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Institute for Clinical Social Work

Exploring the Integration of Mindfulness in Psychodynamic Therapy

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Barb Jochum

Chicago, Illinois June 2016

Abstract

The purpose of this explanatory sequential mixed methods study was to gain a better understanding of the integration of mindfulness techniques into psychodynamic therapy. Research was conducted through a two-phased study which consisted of an Internet survey in Phase One and in-depth interviews in Phase Two. Once the Phase One surveys were completed and analyzed, 10 participants, from two distinct sub-groups of five, were selected to be interviewed in Phase Two. Participants shared their experiences of integrating mindfulness techniques and what that meant to them and their psychodynamic theory or orientation. The findings in this study indicated that the overall belief of the participants was that integrating mindfulness techniques into sessions enhanced the therapeutic process for clients; however, psychodynamic theories have not endorsed this integration. The study also identified barriers, which included the lack of a standard definition of mindfulness in therapeutic practice, and the uncertainty of how to integrate these techniques into the therapy sessions. Mindfulness-based practices have had sufficient research supporting the benefits of using these techniques, but limited research has been done on integrating these techniques into psychodynamic therapy. Thus, the study revealed that the integration of mindfulness techniques into psychodynamic therapy is beneficial, but further research is needed to fully develop an evidence-based integrative practice.

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For my husband and children

Acknowledgments

I would like to thank my committee members: James Lampe, PhD, my chair, for all his support and patience and for helping me maintain my focus when I was moving forward at full force; John Ridings, PhD, for countless hours of consultation and support to help me understand mixed methods research; Michael Casali, PhD, for all his feedback and support during this process starting with our independent studies; Denise Duval-Tsioles, PhD, for being a reader and support throughout; Sue Cebulko, PhD, for being a reader and an extra special thanks for being my mentor and biggest support throughout my entire journey at The Institute for Clinical Social Work. I am eternally grateful for my education, experiences, and all that I have gained from completing this program and to everyone who contributed to it.

Table of Contents

Page Abstract……………………………………………………………………………….….ii Acknowledgments…………………………………………………………………..........v List of Tables……………………………………………………………………………..x Chapter I. Introduction…………………………………………………………………..1 General statement of Purpose Significance of the Study for Clinical Social Work Statement of the Problem and Specific Objectives to Be Achieved Research Questions to Be Explored Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Epistemological Foundation of Project Foregrounding

Table of Contents—Continued

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II. Literature Review…………………………………………………………..15 Introduction Mindfulness Psychodynamic Theory Psychotherapy Integration Conclusion III. Methodology…………………………………………………………..........47 Introduction Rationale for Mixed Methods Research Design Rationale for an Explanatory Sequential Mixed Methods Design Research Sample Research Design Data Collection Data Analysis Ethical Considerations Issues of Trustworthiness Limitations and Delimitation The Role and Background of the Researcher Conclusion

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Table of Contents—Continued

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IV. Results………………………………………………………………........….68 Introduction Phase One Sample Phase Two Sample Mixed Methods Results Conclusion V. Findings, Discussion and Implications…………………………………...120 Introduction Phase One Findings and Discussion Phase Two Findings and Discussion Mixed Methods Findings and Discussion Revisiting Assumptions from Chapter 1 Summary of Interpretation of Findings

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Table of Contents—Continued

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VI. Conclusion and Recommendations….…………………………………...149 Theoretical and Clinical Implications Implications for Clinical Social Work Social Implications Future Research Validity and Limitations Researcher Reflections Conclusion Appendices A. Copy of Recruiting Email…………………………………………………162 B. Informed Consent for Phase One………………………………………...164 C. Survey Questions…………………………………………………………..168 D. Script for Brief Screening Interview……………………………………..172 E. Informed Consent for Phase Two………………………………………...174 F. Interview Guide One………………………………………………………178 G. Interview Guide Two……………………………………………………...180 References……………………………………………………………………...182

List of Tables

Table

Page 1. Summary of Psychodynamic Theories……………………………………40 2. Participant Criteria………………………………………………….……..70 3. Participant Demographics…………………………………………………71 4. Participant Survey Results………………………………………………....76 5. Phase Two Participant Demographic Matrix for Aware Sub-Group…...79 6. Phase Two Participant Mindfulness Summary for Aware Sub-Group…80 7. Phase Two Participant Demographic Matrix for Unaware Sub-Group...82 8. Phase Two Participant Mindfulness Summary for Unaware SubGroup..............................................................................................................83 9. Themes from Aware Sub-Group………...………………….……………...99 10. Themes from Unaware Sub-Group………………………………………114

Chapter 1

Introduction General Statement of Purpose This study addressed the psychodynamic integration of mindfulness therapy techniques with psychodynamic therapy by psychodynamic therapists in the United States. The psychodynamic theories included classical theory, object relations theory, self-psychology theory, and relational and other contemporary theories. An explanatory sequential mixed methods design was used. This involved collecting and analyzing both quantitative and qualitative data in a two-phased approach. In the first quantitative phase, survey data were collected from psychodynamic therapists to explore the prevalence of this type of psychodynamic integration and the process of integration. The second, qualitative phase was conducted as a follow-up to the quantitative results to further explain the quantitative results. In this explanatory follow-up phase, the plan was to explore the integration of mindfulness therapy techniques with psychodynamic therapists. At the beginning of this study, integration was defined as the process of combining one or more concepts together as a whole. “The integration of therapy involves the synthesis of the ‘best and brightest’ concepts and methods into new theories and practical systems of treatment” (Stricker & Gold, n.d., p. 1). Additionally,

mindfulness was considered an umbrella term that was generally defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). Initially, mindfulness therapy techniques were defined as the specific techniques used to implement mindfulness, which often included “awareness of breath and sensations” and “observing feelings” (McWilliams, 2012, p. 239).

Significance of the Study for Clinical Social Work Social workers' identities have been grounded in the work they do. Academic courses have emphasized the ethical standards and practices that social workers are trained to follow. This included using evidence-based practice to ensure the best possible outcomes for clients. As new theories and treatment modalities have become available, it has been important to thoroughly research all possible outcomes, including how different techniques were utilized and implemented. Mindfulness-based treatments have been studied and researched for many years. The outcomes of these studies have shown that mindfulness has a therapeutic value for clients. However, these studies have primarily been done in conjunction with cognitive behavioral therapy, dialectical behavioral therapy, and acceptance and commitment therapy (Crane, 2009; Eifert & Forsyth, 2005; Mace, 2008). Fewer studies have looked at the integration of mindfulness therapy techniques into psychodynamic therapy. This research study aimed to show how mindfulness therapy techniques were integrated into psychodynamic therapy and what impact they had, if any, on clients’ treatment outcomes.

Statement of the Problem and Specific Objectives to Be Achieved Mindfulness was considered an umbrella term that was composed of multiple techniques and/or meanings. Mindfulness practices have been rooted in Eastern Buddhist psychology, which was integrated into Western psychology over the past three decades (Kostner, 2014). As stated by Fulton and Siegel (2005), “Mindfulness has been practiced deliberately for over 2500 years, primarily in the form of mindfulness meditation, to alleviate human suffering” (p. 28). Mindfulness has created an awareness and understanding of one’s suffering, which then could alleviate the pathological suffering through the experience of detaching oneself from its grip (Kostner, 2014). According to research, mindfulness practices have had positive effects on humans’ physical and emotional well-being. There are numerous how-to books to help apply mindfulness practices to one’s life (Crane, 2009; Eifert & Forsyth, 2005; Germer, 2005; Mace, 2008; Siegel, 2010). Mindfulness practice has even infiltrated the medical world, including mental health. Mindfulness therapy techniques have generally been integrated into behavioral therapies such as mindfulness-based cognitive therapy, dialectical behavioral therapy, and acceptance and commitment therapy, with integration into psychodynamic therapies having been relatively recent (Stewart, 2014). Psychodynamic therapy has been rooted in psychoanalytic theory, which would not generally fit with mindfulness therapy techniques (Gold, 2014). McWilliams (2004) defined psychoanalytic therapies, including psychoanalysis, as “approaches to helping people that derive ultimately from the ideas of Sigmund Freud and his collaborators and

followersâ€? (p. 1). This included the following seven factors identified from Blagys and Hilsenroth (2000): 1.

