aspect to address is the delivery of the content of the program
and materials used when teaching via video conferencing. This would
include considering what is necessary to ensure that fidelity is maintained to
the intentions and curriculum of the program. Lastly, but perhaps most
importantly, is how to deliver the MBSR program in such a way that the
teacher is able to express the attitudinal foundations and embodiment of the
practice.

Technical Logistics and Support

There is no question that for those of us who are not tech savvy, teaching
online requires a fairly steep learning curve. There may be initial aversion
to doing so, but by turning toward that which is difficult (like everything
else), it is surprising how quickly teaching virtually may become
manageable and even enjoyable. While it is possible to learn to teach online
on your own, it is extremely helpful to have a technical support person
present when you are teaching, and also someone who can walk you
through the use of technology for online program delivery. In addition,
there are workshops, articles, and YouTube videos available to assist with
this learning, including tutorials online offered by various
videoconferencing platforms.
First, consider the choice of tool or platform you are going to use.
There are many that support videoconferencing, but those that enable
dyadic work or breakout groups are relatively few. Make sure the one you
select is able to do both of these. Ensure that all participants can be seen
and that there is a whiteboard, hand-raising, and polling function to be able
to engage participants for quick responding and frequent interactions. A
chat function is also essential to allow teacher and participants to speak
both privately and with the whole group. Note that in some jurisdictions,
platforms may be restricted due to concerns about privacy and
reimbursement.
Second, the teacher will need to invest in certain equipment. You’ll
need a high-quality adjustable microphone on a long USB cable to capture
sound (be sure to test it before buying) when moving from lying to sitting
or when teaching the mindful yoga practice. You may also need a wide-
angle video camera attached to the computer (webcam) and a second
monitor. These can allow the teacher to move freely and still be seen by the
participants. Hardwiring the computer to the modem (through an Ethernet
cable) may give you better technical performance overall. A reliable
internet connection is also necessary.
Good-quality headphones are also valuable for listening and speaking
and can make the whole process more comfortable when sitting in front of
the computer for extended periods. However, if you are leading a long
period of practice (such as an all-day silent retreat), headphones limit your
mobility as a teacher, so, if possible, it is better to teach without them. If
you don’t have the privacy to do so, invest in an extra-long audio cable (10-
foot leash) or Bluetooth headset, or you will be trapped in your chair for the
day.
Third, the teacher or online coordinator, if one is available, should give
the participants some time and training on the system to get acclimatized to
various functions, such as the hand-raising, chat, and other interactive tools
that they will need to feel comfortable using. These fall outside of the actual
content of the program but are necessary to keep the group engaged and
facilitate interactive sessions and experiential learning. Preparing a
participant handout that details technical requirements and tips can also
support this.

Privacy
Privacy concerns need to be addressed when teaching in the online space.
All teachers, particularly clinicians, need to understand and follow their
state/provincial/national regulations. These requirements may vary widely,
such as where private health information must be stored (locally or
otherwise), how and what one can communicate online when secure or not,
and how to inform participants and gain consent to communicate virtually.
If the teacher belongs to a governing body, they will need to look into the
electronic practice standards for that body or professional organization. If
there are guidelines, the teacher must adhere to them.
Once an online platform is chosen, the teacher and online coordinator
(technical support) should familiarize themselves with all appropriate
privacy settings and ensure that they are enabled.
Consent
Group programs by their very nature reduce the ability to maintain
confidentiality. Consent requires that participants understand and sign off
on the risks of communicating online and via videoconferencing. This
refers to the possibility (unless the platform you are using is 100 percent
secure) that information conveyed may be accessed by others, accidentally
forwarded, or exist indefinitely. Any other communication should take
place via telephone or encrypted email. Participants should also understand
that email, unless secure, should not be used for the purpose of
communicating time-sensitive or emergency information.

Group Guidelines
Group guidelines are necessary for setting the context and code of conduct
for any group. When delivering a program online, there are some aspects of
etiquette that may seem obvious but need to be made explicit to ensure the
group is able to build cohesion and trust. For example, it is important that
the participants recognize that they shouldn’t do anything in the virtual
space that they wouldn’t do in a face-to-face group. With the camera on (the
sound is off unless the participant is speaking), everyone in the virtual room
can see what a participant is doing. This is easy to forget. Participants need
to agree that they will turn cell phones to silent mode, log off email
programs and other social media platforms, not record, copy, and paste the
chat log, or take screenshots or photos, in order to respect the group’s
privacy and maintain confidentiality.
Participants need to understand the rules of communication in the
online space, and how to use the tools of the system to indicate that they
want to speak by raising a virtual or real hand. It should also be noted that
there is a natural delay between a question and the initiation of a response
using this medium. This can be referred to as the online pause. It creates a
slowing down of communication, and acknowledging that this is the case
normalizes it. In addition to raising a hand to speak (on camera or virtually
through a feature of the program) or simply unmuting oneself, the
participant may send a private note to the facilitator when needed or use the
chat function to comment or ask a question.
 Further to understanding these online procedures for communicating,
the teacher clarifies additional guidelines. Participants should ensure that
they are in a private location during the group and will not be interrupted.
The teacher must tell them that for the purpose of confidentiality, they need
to make sure no one else can hear or see the screen. It is also necessary that
if others come into a particular participant’s “group” space that everyone is
aware the teacher will remove the participant from the online room until
privacy is reestablished.

Safety
While safety in groups is an ideal, what allows one person to feel safe may
not be the same for another. The online platform presents some challenges
in this area. Like any other group, the teacher establishes the expectations
for the group process (e.g., respectful communication), sets the guidelines
of group interactions, sets the context for how the group will function, and
addresses what to do should distress show up in the group.
One such way to help the group manage distress and to work with
emotional safety online is to have a discussion and provide participants with
a handout explaining the window of tolerance (regarding a range for the
tolerance of distress) originally developed by Pat Ogden (Ogden et al.,
2006) and Dan Siegel (1999). An understanding of when one is outside this
window and how to reestablish emotional regulation is valuable for
building both distress tolerance and self-efficacy. The use of such a term as
the “window of tolerance” can provide a common language for participants
to talk about when they are moving outside of it, and what to do to move
back into it. Some examples for helping participants manage distress if they
are becoming overwhelmed include the following directions:

Opening your eyes

Standing up, feeling your feet on the ground
Walking around, attending to your feet on the floor
Taking slow in-breaths with longer exhales
Drinking a glass of water or making a cup of tea
Wrapping yourself in a blanket
 Naming five things you can see, hear, and feel (physically),
describing them in as much detail as possible
Splashing water on your face and hands or holding ice in each hand

It is also important for participants to send a private message to the

teacher so that the teacher is aware when people have moved outside the
window of tolerance and that they are taking a break for self-care, rejoining
the group when ready. An image projected on the screen, such as the one in
figure 5, can be a valuable tool to provide a frame of reference for a group
discussion regarding safety concerns, whether physical or
mental/emotional, and how to manage these.
 When teaching MBSR online, there are also some clear logistical
safety parameters the teacher can set. These include, as mentioned above,
the requirement that participants (except during breaks) can always be seen
by the teacher and that it is clear how help will be obtained for each person
in their location. For example, the participants must understand the limits of
confidentiality and the teacher should have the names of their health care
providers and contact information. The teacher should also establish what
would happen should a participant collapse on-screen, conveying the need
to call the emergency contact or police for a wellness check.

