A Mindfulness-Based Compassion Workshop and Pre-Session Preparation to Enhance Therapist Effectiveness in Psychotherapy: A Pilot Study

Abstract

We investigated the impact of a 1.5 hr workshop based on mindfulness-based compassion practices (MBCP) for 6 doctoral student therapists, followed by these therapists engaging in pre-session preparation for each of their clients in one of 3 randomly assigned conditions (MBCP, self-supervision, preparation-as-usual) over a 1-month period. State mindfulness and meditation self-efficacy increased following the workshop. Therapist ratings of session effectiveness were higher following pre-session meditation relative to preparation-as-usual, although there were no client-rated differences in session outcome. In a focus group, therapists reported that the workshop was generally helpful, and noted that pre-session MBCP led to a positive state of being and increased selfcare. However, they felt rushed to fit in the exercises and some doubted their meditation self-efficacy. They suggested that longer, at-home practice might be more beneficial than pre-session exercises. We encourage replication in larger samples varying the amount and format of meditation training for improving outcomes.

Mindfulness meditation and compassion-focused meditation training have been recommended in numerous theoretical papers as useful additions to training to help trainee therapists become more effective counselors (Bibeau et al., 2016; Bien, 2008; Gehart & McCollum, 2008; Seppala et al., 2014). In addition, recent guidelines recommend that therapists engage in mindfulness practices to support not only their own well-being, but to enhance their clinical (e.g., relationship building) skills (Michalak et al., 2019). Empirical data, however, are sparse, and questions remain regarding the overall efficacy, optimal dosage, and mode of delivery for trainee therapists. The overall purpose of the present study was therefore to investigate the effectiveness of such training for trainee therapists.

Mindfulness meditation involves maintaining undistracted, non-judgmental awareness of moment-by-moment experience (Kabat-Zinn, 1990), whereas compassion-focused meditation involves purposeful cultivation of compassion (i.e., the awareness of the suffering of others and the wish to relieve it) through mental exercises (e.g., visualizations and analytical contemplations; see e.g., Hofmann et al., 2011; Jazaieri et al., 2013). This family of practices, called mindfulness-based compassion practices (MBCP), originated in the Buddhist tradition and has evolved (e.g., been secularized) to fit the western psychology framework. The beneficial effects on client outcomes have been widely reported (Grossman et al., 2004; Hilton et al., 2017; Khoury et al., 2013). Furthermore, empirical work in non-therapy adult samples suggests that MBCPs increases prosociality (e.g., empathic concern, warmth and positive thoughts towards others; Donald et al., 2019; Kok & Singer, 2017), emotion regulatory capacity (Leyland et al., 2019), and meta-cognitive awareness (Baird et al., 2014; Kok & Singer, 2017).

Because mindfulness practice involves cultivating self-awareness and an observing quality of mind, and compassion cultivation supports awareness of and insight into the suffering of the self and others, and the active wish to relieve it, MBCP may be fruitful in training the person of the therapist (Aveline, 2005). To effectively use their own personhood, therapists must know themselves, be able to observe their own thoughts and emotions as they unfold in the therapeutic encounter, and manage their internal flow of experiencing (Aponte et al., 2009). Relatedly, others have theorized that mindfulness training could help therapists better understand and accept themselves, subsequently enhancing their capacity to accept their clients, in turn fostering more empathic therapeutic relationships (Bruce et al., 2010).

In studies involving the effects for trainee therapists, MPCPs have been delivered as components of practicum courses (McCollum & Gehart, 2010), semester-long elective courses (Campbell & Christopher, 2012; Christopher et al., 2011; Schure et al., 2008) and daily, 1-hour sessions in the morning (Grepmair et al., 2007). Although requiring substantive time commitments from participants and lacking in active comparison conditions, the results of these studies generally suggest favorable effects of MBCPs, although, some mixed findings are evident. For instance, clients of therapists who completed a 5-week mindfulness course rated session effectiveness more favorably following the course relative to pre-training; however, ratings of therapist presence did not change (Ivanovic et al., 2015). Meanwhile, a 5-minute mindfulness exercise practiced together by clients and therapists at the outset of sessions had no effect on client or therapist ratings of working alliance, or client-rated symptomatology, relative to active and passive control conditions (Mander et al., 2019). However, clients of therapists who participated in a more rigorous training program (i.e., daily 1-hour, teacher led Zen meditation practice prior to the workday) rated therapy as more effective and reported greater improvements in symptoms relative to control (i.e., no intervention) conditions.