Focusing on affect and expressing emotions;

exploring a patientâ€™s resistance;

identifying patterns in a patientâ€™s thoughts;

considering feelings, experiences, relationships, etc.;

looking at past experiences and exploring interpersonal experiences;

emphasizing the transference in the relationship; and

exploring the intrapsychic dynamics, such as fantasies and dreams.

These factors have been primarily explored through talk therapy, not with behavioral techniques. Mindfulness therapy techniques were considered a behavioral intervention and therefore were not considered part of the psychoanalytic frame. Thus, psychodynamic therapy and mindfulness practices seemed to be in direct conflict with each other. Psychodynamic therapy has been based on talk therapy, which explores patterns, feelings, and resistances and looks at the transference in the relationship. In contrast, mindfulness practices have been based on techniques such as meditation and breathing. These techniques have generally been practiced individually, without a relational aspect. The differences in psychodynamic therapy and mindfulness practices seemed to create a barrier to integration and have created confusion as to remaining loyal to the theoretical model of psychodynamic theory. Nevertheless, mindfulness has still managed to infiltrate the therapeutic environment. Despite these inconsistencies, four basic frameworks shared by both

Buddhist psychology and Western psychology have been used to understand psychological disorders (Fulton & Siegel, 2005). These shared frameworks included the identification of symptoms, the etiology of symptoms, the prognosis, and the treatment. Identification of symptoms in Western psychology included subjective states and maladaptive behaviors (Fulton & Siegel, 2005). In Buddhist psychology, mindfulness meditation described a symptom as, “suffering that is inescapable to all who exist” (Fulton & Siegel, 2005, p. 30). It was not viewed as a psychological disorder, but rather “a result of the nature of our relationship to the existential realities of life” (Fulton & Siegel, 2005, p. 31). Both Eastern and Western psychologies have agreed that the etiology of symptoms was not random, but rather a result of conditions. The prognosis of Western psychology varied based on the disorder being treated, while the prognosis for Eastern psychology, using mindfulness, was very optimistic. Both psychologies shared the same goal of “helping to restore an individual to ‘normal’ development as it is understood in that culture, or fuller participation in his or her society” (Fulton & Siegel, 2005, p. 38). There have been multiple comparisons made in regard to Eastern Buddhist psychology and psychoanalysis, as well as the similarities and differences of practice techniques (Stewart, 2014). These studies included Morvay’s (1999) paper on what Karen Horney experienced with Zen Buddhism; Rubin’s (2009) integration of meditation as a way to cultivate evenly hovering attention, as introduced by Freud; Epstein’s (1990) study of Buddhist meditation and psychoanalytic practice; and Cooper's (1999) study on countertransference in Buddhist meditation. A 2014 study done by Chuan-Chuan Tsai

found that “psychodynamic psychotherapists, who practice mindfulness, experience mindful awareness affecting their listening stance, particularly in regard to perceiving, registering and comprehending latent, unconscious meaning and process” (p. 2). This study also compared Eastern Buddhist psychology and psychoanalysis, but focused on the effects of the listening process in understanding the unconscious content. This understanding was based on the psychodynamic therapists’ practices of mindfulness and their interpretation of the effects of the listening process. Although Eastern Buddhist psychology was referenced in this study, the primary focus was on the use of mindfulness therapy techniques in Western psychology and their integration into psychodynamic therapy. Research on Western psychology approaches has shown that mindfulness-based practices have been correlated with positive patient outcomes (Kabat-Zinn, 2009), which included the reduction of psychopathological symptoms. The positive outcomes in these studies implied that mindfulness therapy techniques could be beneficial to any theoretical background, including psychodynamic therapy. However, psychodynamic therapists have had a strong commitment to the psychoanalytic frame and are unlikely to integrate mindfulness therapy techniques into their therapy sessions. This resistance could have been out of fear of not being true to the structure of psychoanalytic theory, including the impact on the transference/countertransference dynamic. Mindfulness therapy techniques could have changed the therapeutic process and the therapeutic outcome for the patient. Mindfulness therapy techniques could have helped impasses, patient symptom management, and a deepening of the treatment. I have believed that mindfulness therapy

techniques have been a vital component to psychoanalytical practice, but the lack of research left a deficit of understanding how that integration looked. There has been some controversy as to whether utilizing mindfulness techniques were in line with psychoanalytic practice (Gold, 2014). Many psychodynamic therapists have integrated mindfulness therapy techniques into their practice, but it has been unclear as to what this integration looked like. Therefore, this study sought to understand how mindfulness therapy techniques were being integrated into the psychodynamic therapy sessions and how this was beneficial to the psychoanalytic community.

Research Questions to Be Explored Quantitative 1. What is the prevalence of psychodynamic therapists who use mindfulness therapy techniques in their sessions? 2. What percentage of psychodynamic therapists who integrate mindfulness therapy techniques are aware of it? Qualitative What is the meaning of integrating mindfulness therapy techniques for psychodynamic therapists? (central qualitative question) 1. How do psychodynamic therapists define mindfulness therapy techniques? 2. Are psychodynamic therapists reluctant to disclose the integration of mindfulness therapy techniques in their practice?

3. How do psychodynamic therapists describe their decision to integrate mindfulness therapy techniques?

Mixed Methods 1. To what extent and in what ways do the survey responses help to identify psychodynamic therapists who can be interviewed to further an understanding of the integration of mindfulness therapy techniques? 2. To what extent and in what ways do qualitative interviews with psychodynamic therapists serve to contribute to a more comprehensive and nuanced understanding of the integration of mindfulness therapy techniques?

Theoretical and Operational Definitions of Major Concepts Mindfulness “Paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4). Psychotherapy integration The integration of therapies involving the synthesis of “concepts and methods into new theories and practical systems of treatment” (Stricker & Gold, n.d., p. 1). Mindfulness therapy techniques Techniques used or taught in a therapy session to enhance clients’ therapeutic experiences through awareness of themselves and others; their situations; and their past, present, and/or future relationships.

Psychodynamic therapists A psychotherapist whose training and education is rooted in psychoanalytic theory (McWilliams, 2004). Psychodynamic therapy Treatment provided by a trained psychotherapist who is rooted in psychoanalytic theory (McWilliams, 2004). Integration The process of combining one or more concepts together as a whole (dictionary.com, n.d.).

Statement of Assumptions Assumption #1 Therapists who integrated mindfulness therapy techniques also practiced them. Assumption #2 Teaching mindfulness therapy techniques to a client enhanced the clientâ€™s therapeutic outcomes. Assumption #3 Therapists who integrated mindfulness therapy techniques into psychodynamic therapy believed it was beneficial to the psychoanalytic community.

Assumption #4 Some therapists who integrated mindfulness therapy techniques were not aware that they were doing so because they had not ascribed a label or language to these techniques. Assumption #5 Integrating mindfulness therapy techniques into psychodynamic therapy impacted transference/countertransference dynamics. Assumption #6 Therapists utilized mindfulness therapy techniques to regulate their clients’ mood/affect prior to deepening the treatment. Assumption #7 Therapists utilized mindfulness therapy techniques to enhance the treatment process.