Content Delivery
Delivery of the MBSR program content necessitates some modifications
when teaching in the online group room. Some of these include maintaining
frequent interactions between all the group members and the teacher using
the tools of polling or hand-raising, small group work (triads preferably
over dyads—in case one person is very quiet) in breakout rooms, use of the
chat space to answer questions where breadth of response is wanted, such as
“What did you notice about sensorial experience (e.g., the raisin’s
qualities)?” The chat space function can also be used when you’re running
out of time and want to cover an item on the agenda that would take longer
if participants were speaking. Be sure to read out all of the answers, as it
can be very powerful for people to hear their words spoken back to them.
Remember that no teaching or guiding can go on for too long (at least in the
early sessions) or group members will disengage.
As in face-to-face teaching, be sure to be prepared with any materials
you as the teacher will need. For example, if using the pleasant and
unpleasant events calendars or the difficult communications calendar, stress
reactivity triangle, or stress response triangle, you will want to have these
documents available to share on-screen at the appropriate time when you
are ready to collect participant responses.
Sometimes delivery of the content can entail creativity on the part of
the teacher. For example, you might choose to create some asynchronous
videos (e.g., to demonstrate how to sit) to help you not become too fatigued
by being on-screen for too long a period. You might also choose to turn
certain aspects of inquiry or the eliciting of information from the larger
group, such as events and people they experience as stressful, into a small-
group timed game in which participants gather as many responses as
possible in 3 minutes and then return to the large group to debrief.
It is also important to note that sessions 1 and 2 are often toughest for
participants, whether in the class itself or with respect to home practice.
Sometimes participants have adverse reactions to the body scan. What
online teachers and participants have reported is that there is something that
may be activating about doing it alone with a video camera watching. For
this reason, in session 1, it may be advisable to ask people to engage in this
practice from a sitting posture rather than lying down.
Practices may have to be shorter because of the setup and time it takes
for people online to move from the computer to their practice posture. For
example, the body scan may need to be 30 minutes and end with a full
seeing practice to help people bring attention to their environment and give
them a few minutes before looking once again into the virtual space.

The Teacher
When learning to teach online, the teacher will initially grapple with the
cognitive load of adapting from face-to-face teaching to virtual teaching.
Remembering that the online space is still a meeting place can assist with
this process. The teacher will need to slow down and pause more
frequently. She may need to ask for clarification more often than in the
face-to-face realm and ensure that there is a shared understanding of what is
being conveyed through the cognitive exercises, formal practices, and
process of inquiry. Using the various functions that allow for written
communication as well as oral (spoken) communication will be helpful.
When and if technical difficulties arise, the teacher can embody
mindfulness for managing these just as she would with any other challenge
arising in the group. Attitudes of patience, non-striving, and genuine
curiosity will allow the MBSR teacher to teach utilizing mindfulness-based
principles, managing the interface between participant and teacher that is a
feature of this technology.
We would suggest that, where possible, the novice MBSR teacher first
deliver the program in person before moving into online delivery. In-person
MBSR enables the teacher to easily pick up on visual cues, respond
immediately to whatever arises in the group, more quickly manage risk, and
promptly receive feedback from participants. The online space creates
another layer between the teacher and the participants that must be skillfully
navigated by the teacher.
In summary, while MBSR can be adapted to the online world, this
often requires a steep learning curve for the teacher in terms of the technical
aspects of delivery, risk management, safety concerns, modification of the
content, and learning how to adapt how one teaches to accommodate the
virtual world.
 REFERENCES

Amaro, H. (2014). Implementing mindfulness-based relapse prevention in diverse populations:

Challenges and future directions. Substance Use & Misuse, 49, 612–616.
American Psychiatric Association. (2018). American say they are more anxious than a year ago;
baby boomers report greatest increase in anxiety. Retrieved September 23, 2020, from
https://www.psychiatry.org/newsroom/news-releases/americans-say-they-are-more -anxious-
than-a-year-ago-baby-boomers-report-greatest-increase-in-anxiety.
Antoniou, A., Ploumpi, A., & Ntalla, M. (2013). Occupational stress and professional burnout in
teachers of primary and secondary education: The role of coping strategies. Psychology,
4(3A), 349–355.
Avasthi, A., Sarkar, S., & Grover, S. (2014). Approaches to psychiatric nosology: A viewpoint.
Indian Journal of Psychiatry, 56(3), 301–304.
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report
assessment methods to explore facets of mindfulness. Assessment, 13(1), 27–45.
Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala,
S., et al. (2017). The Unified Protocol for transdiagnostic treatment of emotional disorders
compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical
trial. JAMA Psychiatry, 74(9), 875–884.
Batchelor, S. (2012). A secular Buddhism. Journal of Global Buddhism 13, 87–107.
Batchelor, S. (2015). After Buddhism: Rethinking the Dharma for a Secular Age. New Haven,
CT: Yale University Press.
Batchelor, S. (2019). Conversation with Patricia Rockman via Zoom (Ontario/France), July 5.
Biegel, G. M., Brown, K. W., Shapiro, S. L., & Schubert, C. M. (2009). Mindfulness-based stress
reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial.
Journal of Consulting and Clinical Psychology, 77, 855–866.
Bishop, S., Lau, M., Shapiro, S., Carlson, L., Anderson, N., Carmody, J., et al. (2004).
Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice,
11, 230–241.
Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., et al. (2009).
Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial.
Substance Abuse, 30(4), 295–305.
Brandsma, R. (2017). The Mindfulness Teaching Guide: Essential Skills and Competencies for
Teaching Mindfulness-Based Interventions. Oakland, CA: New Harbinger Publications.
Britton, W. B. (2019). Can mindfulness be too much of a good thing? The value of a middle way.
Current Opinions in Psychology: Special Issue on Mindfulness, 28, 159–165.
Britton, W., Lindahl, J., Cahn, B. R., Davis, J., & Goldman, R. (2014). Awakening is not a
metaphor: The effects of Buddhist meditation practices on basic wakefulness. Annals of the
New York Academy of Sciences, 1307, 64–81.
Broderick, P. C., & Metz, S. (2009). Learning to BREATHE: A pilot trial of a mindfulness
curriculum for adolescents. Advances in School Mental Health Promotion, 2(1), 35–46.
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in
psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–48.
Buber, M. (1958). I and Thou. New York: Scribner Classics.
Buddhaghosa, B. (1999). The Path of Purification: Visuddhimagga. Seattle, WA: BPS Pariyatti
Editions.
Burch, G., Batchelor, J. H., Heller, N. A., Shaw, J., Kendall, W., & Turner, B. (2014). Experiential
learning—What do we know? A Meta-Analysis of 40 Years of Research. Developments in
Business Simulation and Experiential Learning, 41, 279–283.
Cebolla, A., Demarzo, M., Martins, P., Soler, J., & Garcia-Campayo, J. (2017). Unwanted effects:
Is there a negative side of meditation? A multicentre survey. PloS One, 12(9), e0183137.
Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness training improve cognitive
abilities? A systematic review of neuropsychological findings. Clinical Psychology Review,
31(3), 449–464.
Chiesa, A., Castagner, V., Andrisano, C., Serretti, A., Mandelli, L., Porcelli, S., et al. (2015).
Mindfulness-based cognitive therapy vs. psycho-education for patients with major
depression who did not achieve remission following antidepressant treatment. Psychiatry
Research, 226(2–3), 474–483.
Collaborative for Academic, Social, and Emotional Learning (CASEL). (2020). What is SEL?
Retrieved September 23, 2020, from https://casel.org/what-is-sel.
Collins, E. J., & Segal, Z. V. (2020). Therapeutic mindfulness and depression. In M. H. Trivedi
(Ed.), Primer on Depression (pp. 357–371). New York: Oxford University Press.
Common Sense Media. (2018). www.commonsensemedia.org.
Crane, R. (2008). Mindfulness-Based Cognitive Therapy: Distinctive Features. New York:
Routledge.
Crane, R. (2017). Mindfulness-Based Cognitive Therapy: Distinctive Features (2nd ed.). New
York: Routledge.
Crane, R. S., Kuyken, W., Williams, J. M. G., Hastings, R. P., Cooper, L., & Fennell, M. J. V.
(2012). Competence in teaching mindfulness-based courses: Concepts, development, and
assessment. Mindfulness N Y 3, 76–84.
Crane, R., Brewer, J., Feldman, C., Kabat-Zinn, J., Santorelli, S., Williams, J., et al. (2016). What
defines mindfulness-based programs? The warp and the weft. Psychological Medicine,
47(6), 990–999.
Dalai Lama. (2011). Stages of Meditation: Training the Mind for Wisdom. New York: Random
House.
Davidson, R. J., Dunne, J., Eccles, J. S., Engle, A., Greenberg, M., Jennings, P., et al. (2012).
Contemplative practices and mental training: Prospects for American education. Child
Development Perspectives, 6(2), 146–153.
Deci, E. L., & Vansteenkiste, M. (2004). Self-determination theory and basic need satisfaction:
Understanding human development in human psychology. Richerche di Psicologia, 27(1),
23–40.
Dimidjian, S., & Segal, Z. V. (2015). Prospects for a clinical science of mindfulness-based
intervention. The American Psychologist, 70(7), 593–620.
Dobkin, P. l., Irving, J. A., & Amar, S. (2011). For whom may participation in a mindfulness-
based stress reduction program be contraindicated? Mindfulness, 3, 44–50.
Dobkin, P., Hickman, S., & Monshat, K. (2014). Holding the heart of mindfulness-based stress
reduction: Balancing fidelity and imagination when adapting MBSR. Mindfulness, 5, 710–
18.
Dunne, J. D. (2015). Buddhist styles of mindfulness: A heuristic approach. In B. D. Ostafin, M D.
Robinson, & B. P. Meier (Eds.), Handbook of Mindfulness and Self-Regulation (pp. 251–70).
New York: Springer.
Dvoráková, K., Kishida, M., Li, J., Elavsky, S., Broderick, P. C., Agrusti, M. R. et al. (2017).
Promoting healthy transition to college through mindfulness training with first-year college
students: Pilot randomized controlled trial. Journal of American College Health, 65(4), 259–
267.
Edwards, D., Bush, M., Vega-Frey, J. M., Duerr, M., Horwitz, C., et al. (2007, 2017). The
activist’s ally: Contemplative tools for social change. The Center for Contemplative Mind in
Society. Retrieved September 23, 2020, from http://www.contemplativemind.org/admin/wp-
content/uploads/Ally-Aug_2017.pdf.
Eisendrath, S. J., Gillung, E. P., Delucchi, K. L., Chartier, M., Mathalon, D. H., Sullivan, J. C., et
al. (2014).Mindfulness-based cognitive therapy (MBCT) versus the health-enhancement
program (HEP) for adults with treatment-resistant depression: A randomized control trial
study protocol. BMC Complementary and Alternative Medicine, 14, 95.
Eisendrath, S. J., Gillung, E., Delucchi, K. L., Segal, Z. V., Nelson, J. C., McInnes, L. A., et al.
(2016). A randomized controlled trial of mindfulness-based cognitive therapy for treatment-
resistant depression. Psychotherapy and Psychosomatics, 85(2), 99–110.
Farb, N. A., Anderson, A. K., & Segal, Z. V. (2012). The mindful brain and emotion regulation in
mood disorders. The Canadian Journal of Psychiatry, 57(2), 70–77.
Farb, N., Anderson, A., Ravindran, A., Hawley, L., Irving, J., Mancuso, E., et al. (2018).
Prevention of relapse/recurrence in major depressive disorder with either mindfulness-based
cognitive therapy or cognitive therapy. Journal of Consulting and Clinical Psychology,
86(2), 200–204.
Farber, J. (2008). Teaching and presence. Pedagogy, 8(2): 215–225.
Fielding, L. (2009). A Clinicians’ Guide to Integrating Mindfulness into Evidence-Based
Practice: A Common Elements Approach. Dissertation, Pepperdine University, Malibu, CA.
https://digitalcommons.pepperdine.edu/cgi/viewcontent.cgi?article=1030&context=etd.
Fleury, M. J., Ngui, A. N., Bamvita, J. M., Grenier, G., & Caron, J. (2014). Predictors of health-
care service utilization for mental health reasons. International Journal of Environmental
Research and Public Health, 11(10), 10559–10586.
Flook, L., Smalley, S. L., Kitil, M. J., Galla, B. M., Kaiser-Greenland, S., Locke, J., et al. (2010).
Effects of mindful awareness practices on executive functions in elementary school children.
Journal of Applied School Psychology, 26(1), 70–95.
Flook, L., Goldberg, S. B., Pinger, L., & Davidson, R. J. (2015). Promoting prosocial behavior
and self-regulatory skills in preschool children through a mindfulness-based Kindness
curriculum. Developmental Psychology, 51(1), 44–51.
Forbes Coaches Council. (2018). 14 simple steps to encourage mindfulness in your workplace.
Retrieved September 23, 2020, from https://www.forbes.com/sites/forbescoachescouncil
/2018/07/19/14-simple-steps-to-encourage-mindfulness-in-your-workplace/#167d 426126e8.
Frank, J. L., Reibel, D., Broderick, P., Cantrell, T., & Metz, S. (2015). The effectiveness of
mindfulness-based stress reduction on educator stress and well-being: Results from a pilot
study. Mindfulness, 6(2), 208–216.
Fronsdal, G. (2006). Mindfulness meditation as a Buddhist practice. https://www.insight
meditationcenter.org/books-articles/articles/mindfulness-meditation-as-a -buddhist-practice.
Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., et
al. (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review
and meta-analysis. Clinical Psychology Review, 59, 52–60.
Goldberg, S. B, Knoeppel C., Davidson, R. J., & Flook, L. P. (2020). Does practice quality
mediate the relationship between practice time and outcome in mindfulness-based stress
reduction? Journal of Counseling Psychology, 67(1), 115–122.
Goleman, D., & Davidson, R. (2018). Altered Traits: Science Reveals How Meditation Changes
Your Mind, Brain, and Body. New York: Penguin Random House.
Greenberg, M. T., & Harris, A. R. (2012). Nurturing mindfulness in children and youth: Current
