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Anger Management
Stress Reduction and Management

by Kirk Warren Brown, J David Cresswell, Richard M Ryan (Editors)
Guilford Press, 2015
Review by Roy Sugarman, Ph.D. on Aug 18th 2015

Handbook of Mindfulness

A perceptive reader will notice the names of Deci and Ryan, and ponder the connection between self-determination theory, espoused by both, one of whom is an editor, and mindfulness.

The authors respectively develop this theme in terms of awareness.  Working around this, part one delves into the origins of mindfulness as evolving into modern psychology, section two takes this further into how contemporary psychology has adapted this into attention, mental processing, motivation and behavior, and part three into the findings of application of mindfulness training for various human faculties, and parts four and five the applications for both healthy and clinical populations.

The connections with spirituality and Buddhism are of course known, but some researchers have commented in the letter pages of journals such as the British Psychologist, that without letting patients openly know, we are introducing spiritual-based clinical entities into the clinical setting.  The Kabat-Zinn and others have been criticized for fudging these links. The same journals are also reporting that over the last decades, Cognitive Behavioral Therapy is losing its gloss, with large analytical studies demonstrating waning efficacy, cause unknown. Hence, if it is a 'fad', CBT is losing its luster and now Mindfulness in all its guises is perhaps the new, albeit scientifically proven, fad, for every clinician worth their salt, or Medicare/NHS funding, to take on board. I hear the term all over the place now. Having lived in these clinical circles since the early Seventies, I have seen them come and go, and smiled with ACT emerged, quoting Sixties Jay Hayley and Erikson amongst others. So now it is the turn of Mindfulness. The 1987 emergence of Motivational Interviewing, family to Self-determination theory, is clearly docking with other approaches to human behavior change. The question is, does this approach target human behavior directly?

Diving into Edward Deci's "being aware and functioning fully", we see the connections between awareness and motivation being that one of the functions essential to autonomy is awareness. This is the clear perception of events along with insightful understanding, with the upper end of this skill being relaxed attention and interest in what is going on, a curiosity if you like.  To be open and receptive, to be aware, of these two states, promotes autonomy or what the authors call true self-regulation. Awareness via being mindful, thus supports healthy self-regulation, via the closely related construct of mindfulness, namely an open and receptive attention to what is occurring in the present, and the second, namely, interest taking. This amounts to focused receptivity. Both mindfulness and interest taking promote autonomous regulation. So the connection between the science that has evolved across the years in SDT, or Self-Determination Theory, the brainchild of both Deci and Ryan, is made clear across these chapters.

The point of all this is to live a fuller and more deeply satisfying life, or the experience of eudaimonic well-being as Ryan and colleagues described it.  This leads to a discussion of intrinsic vs extrinsic motivation. Underlying intrinsic motivation are the basic needs of competence and autonomy, namely feeling within our depth and guiding our own lives in what is most cherished in our value system. In terms of awareness, this would be predicted to be low if people are focused on external contingencies and pressures.

A question dealt with in the book is in answer to the question 'is there a neurobiology of mindfulness meditation?' Zeidan presents the neuronal correlations of dispositional mindfulness, as well as in brief training and in extended practice. Many have presumed that there are then going to be cognitive benefits to the practice of mindfulness meditation, and van Vugt follows up on Zeidan with just such evidence.  Meditative focused attention is theorized primarily to impact attention and through that, memory and perception, whereas open awareness is thought to impact cognitive monitoring and attention allocation, and thereby cognitive control and self-serving memory biases. There was and still is quite a lot of confusion in the literature about what processes compose meditation, as the same words tend to be used for different processes by different sources, so the use of mathematical models is put forward as a way of addresses these issues. Benefits again of meditation are discussed for attention, via this to perception, via this to memory, and then a discussion about episodic memory follows, given the impact on attention and working memory upstream, again referring to computational models, and especially free-recall tasks. This refers to self-related autobiographic memory vs other-orientated episodic memory, if attentional pathways are altered. The future in terms of modelling and integrating emotion and cognition are discussed as well.

This leads us to the emotional benefits of mindfulness (Arch and Landy). Since negative emotions are believed to be a primary expression of human suffering, and reflected in psychiatric disorders, the impact is huge. They are however experienced in normal populations as well, and hence the application is wider than just those categorized as ill in some emotional way, that is, where negative emotion leads to psychosocial dysfunction.

So higher 'trait-mindfulness' promotes increased willingness to experience negative emotions, greater endurance in anxiety provoking experiments, or even exposure to thinking about death and so on. Brief mindfulness inductions have also shown utility in this regard and faster recovery from dysphoric mood. Intervention studies take this observation further, even in healthy non-patients, which these authors focus on in their work. Of course, the benefits of mindfulness are not just thought to be intra-psychic, but affect one's presence in relationships, which Parker and her colleagues then address: how does this foster interpersonal benefits, as practitioners are often described as warm, or in touch with the emotions of their fellow human beings. By presence, the authors mean a bare awareness of the receptive spaciousness of our mind, rather pithily, or as Seigel referred to it, a state of receptive awareness of our open minds to whatever arises, as it arises.  The roles of this bare attention, as well as mindful awareness, or mindful practice (directed at one-ness with the activity), are explored. Mind wandering is another thing entirely, the opposite in fact, with all the dangers it encapsulates. As opposed to free association, which is creative, the less voluntary mind wandering is not a good generator of novel value. Later on the discussion moves to attachment, as well as the links between mindfulness, secure attachment and the medial prefrontal cortex. Many of the functions listed, 8/9 in fact, have been shown to co-occur with secure parent-child attachment, and 9/9 are outcomes of mindfulness training, all thus central to integrated self-regulation and successful interpersonal behavior.