Epistemological Foundation of Project As a social worker, I have had a social constructivist view. I believed that meaning was created through one’s interactions in the world. Creswell (2014) cited several assumptions from Crotty (1998) as to how humans constructed their world. This included one’s interpretation, historical and social perspectives, and interaction within the community. The cultural context of human beings created meanings and realities in their lives and their relationships. Therapy also became a social construction. The therapist and client co-constructed new meanings and realities in one’s life (Gergen, 2009).

Research from a constructivist perspective has given a voice to oneâ€™s cultural context (Gergen, 2009). In this research study, I wanted to understand how mindfulness was integrated into a therapy session and what meanings and realities were created from this co-construction. I also believed there were biological components that contributed to the construction or the meanings of our lives. This belief was most in line with a postpositivist view. Freud identified himself as a scientist, having a positivist view. According to Palombo, Bendicsen, and Koch (2009), Freud believed that he would find a biological component that would explain psychopathology. Unfortunately, technology was not on his side, and it was not possible for him to study the brain. In the recent decade, with increased brain studies, neuroscience has supported biological contributions to psychopathology (Schore, 1997). In this research study, I wanted to show the validity of the biological components of mindfulness to support the use of this technique to enhance psychodynamic therapy. Despite my personal worldviews, this study was pragmatic. Because I was doing a mixed methods study, I was not committed to any one philosophy, but inquired from both quantitative and qualitative assumptions (Creswell, 2014). A pragmatic approach allowed me to utilize whatever methods, techniques, and procedures best fit with the needs of the research study. This allowed for the freedom of choice regarding appropriate approaches when I collected data and analyzed results, and it provided the best understanding of the research problem.

Foregrounding Mindfulness has been a topic of interest to me for many years. I was first introduced to the concept of mindfulness in my late twenties when I was looking for “something more” and a friend recommended reading the author Jon Kabat-Zinn. This was my first exposure to the concept of mindfulness and I was very intrigued. I read Kabat-Zinn's book, Full Catastrophe Living, which introduced techniques of mindful awareness, breathing techniques, sitting meditation, eating meditation, walking meditation, the body scan, and mindful yoga. Although it was difficult initially to integrate the concepts into my own life, it left me with a feeling of hope that things could be different. I continued to explore the concept of mindfulness. During my master’s program, I enrolled in a course on alternative techniques in psychotherapy. This class reinforced many of the initial mindfulness techniques I had learned from Kabat-Zinn and also exposed me to different types of energy work, gi gong, and tai chi. My interest in mindfulness continued to grow. After I completed my master’s degree in social work, I started a new job at a local hospital in its adult partial hospitalization program. This program helped stabilize mental health in adults. Although the patients were quite acute in their symptoms, they had a safe and supportive living environment while they attended the program five days a week. I started this job in 2005 and primarily did education with the patients. Over the next 2 years, this position evolved, and I began to do therapy groups and case management. The hospital as a whole began to use dialectical behavior therapy as a therapeutic framework. With the training and implementation of that new framework, we

began to expand our programming direction. Around 2007, I helped create a daily mindfulness group. Every morning after the patients arrived, we started with a mindfulness technique to help ground the patients. As clinicians, we discovered that over time, patients who began to utilize these techniques were able to cope with and even reduce their symptoms. Although I left this program in 2010 to pursue private practice, the mindfulness group at the hospital has continued. My primary initial training as a clinician was cognitive behavioral-focused. When I started my PhD program in the fall of 2010, it was my first real exposure to psychoanalysis. In private practice, I primarily used cognitive behavioral therapy and dialectical behavioral therapy, which included mindfulness techniques. As I continued to research the benefits of using mindfulness, I felt very strongly that it could benefit my clients. When I was cognitive behavioral- focused, it was easy to implement these techniques. As I shifted to a psychodynamic focus, I became very confused as to how to implement mindfulness techniques. In fact, my belief was that it was "not allowed," as it strayed too much from the psychoanalytic frame. As I learned more about psychoanalytic theory, I became more and more curious as to how the two concepts could be combined, with mindfulness techniques enhancing psychodynamic therapy. My initial passion with mindfulness grew as I continued to research and learn more. In researching mindfulness, I came across neuroscientific studies that have supported mindfulness techniques. These studies have shown that mindfulness techniques actually change the neural pathways in the brain. These changes have created long-lasting effects for clients. There was not a lot of research on the integration of

mindfulness techniques and psychodynamic therapy, and that was what piqued my interest. I wanted to understand how mindfulness was integrated into psychodynamic therapy by therapists using mindfulness techniques and how it impacted their clients. This included how they defined the concept of mindfulness and what specific mindfulness techniques they used. Chapter 2 of this study provided a thorough review of the literature to identify the gaps in research. This provided a foundation for the methodology design, which was described in Chapter 3. In Chapter 4 the results from the study were presented. Finally, Chapter 5 presented and discussed the findings of the study.

Chapter 2

Literature Review Introduction Mindfulness has been practiced for more than 2,500 years with positive outcomes in both physical and emotional well-being (Fulton & Siegel, 2005; Kabat-Zinn, 2009). Mindfulness practices originated from Eastern Buddhist psychology and eventually infiltrated Western practices (Kostner, 2014). In Buddhist psychology, mindfulness was a way of being, not a clinical method, whereas Western psychology used mindfulness predominantly as a clinical application (Lin & Seiden, 2014). Western mindfulness has been defined as â€œpaying attention in a particular way: on purpose, in the present moment, and nonjudgmentallyâ€? (Kabat-Zinn, 1994, p. 4). While this definition may still be accurate, there has been a shift in how mindfulness is conceptualized, including mindfulness as a collection of techniques (Hayes & Wilson, 2003). Specific mindfulness techniques have been developed to enhance treatment and have more measurable outcomes. These techniques have been integrated into behavioral therapies such as mindfulness-based cognitive therapy, dialectical behavior therapy, and acceptance and commitment therapy (Stewart, 2014). This study addressed the integration of mindfulness therapy techniques with psychodynamic therapy by psychodynamic therapists in the United States. The psychodynamic theories included classical theory, object relations theory, self-

psychology theory, and relational and other contemporary theories. A critical review of the literature was required to conduct this study. The challenge was that the integration of mindfulness therapy techniques into psychodynamic therapy has been relatively recent, with little literature that defined what that integration looked like. Hence, this literature review consisted of three sections. The first section defined mindfulness and included a distinction between Eastern and Western practices. The second section gave a general overview of psychodynamic theory; the third section reviewed psychotherapy integration, which included the integration of mindfulness therapy techniques with psychodynamic therapy. Each foci included an introduction, discussion, and conclusions/implications (Bloomberg & Volpe, 2012) that related to the integration of mindfulness therapy techniques with psychodynamic therapy. The main search engines used to conduct this literature review were EBSCO, PEP Web, and Google scholar. Key terms used included: mindfulness, integrated psychotherapy, Western psychology versus Eastern psychology, Eastern and Western meditation, psychotherapy integration, psychodynamic theory, psychoanalysis, and mindfulness techniques.