state of research. Child Development Perspectives, 6(2), 161–166.
Greeson, J. M., Juberg, M. K., Maytan, M., James, K., & Rogers, H. (2014). A randomized
controlled trial of Koru: A mindfulness program for college students and other emerging
adults. Journal of American College Health, 62(4), 222–233.
Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive
therapy and mindfulness-based stress reduction improve mental health and wellbeing? A
systematic review and meta-analysis of mediation studies. Clinical Psychology Review, 37,
1–12.
Hall, G., Hong, J., Zane, N., & Meyer, O. (2011). Culturally-competent treatments for Asian
Americans: The relevance of mindfulness and acceptance-based psychotherapies. Clinical
Psychology New York, 18, 215–231.
Haralambos, M., & Holborn, M. (1991). Sociology: Themes and Perspectives (3rd ed.). London:
Collins Education.
Hartranft, C. (2003). The Yoga-Sutra of Patanjali: A New Translation with Commentary. Boston:
Shambhala Publications.
Hayes, S. C. (2004). Acceptance and commitment therapy and the new behavior therapies:
Mindfulness, acceptance, and relationship. In S. C. Hayes, V. M. Follette, & M. M. Linehan
(Eds.), Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (pp. 1–
9). New York: Guilford Press.
Heeren, A., & Philippot, P. (2011). Changes in ruminative thinking mediate the clinical benefits
of mindfulness: Preliminary findings. Mindfulness 2, 8–13.
Hill, W. E. (1915). British cartoonist who reproduced the old woman/young woman from an
anonymous author published in the magazine Puck.
Hofmann, S. G., & Gómez, A. F. (2017). Mindfulness-based interventions for anxiety and
depression. The Psychiatric Clinics of North America, 40(4), 739–749.
Hsu, F. (2016). What is the sound of one invisible hand clapping? Neoliberalism, the invisibility
of Asian and Asian-American Buddhists, and secular mindfulness in education. In R. Purser,
D. Forbes, & A. Burke (Eds.), Handbook of Mindfulness: Culture, Context, and Social
Engagement (pp. 369–382). New York: Springer.
Huijbers, M. J., Crane, R. S., Kuyken, W., Heijke, L., van den Hout, I., Donders, A. R. T., et al.
(2017). Teacher competence in mindfulness-based cognitive therapy for depression and its
relation to treatment outcome. Mindfulness, 8, 960–972.
Iheduru, O. (2006). Social values, democracy, and the problem of African American identity.
Journal of Black Studies, 37(2), 209–230.
Jalali, D., Abdolazimi, M., Alaei, Z., & Solati, K. (2019). Effectiveness of mindfulness-based
stress reduction program on quality of life in cardiovascular disease patients. International
Journal of Cardiology, Heart & Vasculature, 23, 100356.
Jha, A. P., Stanley, E. A., Kiyonaga, A., Wong, L., Gelfand, L. (2010). Examining the protective
effects of mindfulness training on working memory capacity and affective experience.
Emotion, 10(1), 54–64.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients
based on the practice of mindfulness meditation: Theoretical considerations and preliminary
results. General Hospital Psychiatry, 4, 33–47.
Kabat-Zinn, J. (1990, 2013). Full Catastrophe Living: Using the Wisdom of Your Body and Mind
to Face Stress, Pain, and Illness. New York: Bantam Books.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.
Clinical Psychology: Science and Practice, 10, 144–156.
Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L., Fletcher, K. E., Pbert, L., et al. (1992).
Effectiveness of a meditation-based stress reduction program in the treatment of anxiety
disorders. American Journal of Psychiatry, 49(7), 936–943.
Kelly, A., & Garland, E. L. (2016). Trauma-informed mindfulness-based stress reduction for
female survivors of interpersonal violence: Result for a stage I RCT. Journal of Clinical
Psychology, 72(4), 311–328.
Kennedy, B. M., Ard, J. D., Harrison, L., Cornish, B. K., Kennedy, E., Levy, E. J., et al. (2007).
Cultural characteristics of African Americans: Implications for the designs of trials that
target behavior and health promotion programs. Ethnicity & Disease, 17(3): 548–554.
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therein, P., Bouchard, V., et al. (2013).
Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review,
33, 763–771.
Khoury, B., Sharma, M., Rush, S., & Fournier, C. (2015). Mindfulness-based stress reduction for
healthy individuals: A meta-analysis. Journal of Psychosomatic Research, 78(6), 519–528.
Killingsworth, M. A., & Gilbert, D. T. (2010). A wandering mind is an unhappy mind. Science,
330(6006), 932.
Kirmayer, L. J. (2015). Mindfulness in cultural context. Transcultural Psychiatry, 52(4), 447–
469.
Knowles, M. S. (1988). The Modern Practice of Adult Education: From Pedagogy to Andragogy.
Englewood Cliffs, NJ: Cambridge Adult Education.
Kochamba, K. (2017). Integrating mindfulness-based empirically supported treatments (MB-
ESTs) into evidence-based practice (EBP): A replication and extension study. Dissertation,
Azusa Pacific University, Azusa, California.
Kolb, D. A. (2015). Experiential Learning: Experience as the Source of Learning and
Development (2nd ed.). New York: Pearson Education.
Kolb, D. A., & Fry, R. A. (1975). Towards an applied theory of experiential learning. In C.
Cooper (Ed.), Theories of Group Processes. New York: John Wiley and Sons.
Kristeller, J., Wolever, R. Q., & Sheets, V. (2014). Mindfulness-based eating awareness training
(MB-EAT) for binge eating: A randomized clinical trial. Mindfulness, 5, 282–297.
Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., & Kessler, D. (2015). Effectiveness
and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance
antidepressant treatment in the prevention of depressive relapse (PREVENT): A randomised
controlled trial. The Lancet, 386(9988), 63–73.
Kuyken, W., Warren, F. C., Taylor, R. S., Whalley, B., Crane, C., Bondolfi, G., et al. (2016).
Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An
individual patient data meta-analysis from randomized trials. JAMA Psychiatry, 73(6), 565–
574.
Ladson-Billings, G. (2006). Yes, but how do we do it? Practicing cultural relevant pedagogy. In J.
Landsman & C. W. Lewis (Eds.), White Teachers/Diverse Classrooms: A Guide to Building
Inclusive Schools, Promoting High Expectations, and Eliminating Racism. Sterling, VA:
Stylus Publishing.
Lazarus, R., & Folkman, S. (1984). Stress, Appraisal and Coping. New York. Springer.
Le, T. N., Kinh, N. T., & Douang, K. (2019). A randomized study of mindfulness and service-
learning with students in Vietnam. International Journal of Research on Service-Learning
and Community Engagement, 7(1), Article 5.
Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K., & Britton, W. B. (2017). The varieties of
contemplative experience: A mixed-methods study of meditation-related challenges in
Western Buddhists. PLoS One, 12(5), e0176239.
Linehan, M. (1993a). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New
York: Guilford Press.
Linehan, M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New
York: Guilford Press.
Lutz, A., Jha, A. P., Dunne, J. D., & Saron, C. D. (2015). Investigating the phenomenological
matrix of mindfulness-related practices from a neurocognitive perspective. American
Psychologist, 70(7), 632–658.
Lyubansky, M. (2010). Going where Glenn Beck wouldn’t: Defining white culture. Psychology
Today. https://www.psychologytoday.com/us/blog/between-the-lines/201007/going-where -
glenn-beck-wouldnt-defining-white-culture.
MacPherson, S. (2020). Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI-
TAC. Unpublished revision, University of Fraser Valley, Abbotsford, British Columbia.
Magee, R. (2016). Teaching mindfulness with mindfulness of race and other forms of diversity. In
D. McCown, D. Reibel, & M. S. Micozzi (Eds), Resources for Teaching Mindfulness: An
International Handbook (pp. 225–247). New York: Springer.
Magee, R. (2018). Mindfulness and social justice. Movements of the Spirit. https://www
.garrisoninstitute.org/blog/mindfulness-and-social-justice.
Malach, R., Levy, I., & Hasson, U. (2002). The topography of high-order human object areas.
Trends in Cognitive Science, 6(4), 176–184.
Malpass, A., Carel, H., Ridd, M., Shaw, A., Kessler, D., Sharp, D., et al. (2012). Transforming the
perceptual situation: A meta-ethnography of qualitative work reporting patients’ experiences
of mindfulness-based approaches. Mindfulness, 3(1), 60–75.
McCown, D., Reibel, D., & Micozzi, M. (2010). Teaching Mindfulness: A Practical Guide for
Clinicians and Educators. New York: Springer.
Merriam, S. B. (2001). Andragogy and self-directed learning: Pillars of adult learning theory. The
new update on adult learning theory. New Directions for Adult & Continuing Education, 89,
1–102.
Messas, G., Tamelini, M., Mancini, M., & Stanghellini, G. (2018). New perspectives in
phenomenological psychopathology: Its use in psychiatric treatment. Frontiers in Psychiatry,
9, 466.
Mindfulness All-Party Parliamentary Group. (2015). Mindful Nation UK. Retrieved September
25, 2020, from https://www.themindfulnessinitiative.org/mindful-nation-report.
Mindfulness-Based Interventions: Teaching Assessment Criteria: The MBI:TAC tool. (2018).
http://mbitac.bangor.ac.uk/mbitac-tool.php.en.
Morone, N. E., Moore, C. G., & Greco, C. M. (2017). Characteristics of adults who used
mindfulness meditation: United States, 2012. The Journal of Alternative and Complementary
Medicine, 23(7), 545–550.
Mulert, C. (2013). Simultaneous EEG and fMRI: Towards the characterization of structure and
dynamics of brain networks. Dialogues in Clinical Neuroscience, 15(3), 381–386.
Nanamoli, B., & Bodhi, B. (2005). The Middle Length Discourses of the Buddha. Somerville,
MA: Wisdom Publications.
Napoli, M., Krech, P. R., & Holley, L. C. (2005). Mindfulness training for elementary school
students: The attention academy. Journal of Applied School Psychology, 21(1), 99–125.
National Institutes of Mental Health. Any anxiety disorder. Retrieved September 23, 2020, from
https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml.