Notably, qualitative data seem to consistently suggest beneficial effects of MBCPs for trainee therapists. In a series of studies, Campbell and Christopher (2012) reported that a semester-long elective course in mind-body medicine involving mindfulness training, yoga, qigong and didactic instruction promoted self-awareness, acceptance of self and others, compassion, empathy and mental focus. Similarly, trainee therapists described increases in self-awareness, acceptance, and attentiveness in therapy following participation in an academic course unit on mindfulness meditation (Schure et al., 2008). Finally, trainee therapists exposed to mindfulness meditation training through an existing practicum course described improvements in their capacity to be present and offer compassion towards themselves and their clients due to the course (McCollum & Gehart, 2010).

In addition to outcomes in terms of the effectiveness of therapy as noted above, we were also interested in the effects of MBCP in terms of therapists’ perceptions of their ability to be present with clients (i.e., to be immersed in the moment with clients on emotional, physical, cognitive, and spiritual levels in service of benefitting their clients, Geller et al., 2010). In one study, Dunn et al. (2013) examined the effects on trainee therapists of a five-session manualized mindfulness training program followed by either pre-session mindfulness meditation or pre-session distraction (e.g., checking email, chatting with other students) over a period of weeks. Client ratings of session quality and therapist presence were higher following pre-session mindfulness meditation relative to distraction activities. Although Dunn et al.’s findings were compelling, several design-related limitations suggest the need for further research. First, it was not possible to determine whether results were due to the addition of meditation per se or the absence of distraction given that there was not a preparation-as-usual condition. Furthermore, therapists were not asked about their reactions so we do not know how they experienced the benefits and challenges/barriers to using pre-session meditation. Another limitation was that therapists were required to participate in a 5-week meditation training curriculum before engaging in pre-session meditation, which could be burdensome for busy graduate students. Finally, given that Dunn et al. (2013) was the only study we found examining pre-session meditation use in trainee therapists, more research is needed.

Notably, from related literature, we know that therapist pre-session mood predicts session outcome (Chui et al., 2016; Chui & Hill, 2020). Hence, it makes sense that helping therapists modulate their pre-session mood could enhance therapists’ self-perceptions of being able to be present with clients and feel good about the quality of the sessions.

The Purposes of the Present Study

Our purpose in the present study was to investigate the effects of MBCP training for doctoral student therapists using a mixed methods approach involving both quantitative and qualitative analyses. We first examined the effects of a brief MBCP workshop, hypothesizing that therapists-in-training would find it to be effective in terms of enhancing curiosity, ability to decenter, and feelings of self-efficacy for meditating. We then compared the effects of three brief pre-session preparation conditions (MBCP, self-supervision, preparation-as-usual), hypothesizing that MBCP would lead to higher therapist ratings of session evaluation, therapeutic presence, and preparedness than would self-supervision or preparation-as-usual. Our third purpose was to qualitatively investigate the experiences of the therapists about the workshop and pre-session preparation exercises.

We chose to study doctoral student therapists in order to investigate the degree to which MBCP may be a useful addition to therapist training programs. Trainees stand to benefit from MBCP not only for their potential to enhance their therapeutic presence and effectiveness in working with clients, but also for their potential to enhance self-care amidst the many competing demands of graduate school (Felton et al., 2015).

We used a sample of convenience for this exploratory investigation. We conducted the study within a clinic that had an ongoing research program, and so we had to work around the structure of the clinic. Although the sample size was small, the advantage of working within an ongoing clinic setting was that more generalizations could be made to real settings. We asked for therapist input as we designed the intervention and we thus chose a 1.5 hour workshop and a brief, 2-minute pre-session intervention because this was the maximum amount of time therapists could provide. Moreover, therapists conducted all three conditions so that they would serve as their own controls, which was important given our small sample size. Our study design allowed us to collect data on the effects of the pre-session meditation for six therapists over 61 therapy sessions with 20 different clients.

Method

Participants

Six female trainee therapists (5 White European American, 1 international South Asian, age M = 33.3, SD = 6.4) practicing in a university counseling clinic offering low cost, individual psychodynamic psychotherapy to adult community clients provided data for the present study. All therapists were in at least their third year of a counseling doctoral program, had taken at least three practica prior to beginning their externship in the clinic, and engaged in weekly individual and bi-monthly group supervision with licensed psychodynamic psychologists. All therapists espoused a psychodynamic orientation; scores on the Therapist Orientation Profile Scale-Revised (TOPS, Worthington & Dillon, 2003), using a 10-point scale ranging from 1 (not at all) to 10 (completely) were higher for Psychoanalytic/Psychodynamic than for Humanistic/Existential (M = 8.35, SD = 0.79 vs. M = 5.61, SD = 2.41, d = .95), and higher for Humanistic/Existential than Cognitive/Behavioral (M = 5.61, SD = 2.41 vs. M = 3.30, SD = 1.51, d = 1.03).