Mindfulness Definition. Mindfulness has been a multidimensional concept in which clinical applications have been developed and implemented into psychology and health care (Shapiro & Carlson, 2009). Kabat-Zinn (1994) defined mindfulness as â€œpaying attention in a particular way: on purpose, in the present moment, and nonjudgmentallyâ€? (p. 4). Germer

(2005) defined mindfulness as “a skill that allows us to be less reactive to what is happening in the moment. It is a way of relating to all experiences - positive, negative, and neutral- such that our overall level of suffering is reduced and our sense of wellbeing increases” (p. 4). Shapiro and Carlson (2009) stated that mindfulness can be confusing in that it “is both a process (mindful practice) and an outcome (mindful awareness)” (p. 4). This led to a more complex definition of mindfulness from Buddhist scholar and monk Nyanaponika Thera: The unfailing master key for knowing the mind, and is thus the starting point: the perfect tool for shaping the mind, and is thus focal point; and the lofty manifestation of the achieved freedom of the mind; and is thus the culminating point (as cited in Kabat-Zinn, 2005, p. 108). Prior to the 18th century, healing was conducted by holy people such as a Christian saint, an Islamic Sufi, or Buddhist Arahat. These holy people provided a new understanding to someone who was suffering, in order to alleviate that suffering (Symington, 1996). Buddhist psychology has taught that the source of human suffering was craving: people want things to be different than they are and will only be happy when they possess or get rid of someone or something (Chozen Bays, 2011; Shapiro & Carlson, 2009).

Eastern Buddhist psychology. Buddhism was founded by Buddha Shakyamuni, also known as Siddhartha Gautama, as a way to gain freedom from suffering and to become enlightened. Those

who sought to become Buddhist did so through the development of “kindness, inner peace and wisdom through daily practice; and then aim at sharing their experiences with others in order to bring real benefits to this world” (Tashi, 2014, p. 1). This personal development came from the Dharma, the teachings of Buddha. By following the teachings of Buddha, one may discover “true happiness” (p. 1). Some have referred to Buddhism as a religion because it has its own set of beliefs and a complex history, but Buddha was a human being, not a God (Tashi, 2014; Nhat Hanh, 1998). Others have viewed Buddhism as a philosophy or a way of life. There were three main schools of thought in teaching Buddhist traditions: the Theravada, the Mahayana, and the Vajrayana. Despite the different practices and belief systems, all three schools shared the fundamental teachings of Buddha, which were the four Noble Truths and the Noble Eightfold path. The four Noble Truths were the foundation of Buddhism, which aimed for one to achieve enlightenment or Nirvana. Tashi (2014) defined Nirvana as “a state in which one achieves mastery of mind, complete freedom and peace of mind,” which can be compared to heaven on earth (p. 18). The first Noble Truth was the truth of suffering (dukkha). This truth acknowledged that to live is to have suffering, undesirable experiences, and difficulties and accepting these truths began the journey of Nirvana (Chodron, 1990; Nhat Hanh, 1998; Tashi, 2014). The second Noble Truth was the truth of the cause of suffering (samudaya). This truth acknowledged that desire was the cause of suffering and that it came in three forms: ignorance, greed, and hatred. This truth was about identifying and recognizing these desires. The third Noble Truth was the truth of

the end of suffering (nirhodha). This truth acknowledged that by eliminating the desire, it led to an elimination of suffering. The fourth Noble Truth was the truth of the path that frees us from suffering (magga). This truth acknowledged that by following the Noble Eightfold Path, one would have more peace and happiness; this path showed how to end suffering. The Eightfold Path provided rules and principles to be followed as a way to cure suffering (Bodhi, 1998; Nhat Hanh, 1998; Tashi, 2014). These principles were not necessarily followed in any order, but were meant to be interconnected. The first two steps were right view and right intention. These steps fell under the category called wisdom, which was one of three stages of training. Right view was the process of understanding oneself and the world, and it provided a starting point. Right intention was the process of reflecting on the way things were and how that affected one's actions. Right speech, right action, and right livelihood were the next three steps under the training category of moral conduct. Right speech was the understanding of how oneâ€™s words could affect one's life, meaning that it was important to speak the truth. Right action was the process of doing no harm to others and abstaining from unwholesome deeds. Right livelihood was the process of living a meaningful life and finding work that promoted love and compassion. The third category of training was called focus, which included right effort, right mindfulness, and right concentration. Right effort included the process of eliminating negativity and indulgent actions by nurturing positive thoughts and actions. Right mindfulness was the process of being aware, being nonjudgmental, and living in the

present. Finally, right concentration was the process of focusing on one thing at a time, which could be achieved through meditation. By understanding the four Noble Truths and following the Eightfold Path, it was believed that one could eliminate suffering and achieve nirvana (Tashi, 2014). Awareness through right mindfulness and the achievement of right concentration through meditation were only two components of the eightfold path. It was believed that all eight principles were intertwined and needed in order to achieve freedom from suffering. The concept of mindfulness in Western psychology was rooted in Buddhist psychology, but it was pulled from a set of principles that were dependent on one another, which changed the context.

Western psychology. In the Western world, psychology was a framework through which one could learn to understand the self, while increasing self-esteem and self-efficacy (Page & Berkow, 1991). “The self is, perhaps, an indispensable concept for explaining how persons organize perception, encounter the world of experience, and maintain a cohesive image of identity” (p. 83). Stern (2014) defined the self as, “An array of self-states that shift and evolve over time but nonetheless lend a sense of continuity, individuality, and agency to a personality” (p. 142). Sroufe (1989) stated, “The core of self, the basic inner organization, had to do with regularities and experience – cycles of environmental (or state) variation, behavioral disruption, efforts to reinstate organization, and experienced affect” (p. 82). Sroufe believed the core of self “lies in patterns of behavioral and

affective regulation, which grant continuity to experience despite development and changes in context” (p. 83). Western psychology believed there was a psychological cause to one’s suffering. If that psychological cause was alleviated, then suffering would also be alleviated (Fulton & Siegel, 2005). According to Symington (1996), “Psychotherapy means healing of the soul” (p. 3). The Western view of an individual and one’s development of self was individuated. There was a belief that healthy development meant not needing others, but rather reliance on oneself. An individual's struggle with the development of a cohesive sense of self, as well as society's emphasis on the need for autonomy, led to disorders of the self, which caused suffering in the individual. Kostner (2014) stated, “Western society increasingly sees human suffering as grossly abnormal and typically generated from outside sources; it is a state to be eliminated as soon as possible” (p. 55). These beliefs were in direct contrast with Buddhist psychology, which believed suffering was a normal part of living (Fulton & Siegel, 2005) and was alleviated through one’s own introspection (Kostner, 2014), while embedded within a bigger construct that did not emphasize separateness (Fulton & Siegel, 2005). Unlike the contrasted Eastern and Western views of suffering, the view of the Self and the development of the Self were much more aligned. According to Page and Berkow (1991), Buddhist psychology believed that “the self is constructed and structured according to the nature of accumulated past actions and experience” (p. 86). Engler (1998) argued that the parallels of the two traditions could be integrated, because the basis of the development of the Self was “a mental representation or construct, not an

entity” (p. 112). These constructs were ongoing and each moment of experience constructed a new representation which, from a Buddhist point of view, allowed for a detachment of the Self and object representation. This detachment was from their teachings on impermanence and the belief that there was no entity that could be called the Self (Shapiro & Carlson, 2009). The Western practice of mindfulness delineated the difference between the Self and one’s mental activity (Goodman, 2014). Awareness of one’s mental activity allowed for a greater understanding of the Self through insight and understanding of past relational patterns (Kostner, 2014), which resulted in freedom from suffering (Shapiro & Carlson, 2009). Western psychology utilized mindfulness practices as a way to alleviate suffering of any sort, which included reactivity, habits, emotions, patterns and relationships (Shapiro & Carlson, 2009). Through the practice of mindfulness techniques and skills, one's insight into his or her suffering helped alleviate it by changing the relationship with the symptoms that caused the suffering (Sauer, Lynch, Walach, & Kohls, 2011). The difficulty with mindfulness was that “different methods and processes are described with the same term” (Hayes & Wilson, 2003, p. 161).