Niazi, A. K., & Niazi, S. K. (2011). Mindfulness-based stress reduction: A non-pharmacological
approach for chronic illnesses. North American Journal of Medical Sciences, 3(1), 20–23.
Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to
Psychotherapy. New York: W. W. Norton & Co.
Olendzki, A. (2004). The fourth foundation of mindfulness: Sutta study. Barre Center for
Buddhist Studies, Barre, MA. Retrieved September 23, 2020, from https://www
.buddhistinquiry.org/article/the-fourth-foundation-of-mindfulness.
Oman, D., Shapiro, S. L., Thoresen, C. E., Plante, T. G., & Flinders, T. (2008). Meditation lowers
stress and supports forgiveness among college students: A randomized controlled trial.
Journal of American College Health, 56(5), 569–578.
Onken, L. S., Carroll, K. M., Shoham, V., Cuthbert, B. N., & Riddle, M. (2014). Reenvisioning
clinical science: Unifying the discipline to improve the public health. Clinical Psychological
Science, 2, 22–34.
Palmer, P. J. (2007). The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life
(10th anniversary ed.). San Francisco, CA: Jossey-Bass.
Prebish, C., Ponlop Rinpoche, D., & Sutherland, J. (2013). Is Buddhism a religion? Lion’s Roar.
https://www.lionsroar.com/is-buddhism-a-religion-november-2013.
Roemer, L., & Orsillo, S. M. (2003). Mindfulness: A promising intervention strategy in need of
further study. Clinical Psychology: Science and Practice, 10(2), 172–178.
Roeser, R. W., Schonert-Reichl, K. A., Jha, A., Cullen, M., Wallace, L., Wilensky, R., et al.
(2013). Mindfulness training and reductions in teacher stress and burnout: Results from two
randomized, waitlist-control field trials. Journal of Educational Psychology, 105(3), 787–
804.
Rubin, E. (1915). Synsoplevede Figurer (Visual Figures). Københaven og Kristiania:
Gyldendalske Boghandel, Nordisk Forlag.
Russell, T. A., & Siegmund, G. (2016). What and who? Mindfulness in the mental health setting.
BJPsych Bulletin, 40(6), 333–340.
Russinova, Z. (1999). Providers’ hope-inspiring competence as a factor optimizing psychiatric
rehabilitation outcomes. Journal of Rehabilitation, 16(4), 50–57.
Salzberg, S., & Kyodo Williams, A. (2019). Love everyone: A guide for spiritual activists. Lion’s
Roar. https://www.lionsroar.com/love-everyone-a-guide-for-spiritual-activists.
Santorelli, S. F. (2016). Remembrance: Dialogue and inquiry in the MBSR classroom. In D.
McGown, D. Reibel, & M. Micozzi (Eds.). Resources for Teaching Mindfulness: An
International Handbook (pp. 47–68). New York: Springer.
Santorelli, S. F., Meleo-Meyer, F., & Koerbel, L. (2017). Mindfulness-Based Stress Reduction
(MBSR) Authorized Curriculum Guide © 2017 Version Revised. Center for Mindfulness in
Medicine, Health Care, and Society, University of Massachusetts Medical School.
https://www.umassmed.edu/globalassets/center-for-mindfulness/documents/mbsr-curriculum
-guide-2017.pdf.
Sapolsky, R. M. (1994, 1998, 2004). Why Zebras Don’t Get Ulcers: An Updated Guide to Stress,
Stress-Related Diseases, and Coping. New York: Holt Paperbacks.
Satchidananda, S. S. (2012). The Yoga Sutras of Patanjali. Buckingham, VA: Integral Yoga
Publications.
Sauter, S. Murphy, L., Colligan, M., Swanson, N., Hurrell, Scharf, F., et al. (1999). Stress at Work.
National Institute of Occupational Safety and Health. Publication No. 99-101.
https://www.cdc.gov/niosh/docs/99-101/default.html.
Schön, D. A. (1983). The Reflective Practitioner: How Professionals Think in Action. New York:
Basic Books.
Schön, D. A. (1987). Educating the Reflective Practitioner: Toward a New Design for Teaching
and Learning in the Professions. San Francisco: Jossey-Bass.
Schonert-Reichl, K. A., Oberle, E., Lawlor, M. S., Abbott, D., Thomson, K., Oberlander, T., et al.
(2015). Enhancing cognitive and social-emotional development through a simple-to-
administer mindfulness-based school program for elementary school children: A randomized
controlled trial. Developmental Psychology, 51(1), 52–66.
Search Inside Yourself Leadership Institute. (2019). Program Impact Report. Retrieved
September 23, 2020, from https://siyli.org/downloads/Program-Impact-Report.pdf.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-Based Cognitive Therapy
for Depression: A New Approach to Preventing Relapse. New York: Guilford Press.
Segal, Z. V., Anderson, A. K., Gulamani, T., Dinh Williams, L.-A., Desormeau, P., Ferguson, A.,
et al. (2019). Practice of therapy acquired regulatory skills and depressive relapse/recurrence
prophylaxis following cognitive therapy or mindfulness based cognitive therapy. Journal of
Consulting and Clinical Psychology, 87(2), 161–170.
Selye, H. (1956). The Stress of Life. New York: McGraw-Hill.
Shallcross, A., Willroth, E., Fisher, A., Dimidjian, S., Gross, J., Visvanathan, P. D., et al. (2018).
Relapse/recurrence prevention in major depressive disorder: 26-month follow-up of
mindfulness-based cognitive therapy versus an active control. Behaviour Therapy, 49(5),
836–849.
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness.
Journal of Clinical Psychology, 62(3), 373–386.
Shonkoff, J. P., Garner, A. S., The Committee on Psychosocial Aspects of Child and Family
Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on
Developmental and Behavioral Pediatrics, Siegel, B. S., Dobbins, M. I., Earls, M. F., et al. .
(2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129,
e232. Retrieved September 23, 2020, from https://pediatrics.aappublications.org
/content/pediatrics/129/1/e232.full.pdf.
Siegel, D. J. (1999). The Developing Mind: Toward a Neurobiology of Interpersonal Experience.
New York: Guilford.
Siegel, D. (2007). Mindfulness training and neural integration: Differentiation of distinct streams
of awareness and the cultivation of well-being. Social Cognitive and Affective Neuroscience,
2(4), 259–263.
Snowden, L. R., & Yamada, A. (2005). Cultural differences in access to care. Annual Review of
Clinical Psychology, 1, 143–166.
Steele, L. S., Dewa, C. S., Lin, E., & Lee, K. L. (2007). Education level, income level and mental
health services use in Canada: Associations and policy implications. Healthcare Policy, 3(1),
96–106.
Sun, R., Slusarz, P., & Terry, C. (2005). The interaction of the explicit and the implicit in skill
learning: A dual-process approach. Psychological Review, 112(1), 159–192.
Tang, Y., Hölzel, B. K., & Posner, M. I. (2015). The neuroscience of mindfulness meditation.
Nature Reviews Neuroscience, 16(4), 213–225.
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V., Soulsby, J., & Lau, M. (2000).
Prevention of relapse/recurrence in major depression by mindfulness-based cognitive
therapy. Journal of Consulting and Clinical Psychology, 68, 615–623.
Thierry, K. L., Bryant, H. L., Nobles, S. S., & Norris, K. S. (2016). Two-year impact of a
mindfulness-based program on preschoolers’ self-regulation and academic performance.
Early Education and Development, 27(6), 805–821.
Treleaven, D. A. (2018). Trauma-Sensitive Mindfulness: Practices for Safe and Transformative
Healing. New York: W. W. Norton.
Tuckman, B. W., & Jensen, M. A. (1977). Stages of small-group development revisited. Group &
Organization Studies, 2(4), 419–427.
Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E., & Binau, S. G. (2019). Age, period, and
cohort trends in mood disorder indicators and suicide-related outcomes in a nationally
representative dataset, 2005–2017. Journal of Abnormal Psychology, 128(3), 185–199.
Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C. D., Olendzki, A., et al.
(2018). Mind the hype: A critical evaluation and prescriptive agenda for research on
mindfulness and meditation. Perspectives on Psychological Science, 13(1), 36–61.
Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. G. (2016). Acceptance-
and mindfulness-based interventions for the treatment of chronic pain: A meta-analytic
review. Cognitive Behavior Therapy, 45(1), 5–31.
Warnecke, E., Quinn, S., Ogden, K., Towle, N., & Nelson, M. R. (2011). A randomised controlled
trial of the effects of mindfulness practice on medical student stress levels. Medical
Education, 45(4), 381–388.
Washington, E., & Patrick, C. (2018). 3 requirements for a diverse and inclusive culture.
Workplace. https://www.gallup.com/workplace/242138/requirements-diverse-inclusive-
culture.aspx.
Wear, D., & Skillicorn, J. (2009). Hidden in plain sight: The formal, informal, and hidden
curricula of a psychiatry clerkship. Academic Medicine, 84(4), 451–458.
Woods, S. L., Rockman, P., & Collins, E. (2016). A Contemplative Dialogue: The Inquiry Process
in Mindfulness-Based Interventions. Toronto, Canada: Centre for Mindfulness Studies.
Retrieved September 23, 2020, from https://slwoods.com/wp-content/uploads
/2016/02/acomplentativedialogue-2-2012.pdf.
Woods, S. L., Rockman, P., & Collins, E. (2019). Mindfulness-Based Cognitive Therapy:
Embodied Presence and Inquiry in Practice. Oakland, CA: New Harbinger.
Woods-Giscombé, C. L., & Gaylord, S.A. (2014). The cultural relevance of mindfulness -
meditation as a health intervention for African Americans: Implications for reducing stress-
related health disparities. Journal of Holistic Nursing, 32(3), 147–160.
Yamada, A. M., & Brekke, J. S. (2008). Addressing mental health disparities through clinical
competence not just cultural competence: The need for assessment of sociocultural issues in
the delivery of evidence-based psychosocial rehabilitation services. Clinical Psychology
Review, 28(8), 1386–1399.
Zeidan, F., Johnson, S. K., Diamond, B. J., David, Z., & Goolkasian, P. (2010). Mindfulness
meditation improves cognition: Evidence of brief mental training. Consciousness and
Cognition, 19(2), 597–605.
Zenner, C., Herrnleben-Kurz, S., & Walach, H. (2014). Mindfulness-based interventions in
schools: A systematic review and meta-analysis. Frontiers in Psychology, 5, 603.
Susan L. Woods, MSW, LICSW, is a licensed clinical social worker,
conference and workshop speaker, author, and curriculum developer. She is
a national and international teacher and trainer in mindfulness-based stress
reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), and
resides in Vermont.