Clients were 20 (11 female, 9 male; 9 White/European American, 5 Black/African American, 3 Asian American, 2 Latinx, 1 multiracial; age M = 31.7, SD = 8.7 years) adults. Presenting concerns included (non-mutually exclusive): relationships (80%), depression (40%), anxiety (40%), grief/loss (35%), career (25%), and meaning in life (15%).

Measures

We used five measures to assess the variables of interest. Because of the small sample, we do not report internal consistency for any of the measures for this sample.

Toronto Mindfulness Scale (TMS, Lau et al., 2006)

The Toronto Mindfulness Scale (TMS) assesses state mindfulness and is comprised of subscales of Curiosity (i.e., awareness of the present moment experience with an attitude of curiosity) and Decentering (i.e., awareness of the present moment experience with a quality of dis-identification, as opposed to being carried away by thoughts/feelings), reflective of its underlying two-factor structure (Lau et al., 2006). Subscale items are summed to compute subscale scores; higher scores reflect greater state mindfulness. Internal consistency reliability estimates of .86 and .87 have been reported for the Curiosity and Decentering subscales, respectively (Lau et al., 2006). Good concurrent and predictive validity have been demonstrated (e.g., TMS correlated positively with measures of reflective self-awareness, curiosity, and decentering).

Meditation Self-Efficacy

Using the format typical of items assessing self-efficacy (see Lent et al., 2006), we developed two items assessing self-efficacy for meditation for the present study: (1) “How confident are you that using mindfulness practices would enable to you to be more present and fully functioning in your work with most clients over the next week?”, and (2) “How confident are you that you could use mindfulness practices effectively with most clients over the next week?” Both items are rated on a 10-point scale, ranging from 0 (no confidence) to 9 (complete confidence). Because the 2 self-efficacy items were highly correlated at both baseline (r = .8) and post-workshop (r = .6), we averaged scores to create a combined self-efficacy score. Higher scores indicate greater meditation self-efficacy.

Session Evaluation Scale (SES, Hill & Kellems, 2002)

The SES was developed as a 4-item measure to assess the client perspectives about session quality, which was then modified to assess the therapist perspective. Lent et al. (2006) added a 5^th item to increase the variability. Two negatively worded items are reverse scored and item responses are averaged; higher scores reflect more positive session evaluation. Internal consistency reliability of the SES for therapists and clients has been reported as .86 and above (Lent et al., 2006). Regarding concurrent validity, the original SES correlated positively with session depth, understanding, problem solving, and client-therapist relationship quality (Hill & Kellems, 2002).

Therapeutic Presence Inventory-Therapist Version (TPI-T, Geller et al., 2010)

The TPI-T, which assesses therapeutic presence, contains 21 items rated on 7-point scales ranging from 1 (not at all) to 7 (completely). The total score is computed by reverse-coding the 10 negatively worded items and then summing responses, with higher scores indicating higher TP. Internal consistency reliability of .94 has been reported (Geller et al., 2010). A single factor has been shown to underlie the TPI-T; good concurrent validity has been demonstrated (e.g., positive associations with therapist-rated empathy, congruence, and level of regard).

Adherence Check

We developed a single item to assess adherence to the assigned treatment condition. Therapists were asked whether or not they had listened to the assigned meditation or self-supervision. The accuracy of these reports was triangulated through discussion during the focus group in which therapists discussed their adherence to the conditions.

Procedures

First, we obtained IRB approval for this study. Therapists were then recruited by the first author (a student also in the training cohort) for the study. The six therapists currently practicing at the counseling clinic were given the option of volunteering as a part of their externship training; all agreed to participate and signed consent forms.

Immediately before the workshop, therapists completed the TMS and Meditation Self-Efficacy items reflecting on their state in the previous 1.5 hours. The therapists then participated in a 1.5 hour MBCP workshop (Hurley, 2014, 2021) developed and led by a licensed clinical social worker (the 4^th author) with over 30 years’ experience practicing Tibetan Buddhist meditation and over 20 years teaching meditation. The workshop involved didactic instruction along with experiential exercises and question/answer periods. The workshop commenced with instruction on mindfulness practices (i.e., mindfulness of body, feelings, awareness and mental objects), and two self-compassion practices. Next, participants were instructed on ways of cultivating equanimity, gratitude, loving-kindness, and compassion through meditations and reflections. After the workshop, therapists again completed the TMS and Meditation Self-Efficacy items reflecting on their state during the workshop.