Mindfulness therapy techniques. Kabat-Zinn (2009) was the founder of Mindfulness-Based Stress Reduction (MBSR), an eight-week course designed to reduce stress and help people struggling with medical problems. MBSR taught people to be mindful of the present moment and how to utilize different breathing techniques and meditations with an open mind and a non-

judgmental stance. The program used specific techniques including conscious breathing, sitting meditation, walking meditation, eating meditation, a body scan, and yoga. This program taught acceptance of what is while in the process of letting go. As this program grew and research supported the benefits of mindfulness meditation, there was a shift to a more mind-body approach to healing. This shift included mind-body approaches and/or techniques in psychotherapy. Mindfulness therapy techniques have been integrated into multiple therapeutic frameworks, including mindfulness-based cognitive therapy, acceptance and commitment therapy, and dialectical behavioral therapy. Within these frameworks, multiple mindfulness therapy techniques have been used to include mindful awareness, body scans, breathing techniques, and mindful meditations (Crane, 2009; Eifert & Forsyth, 2005). It is anticipated that as the mindfulness movement grows, more mindfulness therapy techniques will be discovered and implemented. For example, Yapko (2011) has considered clinical hypnosis a mindfulness therapy technique. He described clinical hypnosis as an active form of mindfulness. Over the past decade, mindfulness therapy techniques have been integrated into psychodynamic therapy. As mindfulness therapy techniques and concepts were studied in relation to psychodynamic theory, it has been concluded that multiple concepts could already be considered mindfulness therapy techniques. For example, Freud discussed â€œevenly hovering attention,â€? in which he directed others to pay explicit attention to everything they observed (Fayne, 2014, p. 37). This was very much in line with the

technique of mindful awareness. Another example was using mindfulness to create space and awareness, which would become a holding environment or container for the client (Bobrow, 2004). Bobrow (2004) summed up the integration when he stated, “Mindfulness practice extends our capacity for and the range and depth of, experience while expanding the palette of what makes analytic experience valuable, which tends to privilege the represented and symbolized” (p. 27).

Psychodynamic Theory General overview of psychodynamic theory. Psychodynamic therapy is rooted in psychoanalytic theory. Psychodynamic therapy is seen as less intensive than psychoanalysis but dependent on theoretical ideas (McWilliams, 2004). McWilliams stated that within the diverse therapeutic approaches of psychoanalysis was the shared aim of “cultivating an increased capacity to acknowledge what is not conscious – that is, to admit what is difficult or painful to see in ourselves” (p. 1). McWilliams differentiated psychodynamic therapies from cognitive behavioral and other non-psychoanalytic treatment as the underlying assumptions of the therapists’ activities. In practice and thinking, psychodynamic therapists have appreciated both the nonverbal and preverbal experience and have paid more attention to one’s spiritual needs through psychotherapy. Psychotherapy became a term that implied a psychologically-based therapy versus a medically-based therapy provided by psychiatrists. Psychoanalytic interaction, according to Hedges (1983), had the goal of "promoting growth and development,” which is done through understanding how one

experiences life (p. 6). These experiences, or phenomena, were understood through theory. Within the psychodynamic community, there were multiple theoretical perspectives that could be used to understand these phenomena. These theories originated with Freud's classical theory and branched off to include object relations, selfpsychology, relational theory, and other contemporary theories. An understanding of each of these theories is necessary in order to understand psychodynamic therapy, as different lenses may be applied depending upon the theory being used.

Classical theory. Classical Psychoanalytical Theory emerged through the work of Sigmund Freud, who was interested in understanding how the mind works. Freud started out as a researcher in neurology before practicing clinically as a neurologist. When Freud initially started doing clinical work, he used hypnosis as a way to retrieve repressed memories, but soon discovered that talk therapy seemed to alleviate symptoms. One of his related developments was free association, which allowed patients to say whatever came to mind (Mitchell & Black, 1995). Freud tried to â€œlisten with a trance-like receptiveness ('evenly hovering attention') for the themes that emerged in their free associations, to interpret their meanings, and then to convey his understanding to the analysand (the analytic patient)â€? (McWilliams, 2004, p. 14). Freud introduced the concept of countertransference, as feelings were evoked in him from his patients. He cautioned others against acknowledgment of these feelings and encouraged them to â€œact

as mirrors of the patient’s feelings and as blank screens onto which the person’s internal images could be projected” (p. 15). Freud acknowledged and addressed this transference, which he called transference neurosis and defined as “a set of attitudes, affects, fantasies, and assumptions about the analysts that express central, organizing themes and conflicts dating from their experiences as children” (p. 16). Freud used free association in selfanalysis of his personal dreams, believing that dreams were disguised as fulfillment of conflictual wishes (Mitchell & Black, 1995). He believed that, “The true meaning of the dream (the latent dream thoughts) undergoes an elaborate process of distortion that results in the dream as experienced (the manifest content of the dream)” (Mitchell & Black, 1995, p. 8-9). Through his experience with dream interpretation, his progression continued. Freud worked from the positivist philosophical tradition, which was firmly rooted in two propositions: psychic determination and the unconscious (Palombo et al., 2009). The first proposition, psychic determination, was the belief that every event happened because of something prior; everything happened for a reason and was influenced by whatever preceded it. The second proposition was the belief that psychic processes were all unconscious: one was not aware of them and did not have direct access to them. This unconscious psychic process was believed to be the cause of symptoms. By bringing the unconscious material into the conscience, these symptoms would be alleviated (Mitchell & Black, 1995). When a patient was unable to bring the unconscious material into consciousness, Freud assumed it was resistance (Ellman, 1991). Initially, resistance was thought to be an act of will, but later resistance was understood as an unconscious

process. Freud (1963) believed the unconscious was the starting point in psychoanalysis, starting with the primary processes, which he defined as “the residues of a phase of development” (p. 2). He called the tendencies derived from this unconscious process the pleasure principle. Freud (1963) defined the processes of the pleasure principle as a “drive towards gaining pleasure; from any operation which might arouse unpleasantness (“ pain”) mental activity draws back (repression)” (p. 2). The pleasure principle was eventually replaced with the reality principle. The reality principle focused more on the external reality of the outer world and the consciousness that went along with it. These propositions led to Freud’s metapsychological hypotheses, which were the economic, the topographic, the dynamic, the genetic, and the structural hypothesis (Palombo et al., 2009). The economic hypothesis was Freud's first model, which was “used to describe the psychological pressures or forces that either were in conflict with one another or pressed for expression” (p. 15). This was based on the mechanistic view that “the concept of energy is central to understanding the workings of the psyche” (p. 15). Freud determined that the built-up tension had to be discharged in order to relieve the symptoms. The topographical hypothesis divided the mind into three regions: the conscious, the preconscious, and the unconscious. The conscious consisted of inner awareness. The preconscious region encompassed things just outside of our awareness that could be brought into our conscious. The unconscious region included things that were out of our awareness. The dynamic hypothesis referred to intrapsychic forces that acted in opposition to one another (Palombo et al., 2009). The genetic hypothesis referred to individual development. The combination of these first four hypotheses

formed what is now known as the drive theory (Palombo et al., 2009). The fifth hypothesis was the structural theory. This theory differentiated the id, the ego, and the superego. The id represented our instinctual drives and was known as pleasure seeking. The ego represented our realistic self and mediated between the id and the superego. The superego represented our moral development. The structural model addressed the unconscious mind and conflict with its defenses. The defenses, e.g., repression, were a way for the ego to protect and regulate oneself. Repression was initiated by the ego “to keep the unacceptable id wishes from emerging in consciousness because of the threat they represent to the ego” (Palombo et al., 2009, p. 18). Freud's theory of development consisted of psychosexual phases/stages. The oral stage was from birth to approximately 18 months, when an infant derived pleasure from feeding and sucking. The anal stage was from 18 months to about 3 years of age, when a child began toilet training. The phallic stage was from about 3 years of age to 6 years of age, when children became more aware of their bodies. The latency stage was from about 6 years of age until puberty, when children started integrating and consolidating their sexual identity. The genital stage was from puberty to adulthood, when one became more independent and detached from one's own parents. According to Palombo et al. (2009), “Freud’s far-reaching and multifaceted contributions provided the foundations for the developmental theories that followed” (p. 37).