Patricia Rockman, MD, is a family physician with a focused practice in

mental health. She is associate professor in the department of family and
community medicine at the University of Toronto, and cofounder of the
Centre for Mindfulness Studies. She is a public speaker, curriculum
developer, and teaches and mentors in MBCT and MBSR.
 INDEX

A
about this book, 3–4
acceptance and commitment therapy (ACT), 163
accessibility of MBSR, 179, 182, 185, 186
active listening/speaking, 156
Activist’s Ally tool kit, 186
adjourning stage of groups, 33–34
adverse effects, 193, 194
African Americans, 181, 183
agendas: all-day retreat, 126; orientation session, 44–46; Session 1, 58–59; Session 2, 71–72;
Session 3, 83–84; Session 4, 95–96; Session 5, 105–106; Session 6, 114–115; Session 7, 133–134;
Session 8, 141–142
agents of change, 24–37; embodied mindful presence, 34; examples of working with, 35–37; group
process, 32–34; individual learning, 30–32; mindfulness-based practices, 29–30;
protocol/curriculum, 24–29
all-day retreat, 116–126; agenda, 126; instructions for going home, 124–125; lake meditation, 120–
121; loving-kindness meditation, 122–124; mindfulness-based practices, 117, 119–124; mountain
meditation, 119–120; opening orientation, 117–119; reviewing in next session, 129, 131; teacher
preparation, 116–117; transition out of silence, 124; TRIP summary, 116
American Psychiatric Association, 176
anxiety disorders, 174, 176
apprenticeship model, 200
Asian Americans, 181, 183
assessment form, 208–212
attention: research on, 189–190; steady, 146–147
attitude of mindfulness, 189
attitudinal foundations, 150–153; form, 151–152; presence, 150; process, 152–153
autonomy, 22, 31, 132, 133
awareness: breath and body, 76–77, 89, 229–231; choiceless, 97, 98, 100; circle of, 87, 93, 103. See
also breath awareness

B
Ba Khin, U, 8
Batchelor, Stephen, 19
being mode, 48, 73, 98
Bodhi, Bhikkhu, 7
body: awareness of breath and, 76–77, 89, 229–231; mindfulness of, 20, 55
body scan: home practice of, 56, 67, 69; in-session practice of, 55–56, 64–66, 137; meditation script,
219–226
booster groups, 140
bottom-up learning, 17, 172
brain-imaging techniques, 188
breath awareness: body awareness and, 76–77, 89, 229–231; brief practice of, 51–52; home practice
of, 70; sitting meditation and, 69, 76–77, 227–228
Buddhism: foundation principles of, 18–21; mindfulness origins in, 6–8, 180, 188
Buddhist psychology, 18–21; Four Foundations of Mindfulness, 20–21; Four Noble Truths, 18–20;
Three Marks of Existence, 21
business, mindfulness in, 176–178

C
Center for Contemplative Mind in Society, 186
Center for Mindfulness (CFM), 10, 25, 39, 199, 200
choiceless awareness, 97, 98, 100, 138
chronic pain management, 163, 191, 193
circle of awareness, 87, 93, 103
Client Acknowledgment and Agreement form, 215
clinical use of MBSR, 162–170; adaptations created for, 163–164; common elements approach and,
165–167; diagnostic framework and, 164; risk factors related to, 168–169
closing ceremony, 140
cognitive appraisal, 145
cognitive behavioral therapy (CBT), 10
cognitive flexibility, 193
Collaborative for Academic, Social, and Emotional Learning (CASEL), 172–173
college students, 175
common elements approach, 165–167, 200–201
Common Sense Media, 174
communications, difficult, 104, 112–113
competence, 22, 37, 38, 201, 203
Confidentiality Agreements form, 214
Consent to Participate and Waiver of Responsibility form, 213
Consent to Use Electronic Communications form, 216
content barriers, 183–184
context, setting for MBSR, 51
Courage to Teach, The (Palmer), 150
Crane, Rebecca, 201
cultural barriers, 182–183
curriculum/protocol: adaptations of, 161; as agent of change, 24–25; flexibility in adhering to, 49;
form of the teaching and, 151–152; importance of teaching from, 12, 15–16; training teachers to,
199–200