Clients were then randomized within therapists to one of three conditions (MBCP, self-supervision, or preparation-as-usual), such that therapists completed a distinct pre-session exercise depending on the client (and thus served as their own controls). With the exception of one therapist who had two clients assigned to preparation-as-usual and one to meditation, each therapist had at least one client in each condition. In the MBCP condition, therapists listened to a 2-minute audio recording by the workshop leader emphasizing mindfulness, loving-kindness, and compassion. In the self-supervision condition, therapists listened to a 2-minute recording by the workshop leader prompting them to think about what happened in the previous session, what was discussed in supervision, and goals for the upcoming session. Therapists listened to the recordings for these two conditions in a meditation room decorated with a candle, peaceful images, and meditation pillows. In the preparation-as-usual condition, therapists engaged in their typical pre-session activities and did not enter the meditation room.

Within 24 hours after therapy sessions, therapists completed the TPI-T, the SES, and the adherence check. Clients completed the SES immediately after finishing each session.

At the end of the 4 weeks of data collection, the 1^st and 5^th authors led a 30-minute audio-taped focus group with the 6 therapists. Therapists were asked two broad questions: “How was the workshop?” and “How did it go with the pre-session meditation?” with follow-up probes as needed to help them describe their experiences in depth. The audiotape was transcribed by a graduate student; participants were assigned pseudonyms to preserve confidentiality.

Data Analytic Approach

In order to determine any changes in participants’ state mindfulness or mindfulness self-efficacy before as compared to after the workshop, we analyzed the participants’ scores on TMS and meditation self-efficacy items using dependent samples t-tests in SPSS v27. Post-session SES data were analyzed using multilevel models sessions ([level 1] nested within clients [level 2] nested within therapists [level 3]) allowing for random intercepts (Singer & Willett, 2009). Models were specified using the lme4 and lmerTest packages in R (Bates et al., 2015; Kuznetsova et al., 2017) using restricted maximum likelihood estimation. Significance values were computed using Satterthwaite’s method (see Kuznetsova et al., 2017). In models evaluating the post-session measures, pre-session condition was entered as a fixed predictor with meditation as the reference group. Preparation-as-usual was specified as the reference group to assess differences between preparation-as-usual and self-supervision in a second set of models. Session number was entered as a predictor to assess time effects, and if non-significant, was dropped from final models.

Due to our small sample size, effects were primarily evaluated using effect size, with medium and large effect sizes interpreted as meaningful effects. Cohen’s d was used to quantify effect size in paired samples t-tests (>.50 is a medium effect, >.80 is a large effect). In multilevel models, standardized coefficients were used to estimate effect sizes (Lorah, 2018) and interpreted according to Cohen’s conventions for small (.1), medium (.3) and large (.5) correlation coefficients.

Qualitative data were analyzed by a team of three coders (all co-authors) using consensual qualitative research-modified (CQR-M, Spangler et al., 2012). They independently reviewed the focus group transcript and identified themes, which they then discussed until agreement on the final list of themes and their definitions was reached. The first author developed a list of categories and definitions based on the discussion, which were then discussed and revised within the team. Next, the coders independently assigned a category to each unique phrase in the transcript, resolving any discrepancies via consensus in a team meeting. In Results, we report on findings expressed by at least two therapists.

Results

We first present the quantitative data from the workshop and post-session, and then present the qualitative findings. Quantitative and quantitative results are also summarized in Tables 1 and 2, respectively.

Table 1.

Summary of Quantitative Findings

Hypothesis	Outcome
Therapists will report increases in state mindfulness and meditation self-efficacy in response to a 1.5 hour MBCP workshop	Partially supported
Pre-session meditation will lead to greater therapist-rated therapeutic presence relative to self-supervision and preparation-as-usual	Not supported
Pre-session meditation will lead to greater therapist-rated session evaluation relative to self-supervision and preparation-as-usual	Partially supported
Pre-session meditation will lead to greater client-rated session evaluation relative to self-supervision and preparation-as-usual	Not supported

Table 2.