Object relations theory. According to Ogden (1983), object relations theory was “a theory of unconscious internal object relations in dynamic interplay with current interpersonal experience” (p. 227). Ogden (1983) stated, “The analysis of internal object relations center upon the exploration of the relationship between internal objects and the ways in which the patient resists altering these unconscious internal object relations in the face of current experience” (p. 227). This concept of object relations started with Freud and evolved over time. According to Mitchell and Black (1995), “Freud had introduced the term object to refer to the target of instinctual impulses, through which the instinctual tension is discharged” (p. 39). Freud’s concept of the object was that it was not intentionally sought out, but rather a release for the impulse. Klein expanded on Freud’s theory regarding objects, viewing it as the infant’s ability to develop an integrated sense of self rather than a discharge of the impulse. Object relation theorists who were independent of Freud and Klein presumed that people were seeking a connection or relationship with others. Fairbairn believed that internal objects were substitutes for real relationships (p. 117). Klein and Fairbairn had two different perspectives as to the concept of internal objects. Klein believed that “internalized object relations were the primary forms of thought and experience” (Mitchell & Black, 1995, p. 117). Fairbairn, on the other hand, concluded that “internal objects are not essential and inevitable accompaniments of all experience, but rather compensatory substitutes for the real thing, actual people in the interpersonal world” (Mitchell & Black, 1995, p. 117).

Melanie Klein changed the emphasis from libidinal drive to the internalization of objects in the development of object relations. Fairbairn assumed (as cited in Mitchell & Black, 1995, p. 117) that if the child’s needs were not met, the child would internalize and fantasize about those features of the parents as if being inside of them and a part of them. Further, “Internal objects of the kind Klein described were understood to result from inadequate parenting” (p. 117). Klein introduced the concept of the positions, the paranoid-schizoid and the depressive. Paranoid referred to the fear of persecution coming from the outside; schizoid was the defense of splitting of the good and bad. The paranoid-schizoid position was shared by everyone in the early months of life and then periodically throughout one’s life (Mitchell & Black, 1995). It was safer to believe that paranoid anxiety was outside of oneself versus inside of oneself, with no escape. The depressive position moved from splitting to whole objects. In the depressive position, the child moved toward management of aggression. “To be able to keep her objects whole, the child has to believe that her love is stronger than her hate, that she can undo the ravages of her destructiveness” (Mitchell & Black, 1995, p. 94). The movement back and forth between the paranoid-schizoid position and the depressive position was how the self-developed. These positions were not linear but remained with us throughout the life cycle. Fairbairn (1943) introduced the concept of the moral defense. This defense was a protective concept taken on by the child as a way to relieve the child of carrying the burden of being unconditionally “bad.” When being raised by a parent who was not taking care of the child’s needs, the child would internalize that the child was “bad” in

order to carry the burden for the parent and make the parent, in turn, a “good” object. The child was considered unconditionally “bad” from a libidinal standpoint because the child's development was based on identification. This led to internalized “goodness” versus “badness"; the child then internalized his “goodness” via his superego, as this was preferable to the unconditional “badness.” Winnicott introduced the concept of the false self-disorder (Mitchell & Black, 1995). He was concerned with “the sense of inner reality, the infusion of life with a feeling of personal meaning, the image of oneself as a distinct and creative center of one’s own experience” (p. 124). Winnicott believed that a mother’s connection with her infant was directly associated with false self-disorder. Those who developed a false selfdisorder were deprived of quality responsiveness to their needs from their mothers. Thus, one may act and function like a person, but may not “feel to himself like a person” (p. 124). Winnicott determined that a holding environment would prevent this situation. He described a holding environment as one in which the mother was there for her child whenever the child needed her, but it was “equally crucial that she recede when she is not needed” (Mitchell & Black, 1995, p. 126). According to Stern (2014), “Movement from this perfectionistic, defensive stance- a position that brings both unstable grandiosity and depression- toward a more ordinary, stable self is an important part of the therapy process” (p. 143). Therefore, the therapeutic relationship could create movement away from the false self-disorder.

Self-psychology theory. The shift to self-psychology started with Kohut’s dissatisfaction of the limitations of classical theory (Mitchell & Black, 1995) and his understanding of empathy. Kohut (1959) described an observational method, which included introspection and empathy that he believed was essential to understanding another person. This term later became known as empathic introspection. Although he did not explicitly define it, the implied definition of vicarious introspection was “the analyst attentive listening while keeping himself as free as possible of preconceived notions about the significance of what the patient was saying, and the analyst's awareness of his own contribution to the patient's mental state” (Basch, 1990, p. 4). Through vicarious introspection, the therapist looked at what the patient was telling him, through the patient's eyes, and provided an understanding of what the patient was feeling, from unconscious communication. Empathy, “as the key observational method of the psychoanalyst, constitutes the foundation of self-psychology” (Ornstein & Ornstein, 1996, p. 88). Page and Berkow (1991) stated, “The image of self that the person constructed was thought by Kohut to be the product of internalizations of experiences of connectedness with others” (p. 84). This connectedness with others was a selfobject experience. Mitchell and Black (1995) noted three “selfobject experiences” as described by Kohut in order to have a healthy development (p. 159). The first selfobject experience was one that validated the child’s expansive state of mind. The second selfobject experience was a powerful validation from others. The third selfobject experience was one that confirmed a sense of likeness “between the child and themselves” (p. 159).

Children primarily got their selfobject experiences met via their parents. When a parent failed to meet these needs, a child’s development was potentially impaired. In self-psychology, it was a fundamental feature that “the consistent use of the empathic mode of observation, that is, to listen and understand from within the vantage point of the patient,” was recognized, but could evolve and change (Fosshage, 1995, p. 238). Although most therapists practicing today were trained to use empathy as a basic tool, very few therapists were empathy-centered except for self-psychological psychotherapists (Rieveschl & Cowan, 2003). According to Ornstein and Ornstein (1996), “Feeling understood is the adult equivalent of being held, which on the level of self-experience results in firming up or consolidating the self” (p. 94). This helped to build their self-structure and self-cohesiveness. Being understood was a way for patients to start to heal. When their self-structure was stronger, they were able to start to resolve some of their conflicts and fill in some of their deficits (p. 94). To some it may have seemed that empathy was curative. Basch (1990) believed that it was curative “only in uncomplicated cases” (p. 7). Kohut (1991), however, thought that just being empathic with one's patient would cure the patient. Kohut (1991) defined empathy on different levels. On one level, empathy was the gathering of information that led to action; on another level it was used as a therapeutic tool. Basch (1991) argued that Kohut’s definition of empathy, being therapeutic, did indeed contribute to it being curative. Geist (2007) believed that empathy had three listening perspectives that all overlapped. The first was vicarious introspection, which Geist (2007) suggested had a cognitive versus affective feel, when used at the beginning of

treatment and when relationships with patients were more distant. The second listening perspective was empathic resonance. Geist (2007) defined empathic resonance as occurring when “we react unselfconsciously to the patient's associations and do not recognize the rationale for our responses until we look back and analyze their context” (p. 10). The third listening perspective was somatic empathy, “which connects analyst and patient through the experience of physical feelings that reflect a visceral communication” (p. 12). According to Rieveschl and Cowan (2003), “Empathy nourishes what is unique in each person’s perspective and, more deeply, in their nuclear life plan” (p. 112). They believed that one could never completely think and feel subjectively because of the “joint construction of emerging meanings” (p. 118). One was never completely free from one's own biases and experiences, and hence, empathy was jointly constructed from the therapist’s own experience base. The quality of the empathy was most important. If a patient felt understood, this could have a positive impact on growth and healing, even if a particular need could not be gratified (Rieveschl & Cowan, 2003). Lachmann (2000) summed up empathy when he stated: Kohut considered empathy as a mode of observation, the way in which we gather information about the subjective life of another person. Through vicarious introspection, what it feels like to live in that person's shoes, the analysts grasps the subjective life and experiences of the patient. To be so exquisitely attended to and understood is felt to be a beneficial experience by many. (p. 110)

Empathy was the central focus of self-psychologists, which allowed the co-construction of the patient's frame of reference (Lachmann, 2000). There could have been empathic failures, but if they were identified, they could maintain or repair the therapeutic relationship (Lachmann, 2000). There were times when a therapist would fail his patients, where patients were misunderstood or provided a misinterpretation. However, as long as empathic failures were recognized, there might only be minimal disruption to the therapeutic relationship.