D
Dalai Lama, 8
de-centering, 192
depression, 192–193, 194
diagnostic framework, 164
dialectical behavior therapy (DBT), 163
different chair exercise, 128, 130
difficult communications calendar, 104
difficult communications styles exercise, 112–113
discernment, 148–150
dismantling studies, 192
distress tolerance, 192
diversity issues, 179–186; content barriers, 183–184; cost of teacher training, 202; cultural barriers,
182–183; interpersonal mindfulness, 184–185; logistical barriers, 181–182; teacher background,
185–186
doing mode, 73, 92, 98

E
educational settings, 171, 172–176; college students and mindfulness in, 175; mindfulness-based
programs in, 173–174; schoolteachers and mindfulness in, 175–176; SEL and mindfulness in,
172–173
embodied mindful presence, 34, 144–153; attitudinal foundations of, 150–153; discernment and,
148–150; open monitoring and, 147–148; present moment orientation and, 145; steady attention
and, 146–147; teacher requirement for, 204
environmental stressors, 131–132, 133
experiences: learning to be with, 60; paying attention to, 145
experiential learning, 22
extrinsic motivation, 31, 32
eye contact, 118

F
feelings, mindfulness of, 20
Feldman, Christina, 8
five agents of change. See agents of change
Five Facets Mindfulness Questionnaire (FFMQ), 166, 188
Forbes Coaches Council, 177
form of the program, 144; embodied mindfulness and, 151–152; inquiry and, 155–156
formal mindfulness practices, 29, 30
forming stage of groups, 32
forms: Client Acknowledgment and Agreement, 215; Confidentiality Agreements, 214; Consent to
Participate and Waiver of Responsibility, 213; Consent to Use Electronic Communications, 216;
Intake/Assessment, 208–212
Four Foundations of Mindfulness, 20–21
Four Noble Truths, 18–20
Fronsdal, Gil, 189
Full Catastrophe Living (Kabat-Zinn), 2, 9, 15, 25, 39, 198, 199

G
Goenka, Satya Narayan, 8
Goldstein, Joseph, 8
Goleman, Daniel, 8
group discussions: on circle of awareness, 93; on stress reactivity, 91–93; on stress response, 101–
102
groups: developmental stages of, 32–34; norms and guidelines for, 42–43
guided reflection, 138–139

H
Hayes, Steven, 163
Healing and the Mind with Bill Moyers documentary, 10, 198
health care: mindfulness in, 163–164; research on MBSR in, 190–192, 195
heart of teaching, 3
Hill, William Ely, 69
home practice assignments: Session 1, 56–57; Session 2, 69–70; Session 3, 82; Session 4, 94;
Session 5, 104; Session 6, 113–114; Session 7, 132; Session 8, 139
hope, instilling of, 22
horizontal inquiry, 54, 64
Hsu, Funie, 180

I
inclusion issues, 179, 185
individual learning, 30–32
informal mindfulness practices, 29, 30, 56, 132
informed consent, 169, 213
inquiry, 53–55, 154–159; definition of, 154; embodied presence and, 155; form of, 155–156;
horizontal vs. vertical, 54; process of, 156–159
inquiry process, 156–159; Session 1, 53–55, 56; Session 2, 64–66, 69; Session 3, 79–81; Session 4,
86, 90–91; Session 5, 98, 100–101; Session 6, 108, 110–111; Session 7, 128, 131; Session 8, 136,
138
Insight Meditation Society, 8
intake/assessment form, 208–212
intentions, 37, 39, 189. See also TRIP approach
internal locus of control, 31
International Meditation Center (IMC), 8
interpersonal barriers, 184–185
intersubjective space, 146, 150
interviewing participants, 43, 47
intrinsic motivation, 31–32

K
Kabat-Zinn, Jon, 2, 8, 9–10, 13, 14, 15, 25, 39, 92, 162, 180, 188, 198
Kindness Curriculum, 173
Knowles, Malcolm, 21, 31
Kolb, David, 31
Kornfield, Jack, 8
Koru mindfulness program, 175

L
lake meditation, 120–121
learning: bottom-up, 17, 172; experiential, 22; individual, 30–32; mindfulness for, 172; theories of,
21–22
Linehan, Marsha, 163
lockdowns, school, 175–176
logistical barriers to MBSR, 181–182
loving-kindness meditation, 122–124
lying-down yoga, 74, 77–78, 109

M
meditation practices: body scan meditation, 219–226; breath and body awareness, 76–77, 89, 229–
231; breath awareness, 69, 76–77, 227–228; lake meditation, 120–121; loving-kindness
 meditation, 122–124; mountain meditation, 119–120; seeing meditation, 68; sitting meditation, 69,
89, 100, 110, 130, 138, 227–231; walking meditation, 74, 78
meditation scripts, 218–231; body scan meditation, 219–226; sitting meditation–awareness of breath
and body, 229–231; sitting meditation–awareness of breathing, 227–228
meditation therapy, 164
memory improvements, 193
mental health issues, 164, 165, 168, 174, 191, 194
mentorship programs, 199, 202
meta-cognition, 145, 192
Midcourse Check-In handout, 217
mind: contemplating, 20–21; knowing and freeing, 224
mindful eating practice, 56
mindful embodiment. See embodied mindful presence
mindful yoga, 232–235
mindfully informed programs, 165
mindfulness: attitudinal foundations of, 150–153; clinical benefits of, 192–193; college students and,
175; common elements approach to, 165–167; contemporizing of, 8–9; definition of, 188, 189;
educational settings and, 171–176; embodied mindful presence and, 34; formal and informal
practice of, 29–30; health care and, 163–164; historical overview of, 6–8, 180, 188; inquiry
related to, 53–55; integrating into everyday life, 133; introductory session on, 48–58; limitations
and risks of, 193–195; monoculture of, 180–181; personal practice of, 10, 12, 16–18, 199;
research on, 187–193; schoolteachers and, 175–176; social-emotional learning and, 172–173;
workplace and, 176–178
mindfulness-based cancer recovery, 163, 191
mindfulness-based chronic pain management (MBCPM), 163, 191
mindfulness-based cognitive therapy (MBCT), 10, 163, 192–193, 194
Mindfulness-Based Cognitive Therapy (Woods, Rockman, & Collins), 37
mindfulness-based eating awareness training, 163
mindfulness-based empirically supported treatments (MB-ESTs), 163, 166–167
Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC), 201
mindfulness-based programs (MBPs), 1, 11, 13, 171, 173–174, 194, 195
mindfulness-based relapse prevention, 163
mindfulness-based relationship enhancement, 163
mindfulness-based stress reduction (MBSR): all-day retreat in, 116–126; clinical populations and,
162–170; common elements approach to, 165–167; delivery tensions with, 11–12; diversity issues
for, 179–186; flexible approach to teaching, 49; forms and handouts for, 208–217; future
directions for, 202–204; importance of protocol for, 12, 15–16; meditation scripts for, 218–231;
mindful yoga in, 232–235; online teaching of, 237–242; orientation session for, 40–47; origins and
creation of, 2, 9–10; poetry used in, 236; research in health care and, 190–192, 195; schoolteacher
study on, 176; setting the context for, 51; summary of sessions in, 25–29; training programs in,
198–204. See also specific sessions
MindUP curriculum, 173
motivation, 31–32
mountain meditation, 119–120

N
Nanamoli, Bhikkhu, 7
National Institute of Mental Health, 174
Nhat Hanh, Thich, 8
nine dots exercise, 56, 68
Noble Eightfold Path, 18, 19, 20
norming/performing stage of groups, 32–33

O
online MBSR instruction, 237–242; consent issues, 238–239; content delivery, 241–242; group
guidelines, 239; privacy concerns, 238; safety considerations, 239–241; teaching process, 242;
technical logistics and support, 237–238
open monitoring, 147–148
orientation session, 40–47; agendas, 44–46; group norms and guidelines, 42–43; individual
interview, 43, 47; introduction to MBSR, 41; program structure, 41; record keeping, 43–44; TRIP
summary, 40