Summary of Qualitative Findings

Overarching Category	Examples
Perceived Benefits of Meditation	Enhanced reflection Cultivation of positive inner states Enhanced self-care Increased interest in meditation
Perceived Challenges to Meditation Practice	Rushing to fit in the meditation between sessions Low meditation self-efficacy Tiredness
Feedback on the Meditation Intervention	More time practicing meditation is needed, ideally outside the clinic setting The TPI-T items were long and confusing The workshop should be less didactic and more experiential

Effects of the Meditation Workshop

Dependent-measures t-tests revealed that therapist ratings were significantly higher (large effect sizes) after compared to before the workshop on both TMS-Curiosity (M = 9.2, SD = 6.6 vs. M = 17.5, SD = 5.8, t(5) = 5.26, p = .003, d = 2.1) and TMS-Decentering (M = 10.0, SD = 5.4 vs. M = 19.3, SD = 4.2, t(5) = 6.23, p = .002, d = 1.5). Changes in therapists’ meditation self-efficacy following the workshop were marginally significant but had a large effect size: M = 6.6, SD = 1.7 vs. M = 7.4, SD = 0.9, t(5) = 1.96, p = .11, d = 1.0. Thus, the workshop appeared to be effective in terms of stimulating curiosity, decentering, and meditation self-efficacy.

Effects of Pre-Session Preparation

Treatment Adherence and Preliminary Analyses

In an adherence check, we noted that therapists failed to complete the pre-session assignment 6 times (out of 33) in the MBCP condition, 9 times (out of 24) in the self-supervision condition, and 8 times (out of 27) in the preparation-as-usual condition. Across conditions, the average adherence rate within each therapist trainee was 76% (range = 57 to 96%). These non-adherent sessions were dropped from the analyses, such that therapists had an average of 5.4 (SD = 2.1) sessions of data for MBCP, 3.0 (SD = 1.2) sessions for self-supervision, and 3.2 (SD = 2.1) sessions for preparation-as-usual.

All variables fell within the +- 2 skewness and kurtosis range, indicating normality and no outliers. Furthermore, because there was no evidence of growth over time in the outcome measures, session number was not included in any of the final models. We did not hypothesize a priori that therapeutic presence and session effectiveness would increase over time, and the lack of growth makes sense given the short time (i.e., 4 weeks) that therapists engaged in pre-session activities.

Therapist Post-Session Ratings

An empty multilevel model indicated that 31% of the variance in session quality ratings was attributable to therapists, 21% to clients, and 47% to sessions. Scores were significantly higher (medium effect size std. beta = −.41) for MBCP than preparation-as-usual, M = 4.5, SD = 0.5 vs. M = 4.0, SD = 0.6, b = −.53, t(11.8) = −2.8, p = .02, and marginally significantly higher (small effect size std. beta = −.26) for MBCP than self-supervision, M = 4.5, SD = 0.5 vs. M = 4.3, SD = 0.6, b = −.35, t(13.7) = −1.9, p = .08. Thus, therapist-rated session effectiveness was significantly higher in the MBCP than preparation-as-usual condition, and marginally higher in MBCP than self-supervision.

An empty multilevel model examining TPI-T indicated that 59% of variance was attributable to therapists, 5% to clients, and 36% to sessions. No differences were found between MBCP and self-supervision, M = 84.7, SD = 8.6 vs. M = 87.1, SD = 10.6, b = .98, t(8.8) = .42, p = .69, small effect size std. beta = .05, or between MBCP and preparation-as-usual, M = 84.7, SD = 8.6 vs. M = 83.8, SD = 8.1, b = .94, t(6.8) = .40, p = .70, small effect size std. beta = .05. Thus, therapists’ perception of their therapeutic presence was not differentially related to type of pre-session preparation.

Client Post-Session Ratings

In an empty multilevel model examining client-rated SES, the variance attributable to therapists was estimated as 0 and singularity was evident, so we dropped the therapist level to simplify the random effects structure (Barr et al., 2013). In the resulting two-level model, 28% of the variance was attributable to clients and 72% to sessions. No differences were found between MBCP and self-supervision, M = 4.6, SD = 0.50 vs. M = 4.3, SD = 0.63, b = −0.28, t(19.1) = −1.21, p = .24, small effect size std. beta = −.21, or between MBCP and preparation-as-usual, M = 4.6, SD = 0.50 vs. M = 4.05, SD = 0.57, b = −0.18, t(16.7) = −0.80, p = .44, small effect size std. beta = −.15. Thus, client session evaluations did not differ among the 3 conditions.

Focus Group Results

In this section, we use pseudonyms for the 6 participants. We report only those data for which we had evidence from at least 2 participants.