Relational and other contemporary theories. Harry Stack Sullivan introduced relational or interpersonal theories which were social constructivist in nature. According to Mitchell and Black (1995), Sullivan defined empathic linkage as a “contagious spread of mood from caregivers to babies” (p. 67). Sullivan suggested that if a caregiver was irritable, then the baby would become irritable. If the caregiver was content, then the baby would be content. Sullivan believed that all humans fought against anxiety and that in babies, anxiety was picked up from other people, especially their caregiver. Sullivan suggested that even if the anxiety from the caregiver was unrelated to the baby, the baby would take on feelings of anxiety. Sullivan viewed this as the first experience with the “good mother” and “bad mother” for a child. “Good” meant not anxious and “bad” was anxious, no matter who the person was. According to Mitchell and Black (1995), Sullivan believed that as the child became aware of this process, the child then realized the child's impact on the caregiver.

Mitchell (1988) stated, “In the relational model, biology and interpersonal processes constitute perpetual cycles of mutual influence” (p. 4). Relationships, both early and later, were multiple and complex. Relationships were experienced through “psychological response patterns, constitutional features of temperament, sensitivities, and talents, and worked over, digested, broken down, recombined, and designed into the new, unique patterns which comprise the individual life” (p. 20). Mitchell identified three basic strategies to understand the experience of human relationships, which he believed were followed by most relational model theorists. The first strategy was that people were relational by design; humans were biologically constructed to be drawn together. The second strategy was that people were relational by intent; humans were hedonistic and seek pleasure while avoiding pain. Mitchell (1988) claimed that psychopathology could be defined broadly as “the tendency of people to do the same painful things, feel the same unpleasant feelings, establish the same self-destructive relationships, over and over and over” (p. 27). The third strategy was that people were relational by implication; the development of one’s sense of self was a complex process, “an intricate and multifaceted construction, that is a central motivational concern throughout life and for which we are deeply dependent on other people” (p. 30). Thus, repetitive patterns developed as a way to maintain connections and continuity of one’s interactions with others. Stewart (2014) emphasized relationships as “central to the development of personality, psychopathology, and therapeutic growth” (p. 1). According to Mitchell (1988), “The basic relational configurations have, by definition, three dimensions – the

self, the other, and the space between the two” (p. 33). He believed that outside a matrix of relationships with others, there was no “self.” This “relational matrix” created one’s psychological world through the psychic space in which one interacted. Recent theories of relational psychodynamic theorists have included dissociation, self-states, unformulated experience, and enactment (Stewart, 2014). Bromberg helped to clarify how dissociation within the relational model looked. He normalized dissociation as part of our personality structure, stating that everyone dissociated (Bromberg, 1996). He further explained the shift toward the self as decentered, with the mind configured of “shifting, nonlinear, discontinuous states of consciousness in an ongoing dialectic with the healthy illusion of unitary selfhood” (p. 512). In the relational model, dissociation “is a healthy, adaptive function of the human mind” (Bromberg, 1996, p. 514). Bromberg (1996) went on to describe dissociation as a proactive defense to trauma. When one was so overwhelmed that one could not process and deal with a state of conflict and “the illusion of unity is too dangerous to be maintained,” one dissociated (p. 515). This became a way for one to maintain coherence, personal continuity, and the integrity of the sense of self. Interestingly, Bromberg believed Winnicott’s true and false self to be too farreaching. Bromberg challenged Winnicott’s true and false self with the concept of multiplicity of self. Bromberg (1996) stated, “The presence of an ongoing dialectic between separateness and unity of one’s self-states” allows one to live with both “authenticity and self-awareness” (p. 514). In normal multiplicity of self, one was

minimally aware of the existence of individual self-states because there was an illusion of a healthy cohesive personal identity. Each self-state was a function of a whole. The unformulated experience was made up of the domain of experiences that have been dissociated (Stewart, 2014). The unformulated experiences were constructed through one’s narrative and the ability to give one’s experience symbolization through language. This language created meaning and gave insight to the unconscious (Stern, 1983). This meaning was created and/or changed through the therapeutic action of an analyst’s interpretation (Stern, 2009). Stern believed that neither the interpretations nor the stories were as important as the relationship between the therapist and the client. Stern (2009) stated, “This new recognition of each by the other is a product of the resolution of enactments and the dissociations that underlie them, and the resulting capacity of analyst and patient to inhabit more fully one another’s experience, to listen more frequently through one another’s ears” (p. 726). Maroda (2010) defined an enactment as when “both therapist and client are simultaneously experiencing strong, unacceptable emotions originating in their past and they act these out in their relationship” (p. 112). Having recognized those enactments helped put a language or narrative to them, which created meaning and insight to the therapeutic process (Stern, 2009). Psychoanalysis has been misunderstood, made fun of, and misperceived throughout its history (Mitchell & Black, 1995). People who had benefited from psychoanalysis rarely talked about it in a non-psychoanalytic community. Psychoanalytic concepts were born from the experiences of the analytic process, which

was an “intensely emotional, highly charged, deeply personal experience for both participants” (Mitchell & Black, 1995, p. xv). Mitchell and Black (1995) expanded on the definition of psychoanalysis: Psychoanalytic thought helps knit together different domains of experience: past and present, waking and sleeping, thinking and feeling, interpersonal events in the most private fantasies. To the psychoanalytically informed mind, analytic concepts provide useful tools for expanding, consolidating, and enriching one’s own life and one’s relationships with others. Yet it is hard to convey this to someone who is not experienced it. To those for whom psychoanalysis is not a lived reality, psychoanalytic concepts can seem odd, abstract, alien, and out of reach. It is sometimes hard to believe they are, themselves, derived from actual human experience. (p. xv-xvi) Although psychoanalysis had changed throughout the years, as summarized in the table below, it was still a way to approach human experience, as well as a way to have experienced ourselves in our minds. Epstein (1998) stated that “mindfulness practices prompt development within the ego,” which then encouraged “a thorough and relentless scrutiny of each moment of consciousness that ultimately permits the impermanent nature of all experience to be discerned with finer and finer levels of perception” (p. 124). Mindfulness skills or techniques, used in conjunction with psychodynamic therapy, created an “expansion of the patient’s conscious understanding,” which created space and allowed for insight of this new understanding (Fayne, 2014). Table 1 presents a summary of psychodynamic theories.