P
Pali Canon, 7
Palmer, Parker, 150
participant interviews, 43, 47
perception, role of, 60
perceptual biases exercise, 69
personal practice, 10, 12, 16–18, 199
physical sensations: stress reactivity and, 91–93; working with intense, 89
pleasant events calendar, 70
poetry, using in MBSR, 236
positivity bias, 194
practice skills, 37, 39. See also TRIP approach
practices based on mindfulness: all-day retreat, 117, 119–124; Session 1, 49–50, 51–57; Session 2,
61–62, 63–70; Session 3, 74–75, 76–82; Session 4, 86–87, 88–94; Session 5, 98, 99–104; Session
6, 108–114; Session 7, 128–132; Session 8, 136–140
presence: description of, 144, 150, 155. See also embodied mindful presence
present moment orientation, 145
process of practice, 144; embodied mindfulness and, 152–153; inquiry and, 156–159
professional development, 203–204
protocol/curriculum. See curriculum/protocol
psychological theories, 22–23
Public Broadcasting Service (PBS), 10
PubMed search engine, 190, 192

R
raisin practice, 52–53
Ram Dass, 8
rationales, 37, 39. See also TRIP approach
record keeping, 43–44
Reibel, Diane, viii
relatedness, 22
relationship skills, 173
re-perceiving, 189
research on mindfulness, 187–193; adverse effects, 193; clinical benefits, 192–193; concerns about,
187; in health care, 190–192; protocols as essential for, 10, 11, 16; studies of underlying
mechanisms, 189–190; trait vs. state mindfulness, 188
response to stress, 97, 98, 101–102; group discussion on, 101–102; triangle illustrating, 102
responsible decision making, 173
retreat session. See all-day retreat
Rhys Davids, Thomas William, 7
Rubin vase, 69
Rubin, Edgar, 69
Rumi, vii

S
Salzberg, Sharon, 8
Santorelli, Saki, 14, 16
Satipatthana Sutta, 7
Schön, David, 31
school settings. See educational settings
schoolteachers, mindfulness for, 175–176
screening criteria, 194
scripts. See meditation scripts
Search Inside Yourself Leadership Institute, 177
seeing meditation, 68
Segal, Zindel, 10
self as process, 152
self-awareness, 172
self-care, 118
self-determination theory (SDT), 22, 31
self-efficacy, 31, 51, 67, 99, 137
self-guided practice, 129, 130, 132, 139
self-management, 172
self-report questionnaires, 188
Selye, Hans, 92
Session 1, 48–59; agendas, 58–59; home practice assignments, 56–57; inquiry process, 53–55, 56;
mindfulness-based practices, 49–50, 51–57; opening the session, 50–51; setting the context, 51;
teacher preparation, 49, 50; TRIP summary, 48
Session 2, 60–72; agendas, 71–72; home practice assignments, 69–70; inquiry process, 64–66, 69;
mindfulness-based practices, 61–62, 63–70; opening the session, 62–63; review of home practice,
67–68; teacher preparation, 61, 62; TRIP summary, 60
Session 3, 73–84; agendas, 83–84; home practice assignments, 82; inquiry process, 79–81;
mindfulness-based practices, 74–75, 76–82; opening the session, 76; review of home practice, 82;
teacher preparation, 74, 76; TRIP summary, 73
Session 4, 85–96; agendas, 95–96; home practice assignments, 94; inquiry process, 90–91;
mindfulness-based practices, 86–87, 88–94; opening the session, 88; review of home practice, 91;
teacher preparation, 86, 88; TRIP summary, 85–86
Session 5, 97–106; agendas, 105–106; home practice assignments, 104; inquiry process, 98, 100–
101; mindfulness-based practices, 98, 99–104; opening the session, 99; review of home practice,
104; teacher preparation, 98, 99; TRIP summary, 97
Session 6, 107–115; agendas, 114–115; home practice assignments, 113–114; inquiry process, 108,
110–111; mindfulness-based practices, 108–114; opening the session, 109; review of home
practice, 111; teacher preparation, 108, 109; TRIP summary, 107
Session 7, 127–134; agendas, 133–134; all-day retreat discussion, 131; home practice assignments,
132; inquiry process, 128, 131; interacting with the world discussion, 131–132; mindfulness-based
practices, 128–132; opening the session, 129; review of home practice, 131; teacher preparation,
128, 129; TRIP summary, 127
Session 8, 135–142; agendas, 141–142; closing ceremony, 140; home practice assignments, 139;
inquiry process, 136, 138; MBSR program review, 136, 138–139; mindfulness-based practices,
 136–140; opening the session, 137; review of home practice, 139; teacher preparation, 136, 137;
TRIP summary, 135
Siddhartha Gautama, 6–7
silence, transitioning out of, 124
sitting meditation: awareness of breath, 69, 76–77, 227–228; awareness of breath and body, 76, 89,
229–231; instructions for teacher guidance, 89, 100, 110, 130, 138; meditation scripts, 227–231
skillful response, 149
social awareness, 172–173
social stressors, 131–132, 133
social-emotional learning (SEL), 171, 172–173
sociocultural issues, 181
Spirit Rock Insight Meditation Center, 8
standing yoga practice, 52, 63–64, 88, 99–100, 109
state mindfulness, 188
steady attention, 146–147
storming stage of groups, 32–33
stress: college students and, 175; difficult communications and, 107, 112–113; exploring stressors
and, 85, 91–93; managing with mindfulness, 133; problem with defining, 15; responding to, 97,
98, 101–102; schoolteachers and, 175–176; suffering equated with, 162; understanding and
accepting, 19; workplace-related, 176; world interactions and, 131–132
stress reactivity: group discussion on, 91–93; mindfulness meditation and, 175; triangle illustrating,
87, 92
Stress Reduction and Relaxation Program (SRRP), 9
stress response: group discussion on, 101–102; triangle illustrating, 102
substance use disorders, 191
Suzuki, D. T., 8

T
teacher preparation: all-day retreat, 116–117; Session 1, 49, 50; Session 2, 61, 62; Session 3, 74, 76;
Session 4, 86, 88; Session 5, 98, 99; Session 6, 108, 109; Session 7, 128, 129; Session 8, 136, 137
teaching MBSR, 14–38; Buddhist psychology and, 18–21; diversity issues with, 181–186; five
agents of change in, 24–37; learning theories and, 21–22; personal practice and, 16–18;
protocol/curriculum and, 14–16, 49; psychological theories and, 22–23; training programs for,
198–204; TRIP approach in, 37
teaching skills, 1
Teasdale, John, 10
themes, 37, 39. See also TRIP approach
Theravada Buddhism, 7
Three Marks of Existence, 21
Titmuss, Christopher, 8
training programs, 198–204; current state of, 198–202; future directions for, 202–204
trait mindfulness, 188
transdiagnostic approaches, 162, 164, 165
triangle illustration: stress reactivity, 87, 92; stress response, 102
TRIP approach, 37, 39; all-day retreat, 116; orientation session, 40; Session 1, 48; Session 2, 60;
Session 3, 73; Session 4, 85–86; Session 5, 97; Session 6, 107; Session 7, 127; Session 8, 135
Trungpa, Chögyam, 8

U
Unified Protocol, 165
unpleasant events calendar, 82
 V
values, diversity of, 183–184
vertical inquiry, 54, 110
Vipassana meditation, 7, 8, 17, 20, 21

W
walking meditation, 74, 78
Watts, Alan, 8
web-based instruction. See online MBSR instruction
website for book, 4, 207
white privilege, 182, 184
Williams, Mark, 10
workplace, mindfulness in, 176–178
world interactions, 131–132

Y
yarn ceremony, 140
yoga practice, 17, 137–138; lying-down yoga, 74, 77–78, 109; mindful yoga, 232–235; standing
yoga, 52, 63–64, 88, 99–100, 109