Perceived Benefits of Meditation

The first benefit that trainee therapists noted from participating in the study was enhanced reflection. Reflecting on the workshop and facilitator, Kiera noted, “There was something he said about like radiant healing light and imagining that, and just that stuck with me.” Sheera commented, “I love the whole garden idea that you’re trying to foster something [by] taking out weeds and other kinds of doubts and things like that.” Reflecting on the pre-session preparation conditions, therapists noted that the meditation condition provided an opportunity to engage in self-reflection and cultivate positive inner states prior to sessions. Nadia stated, “I really experienced it as very positive for my inner state of being.” Kiera noted that she “loved the mindfulness [condition]” and Elena “liked the fact that [the meditation condition] was like, bringing in the kindness, the kindness towards others.”

A second benefit was enhanced self-care, particularly between sessions. Therapists found the pre-session meditation condition helpful in managing the challenges of having back-to-back client sessions. Nadia stated, “I found it really did help me be present with my clients, especially during the back-to-back portion.” Aliya added that it was particularly helpful for managing “the more emotional [client sessions],” and stated that the instruction to “let your emotions settle” present in the pre-session meditation recording “always helped [her].” Therapists also commented on how structural supports for meditation further supported their self-care. Nadia expressed appreciation for having a meditation space, and for the candle in particular (“I felt really cared for having space that that for me was really nice and the candle”), which Kiera echoed. Several therapists appreciated having a booklet to take home for future reference following the workshop.

A third benefit was an enhanced interest in meditation among therapists, as several therapists commented about how they felt an increased interest in and desire to practice meditation as a result of the study. For example, Emily reported looking into meditation smartphone apps in order to pursue meditation practices beyond the study conditions. Several trainees also commented that they learned interesting and useful information about meditation in the workshop. In addition, some therapists noted a greater tendency to recommend meditation to clients. For instance, Emily commented, “I’ve been recommending meditation to my clients a ton in the past month . . . I’m like, ‘did you know you should meditate?’ I’ve told that to 7 people I think.” Similarly, Kiera expressed an interest in sharing the pre-session meditation recording used in the study with her clients.

Perceived Challenges to Practicing Meditation

Although the meditation condition was perceived as supporting between-session self-care, therapists also noted that a challenge was that the study added stress to their already hectic schedules. Furthermore, they expressed a more general wish to feel less rushed between sessions. Elena stated, “It was like now you have to unwind and I don’t have time for that.” Nadia added, “The intervention made us aware of how little time we feel we have to be present and that maybe this is us craving more time for that.” Kiera commented on the logistical challenges: “If I was running from someplace else, it was like, ‘okay now you have to find the recording and the earbuds.’” Kiera noted that the self-supervision condition was “irritating” because it disrupted her typical pre-session routine of reviewing her session notes. Emily commented about how the obligatory nature of the experiment added a layer of stress: “It felt stressful to feel obligated to do something right before the session.”

Another challenge described by trainee therapists involved having low self-efficacy for practicing meditation. Emily noted,

I think self-efficacy for meditation played a big role at least for me, because I have pretty low self-efficacy for meditation and I think maybe going to the workshop increased it a little bit, but I still think of myself as someone who doesn’t know how to meditate, and so that would kind of be in my head as I was listening to the recording. I’d be like, “I’m pretty sure I’m not doing this right.”

A third challenge for using MBCP involved an overall sense of tiredness that detracted from the ability to implement meditation. Some also note that a certain level of energy is needed for pre-session meditation to make an impact on therapeutic presence. Kiera noted,

Sometimes I felt tired, well that was going to be true regardless of what I did before the session. So if I was tired, I was tired. And being mindful for two minutes was not going to make that go away.

Elena noted that her client assigned to the meditation condition was her last of six clients in a row, and at that point she felt that “mindfulness only does so much.”

Feedback on the Meditation Intervention

Therapists reflected about whether the meditation increased their therapeutic presence level, oftentimes struggling to reach a definitive conclusion due to multiple influences on therapeutic presence, including client and session-related factors. Elena commented, “I have three clients now, and they’re each in the three different conditions, and it was just hard, because I attributed [therapeutic presence] also so much to the clients that it’s hard to know.” Emily remarked, “I just attributed that to the nature of the session, and not the intervention. So when I endorsed the items that said I felt bored […] it was because it was a boring session. Not because I wasn’t centered or something.” Kiera was doubtful that the pre-session preparation benefited her therapeutic presence: “I really liked it, but I don’t think it did. But I’ll be really interested to see, because I don’t know, who knows.” Conversely, Nadia noted potentially favorable impacts of the pre-session preparation on her session process, “I really found that I was maybe more reflective in session, less active, which to me is a good thing.” Therapists speculated that having more time practicing might be required for the impacts on therapy sessions to become apparent.