Stress reduction in health adults is spotlighted by Shapiro and Jazaieri, and in children and adolescents by David Black. The idea however that the benefits to stress reduction and improved sense of wellbeing are solely the outcome of mindfulness based stress reduction is not proven, as distinct from other active interventions rather than waiting lists for instance, in more than a very few studies. One study that is quoted appears to have low numbers of subjects and covered only 6 hours of intervention compared to relaxation, but with positive results on this group. Gains in most studies did extend beyond the interventions, usually around 8 weeks, and there is evidence now that particularly canonical mindfulness training can enhance mental health-related subjective experience.  As noted by Parker and her colleagues, in children and adolescents, Black again returns to the executive functions in their self-regulatory guise, in what he refers to as an umbrella term for the system that coordinates attention, planning, decision-making, self-regulation and goal directed behaviors. A multiple page table covers the studies examining mindfulness training in youth, seeming all with positive things to say about mindfulness training.

Negative cognitions were improved in these groups, not just executive functions, and in the next chapter, Brown examines the enhancement of positive functions in mindfulness training. Too much self-control, as much as too little, can also cause problems in functioning, which Lynch and colleagues Lazarus and Cheavens take on in the next chapter.  As noted before, the constructs defined here are often confused in the literature, operationalized or collapsed into one construct which includes emotional eliciting and emotion regulatory factors, making comparisons difficult. The quintessential under-controlled disorder would be Borderline Personality, referring to DBT, as well as radically open DBT as therapies, with mindfulness a key component of these approaches. Moving from self-control to self-regulation is an interesting concept, and their neuro-regulatory model, still to be published, apparently challenges the linear assumptions regarding the desirability of self-control, and the wise limits of optimal and balanced capacity in this regard, rather than more is better philosophies, leaving one rather in an open stance in terms of willingness to experience. The differentiator in DBT is not to be distant from reality, but to rather engage with uncomfortable reality in a productive way.

Depression is another target for research in mindfulness, and Irving and her colleagues examine this field, followed by Hayes-Skelton and hers in the treatment of anxiety.  Addiction is another target (Bowen and colleagues) with awareness being the functional opposite of denial of deficit or denial of the risks of addiction. Physical disease and conditions are another target, with Linda Carlson in the driver's seat, seeking the value of awareness based interventions in medical conditions. The target is mood state and symptoms of stress, as well as decreases in inflammatory markers, and various killer cytokines apart from the inflammatory ones. The evidence is clear that targeting the neuropeptides as much as the autonomic nervous system pays dividends.  David Creswell continues this theme as he targets the linkages between mindfulness and health, focusing initially on the mindfulness stress-buffering hypothesis, and then building a biological model of mindfulness and health, again, as others have done, bringing in the prefrontal cortex.

Another  model, this time from Watkins  much earlier in the book, is proposed, drawing on Processing Mode Theory, explained with a nice diagram on the interacting cognitive subsystems of depression, with implicational vs propositional meaning dissected in the two loops, the sensory and the cognitive in the maintenance of depression via an "interlock".  This chapter carries further the explanation of the attentional systems interface with affective bias via the mindfulness interventions.

The book is thus nicely balanced between the need for beginners to understand the substrates involved, and the experienced practitioner to keep up with the progress and welling up of the science supporting the practice in modern clinical settings.

As with the other approaches in Clinical Psychology, namely CBT, ACT, Psychodynamic, Family, DBT, CT, and multiple others, Mindfulness will have its time in the limelight, as it has done in other settings for thousands of years, and then perhaps, as with CBT apparently, wane somewhat and make its way into the somewhat less lustrous bin. However, perhaps in contrast, it is clear that the value of meditation in all its forms, and certainly in Mindfulness based approaches, is discernible in multiple other approaches to engaging with pathology, namely SDT and Motivational approaches, and a cognitive neuroscience database is emerging that supports the practice and provides the burgeoning evidence based showcased in this book. So perhaps this most useful tool in clinical toolboxes with have legs on it, and continue to grow both its evidence and applied efficacy in various settings, as it has done in sporting circles for instance.

This book appears to be a major feat in the industry, as many have come before it, certainly many reviewed on the internet, but seldom does one see something this complete, detailed, well balanced by the editors, informative, solid, and reliable in not pandering to the spiritual, but rather in answering the questions it set out to address: the nature of the theory, research and practice of mindful interventions.

It belongs on your shelf.


© 2015 Roy Sugarman


Roy Sugarman, PhD, Director Applied Neuroscience, Performance Innovation Team, EXOSäUSA