In addition, many therapists noted difficulties with therapeutic presence measure, which appeared to compound their difficulty in determining the impact of pre-session meditation. Therapists experienced the TPI-T measure as too long and items as confusing. Emily noted, “There were very few where I endorsed more than the midrange, and part of that was that I didn’t understand what the questions were asking.”

Related to comments about the workshop being overly didactic, almost all therapists expressed a wish to have had more time for experiential practice during the workshop. Furthermore, to resolve some of the concerns they had mentioned, including being unsure as to whether the pre-session exercises made an impact and the busyness created by the experimental paradigm (i.e., doing meditation immediately before sessions and time-consuming self-report measures afterwards), they suggested the potential benefits of meditating outside of the clinical setting for longer duration. Sheera noted, “I think it does sometimes take a bit longer, so I like the idea of having something longer at a different point in time, like once a week or once a day.”

Some of therapists raised comments reflecting a lack of interest and/or boredom during the workshop, experiencing the content as overly focused on the theoretical and empirical bases for practicing meditation. Emily stated that “it felt like a class,” and Kiera commented, “I thought it was kind of dull.” Many comments reflected a process of relating the material with prior experiences with and expectations about meditation. Sheera, with seemingly greater prior experience with meditation, connected the material to a meditation workshop she had attended called Conscious Relationships led by prominent US-based meditation teacher Tara Brach. She speculated that the in-pairs exercises presented in that workshop might more favorably impact therapy relative to individual meditation: “The other person thinks of an instance of something, and you try to imagine what they’re feeling just looking at them, so you know that might be a little closer to therapy because you’re working in dyads.”

Discussion

Overall, we found that a 1.5 hour MBCP workshop was effective for six doctoral student therapists working with adult community clients in individual psychodynamic psychotherapy. Specifically, therapists benefited from the workshop in terms of enhanced curiosity, de-centeredness, and self-efficacy. Furthermore, therapists described several benefits from participating in the MBCP workshop (e.g., the instructor’s use of metaphors such as gardening to illustrate mind training and the emphasis on kindness towards others) and pre-session meditation (e.g., increased positive inner states like kindness, an improved capacity to effectively manage the emotional demands of back-to-back sessions, and having a dedicated space available to them to use to prepare prior to sessions). These findings are similar to those of prior studies suggesting that MBCP improves therapy effectiveness (Grepmair et al., 2007; Ivanovic et al., 2015), enhances trait-like empathy in medical students (Shapiro et al., 1998) and promotes self-care for therapists in training (McCollum & Gehart, 2010).

The results for the two-minute pre-session preparation was less conclusive. Therapists evaluated sessions preceded by listening to a brief meditation recording as significantly more effective than those preceded by preparation-as-usual, but brief meditation was not better in terms of client-reported session effectiveness. One study testing a much longer meditation intervention (i.e., 1 hour per day, 5 days per week) reported that therapist meditation enhanced client-reported session effectiveness (Grepmair et al., 2007). We suspect that two minutes of meditation was too small a dose to induce substantive changes in therapists. In addition, perhaps there were other changes that occurred within therapists that led them to view their sessions more favorably following meditation relative to control conditions. The meditation recording involved instruction on kindness, compassion and mindfulness, and therapists thus could have experienced an increase in positive emotions, leading them to appraise and recollect their sessions more positively. Indeed, therapist pre-session mood has been shown to predict session outcome (Chui et al., 2016; Chui & Hill, 2020), and thus, pre-session mood could have enhanced therapists’ perceptions of session quality. Finally, although therapists experienced many benefits from meditation, they also voiced several challenges and barriers. Tiredness and low self-efficacy for meditation were noted, along with feeling rushed to “fit in” the meditation exercise between sessions. It is interesting that some therapists in this study viewed the pre-session meditation as obligatory, and even added a layer of stress. Future exploratory research might seek to identify what therapists actually do or find useful before a session.

Interestingly, we found no differences among conditions for therapist self-rated therapeutic presence. Similarly, Ivanovic et al. (2015) found that therapist engagement in five 20-minute mindfulness training session did not lead to changes in therapeutic presence. In contrast, Dunn et al. (2013) found that pre-session meditation led to higher therapist ratings of therapeutic presence than did pre-session control conditions. It is worth emphasizing, however, that Dunn et al. asked therapists to engage in distracting activities (e.g., checking email) during the control condition and thus, it is possible that detrimental effects of pre-session distraction partially contributed to the apparent superiority of pre-session meditation. Differences in the amount and type of MBCP training make it difficult to identify if and how much MBCP impacts therapeutic presence. However, it is possible that brief interventions are relatively limited in their capacity to improve outcomes. Consistent with the notion that longer practice may promote greater gains, therapists in our study expressed the view that meditating for longer periods outside the clinic setting might be more effective in enhancing therapeutic presence relative to brief pre-session practices. Further supporting the limitations of brief practice in clinical settings, a recent study examining the effects of 5-minute mindfulness practiced by clients and therapists at the start of sessions reported no beneficial effect on client symptoms (Mander et al., 2019).

Evidence does suggest that consistent at-home practice may favorably impact therapists’ presence and clinical skills. Specifically, therapists’ own regular mindfulness practice outside the clinic setting has been shown to foster a present-centered and accepting attitude within sessions (Cigolla & Brown, 2011). Furthermore, longer practice duration has been shown to predict greater changes in mindfulness and other therapeutic outcomes in patient samples (Carmody & Baer, 2008), suggesting that longer practice among therapists outside the clinic setting could also engender greater gains relative to brief pre-session practice.

Limitations and Implications

We did not include comparison or control conditions for testing the effects of the workshop, so we cannot claim causality for the workshop. In addition, therapists served as their own controls in this study for the pre-session preparation, which allowed us to control for therapist effects but prevented us from ruling out that the therapists may have provided biased ratings based upon suspicions about study hypotheses. Furthermore, our sample size was small and all therapists were women, most were White, all were from one doctoral program, and all worked in a psychodynamic clinic, so results might not generalize beyond this sample. Future studies could explore differences among therapists of different genders or racial/ethnic backgrounds to determine the similarities and differences among these groups. In addition, we did not explore the impact of the psychodynamic theoretical orientation on the results. Future researchers could explore how theoretical orientation impacts the benefits or hindrances to meditation and compassion practices.

It is possible that our brief intervention comprised of a single workshop and 4 weeks of pre-session exercises was not a strong enough “dose” to induce effects on therapeutic presence or client ratings of session effectiveness, and that doing the meditation immediately prior to sessions, as opposed to outside the clinical setting, was suboptimal. Indeed, therapists suggested that increasing the length of practice time and encouraging regular practice outside the clinic setting might have been more beneficial. Furthermore, some noted that it was hard to “fit in” the pre-session exercises between sessions, such that any potential benefits engendered by meditating may have been counteracted by rushing around to fit in the exercise. We recommend that future researchers explore the structural barriers that hinder therapists’ meditation practices, such as providing more “down time” for clinicians or adjusting other clinic practices to better support clinicians. Also, pre-session MBCP may impact therapeutic presence in some therapists and not in others, suggesting that there may be therapist-level moderating factors (e.g., interest in and motivation to meditate) that we would have been underpowered to detect in quantitative analyses. Further research is needed to identify the impact of therapist-level factors as well as to determine ways to intervene to address any barriers, such as increasing motivation. Therapists’ prior experience with meditation and how that possibly facilitates openness to meditation practice should be further explored.

Notably, the measure of therapeutic presence had its downsides (e.g., problems noted by therapists with some of the items), and may have been a suboptimal measurement strategy. Indeed, other studies that found a positive association between meditation practice and therapeutic presence have used journal assignments and qualitative analyses (e.g., McCollum & Gehart, 2010). Moreover, given that asking therapists to complete measures before and after the 2-minute practice would have taken time and detracted from any cultivated mindfulness state, we do not know if therapists achieved a state of mindfulness from the practice. Future researchers could use physiological indices or external raters to assess therapists’ mindfulness.

In spite of these limitations, these analyses provide preliminary support for the potential benefits of MBCP workshops and pre-session preparation on the psychotherapy process. To the best of our knowledge, this study is one of just two (see also Dunn et al., 2013) employing a longitudinal design to investigate the effects of pre-session practice on the therapy process among trainee therapists. More empirical research on the relationship between MBCP and therapy effectiveness is needed. We encourage future researchers to investigate the effects of MBCP workshops and pre-session practice as well as meditation training outside the clinic setting on therapeutic presence, session effectiveness, and client outcomes. Researchers could also explore the relative benefits of pre-session practice versus other practice formats (e.g., at-home, within-classroom, via meditation workshops and courses) and comparing mindfulness with compassion-based practices.

Practical Implications.

• Therapist engagement in 2 minutes of meditation immediately prior to sessions may support therapy effectiveness

• Brief meditation provides an opportunity for therapists to engage in self-care and grow positive inner states like kindness

• Therapists who implement pre-session meditation may encounter challenges and barriers, such as feeling tired and difficulty fitting in meditation between therapy sessions