Table 1 Summary of Psychodynamic Theories Theoretical Model Classical Theory

Development of Self Psychosexual stages/phases

Psychopathology

Object Relations

Internal representatio ns of objects; Paranoidschizoid and depressive positions

SelfPsychology

Experience of selfobject functions

Relational Theory

Self-states; interpersonal relationships

Constricted internal world due to presence of internal bad objects; enslavement to old, stereotyped modes of experiencing and relating to self and others Longings for benign emotional experience with parent; patient presses therapist to provide for unmet early caretaking needs Dissociation; unformulated experience; enactments

Unconscious turmoil related to sexual and aggressive phantasies and anxieties

Therapeutic Goal Memory, insight, and acceptance of reality (i.e., renunciation of infantile wishes); perception of reality defused from primitive phantasy Freedom from ties to internal bad objects; expanded and more complex view of self and others

Therapeutic Technique Evenly hovering attention; free association; interpretation of defenses, anxieties and transferences

Revived maturation, authenticity, strengthened selfregulation and selfesteem Understandin g/ strengthening the relational bonds

Empathy; vicarious introspection; nurturing, nonconfrontational

Observation, understanding and interpretation of relational enactments within the transference and countertransferenc e

Empathy; mutuality and collaboration

Psychotherapy Integration Historical context of integration techniques/therapy. According to Gold (2014), “The term ‘psychotherapy integration’ refers to the theoretical or conceptual enterprise of synthesizing two or more discrete systems of psychotherapy into a more complete and expanded system” (p. 19). In contrast, the term “integrative psychotherapy” referred to the “clinical application of this type of conceptual synthesis” (p. 19). There were four general modes of integration identified within the field of psychotherapy integration. The first mode was technical eclecticism, which was achieved by utilizing a single theory with an expanded selection of interventions. The selection of techniques was based on clinical experience or empirical literature that would best fit the client’s needs. The second mode was a common factors approach, which assumed that a set of change factors already existed that were shared by effective psychotherapies. The third mode was assimilative integration, which involved using a consistent single theory and method, and then integrating techniques from other psychotherapies. The fourth mode was theoretical integration. This mode consisted of constructing a theory and associated integrated treatment from two or more approaches to psychotherapy. “Integrative therapists see change as circular and multidirectional, and understand that change in one sphere of psychological life can have important effects on other spheres” (Gold, 2014, p. 23). In recent studies, the trend has been for psychotherapists to use some form of integration, based on their personal and professional development and training (Rihacek, Danelova, & Cermak, 2012). The main finding of a study conducted by Rihacek et al.

(2012) was that “the development towards integration was an unintended consequence of the participants endeavor to develop an autonomous Personal Therapeutic Approach” (p. 560). The study found that the Personal Therapeutic Approach was conceptualized by meeting the criteria of congruence and perceived efficacy. Congruence was determined by how well it fit with what the therapist preferences were, and perceived efficacy was dependent on how useful the therapist found it. The goal of one’s Personal Therapeutic Approach was to create “a working style that would fit both themselves and their clients” (p. 561).

The pros and cons. With over 450 different types of therapies, it could be confusing for new psychotherapists (Manickam, 2013). There has been both integration of techniques as well as unification of theories. While integration methods have been helpful for individual clients, there has been opposition to developing a unified theory. Therefore, a dilemma arose regarding the integration of techniques versus theories. Lazarus (2005) acknowledged that “it became clear that no one school could provide all the answers and that many approaches offered potentially helpful methods” (p. 150). In his skepticism, he viewed “eclectics as wishy-washy thinkers who had no backbone” (p. 150). His biggest concern in these attempts to integrate was that efficient and effective psychotherapy would be lost. However, the goal of most integrationists was to develop “the most effective forms of psychotherapy possible” by combining “the ‘best and brightest’

concepts and methods into new theories and practical systems of treatment” (Stricker & Gold, n.d., p. 1). Historically there has been an interest in integrating behavioral and psychodynamic approaches (Stewart, 2014). Frank (1992) explored the integration of action techniques with psychoanalytic therapy. He concluded that this integration was not new and that “Freud himself, speaking at the Budapest Congress in 1918, explained that the efficacy of psychoanalysis could sometimes be enhanced by the addition of an active technique to influence behavior” (p. 57). These active techniques could become supportive to psychodynamic formulation of the patient’s struggles (Frank, 1993). Stricker and Gold (n.d.) were in favor of an assimilative, psychodynamic approach that utilized contemporary psychodynamic theories while integrating methods and interventions of other therapeutic systems. They supported this integration when it would “promote changes in the person’s current functioning” and have an “impact on central intrapsychic and characterological processes” (p. 6).

Integration of mindfulness and psychodynamic therapy. According to Stewart (2014), the most recent development in psychotherapy integration was “a growing emphasis on the role of mindfulness as a common factor that cuts across the various sectarian schools of psychotherapy” (p. 23). He described mindfulness-based approaches as functional contextual psychotherapies, which included acceptance and commitment therapy, dialectical behavior therapy, and functional analytic psychotherapy. Functional contextualism provided meaning in relation to an event and

used that meaning as a way to assess the effectiveness of the therapy. Those approaches helped to expand the therapeutic process through the development of a subjective truth, rather than an objective truth. Thus, the client created his own meaning in a given context. In psychoanalytic-rooted therapies, the therapist would interpret transferences and resistances (McWilliams, 2004). Those interpretations may have been accurate but not necessarily helpful to the client (Stewart, 2014). Maroda (2010) stated that the client is the one who decides how effective the technique was and that “correctness of content is irrelevant if the client cannot hear what the therapist is saying, understand its meaning, and use it productively” (p. 83). Mindfulness cultivated an awareness that facilitated the process of having “an open receptive attention” (Shapiro & Carlson, 2009, p. 4), which then allowed insight and greater meaning. Based on the literature review by Gold (2014), he determined that mindfulness should be considered “a meeting point or foundation upon which integrative models of therapy can be built” (p. 23). Regardless of the theoretical orientation, psychodynamic therapists who used integration agreed that “it is the aided moving into experience and not away from it that is the essence in the treatment exchange” (Lin & Seiden, 2014, p. 4). Mindfulness could enhance the therapeutic process by providing alternative forms of adaptive behavior, while at the same time advancing insight (Frank, 1993). Epstein (1998) stated that mindfulness “precipitates psychological insights into the nature of the self that have not yet been explored from a psychodynamic perspective” (p. 121). Stern (2014) explained that “adding a mindfully informed perspective and mindful practices to more traditional psychoanalytic conceptions and therapeutic interventions can help

patients achieve a sense of themselves that is more ‘proportional’ or ‘ordinary’” (p. 142). He described an ordinary self as one that moved away from a perfectionistic, defensive stance, which ultimately could bring great relief.

Conclusion In summary, “Mindfulness is a skill that allows us to be less reactive to what is happening in the moment. It is a way of relating to all experience- positive, negative, and neutral – such that our overall level of suffering is reduced and or sense of well-being increases” (Germer, 2005, p. 4). Mindfulness originated from Buddhist psychology; specifically, it was one of the principles in the eightfold path. As mindfulness infiltrated the Western world, it became utilized as a technique versus a Buddhist way of life. In recent years, mindfulness techniques have been integrated into different theories of practice to enhance therapeutic outcomes. Given the complexity of psychotherapy, most integrationalists have agreed that it was unlikely that “one theoretical orientation, method of investigation, or one type of knowledge seeker will ever be able to provide the field with a comprehensive view of therapeutic change and a complete set of interventions to alleviate psychological problems” (Castonguay, 2011, p. 125). Despite the potential benefits of integrating theories and techniques, there were still a lot of gaps to be researched. One of these gaps was in the integration of mindfulness therapy techniques into psychodynamic therapy. This study explored how that integration happened. A survey was first conducted to understand the extent of mindfulness therapy techniques utilized by psychodynamic therapists in their practice.

In-depth interviews were then conducted with ten therapists to find out in detail how they integrated mindfulness therapy techniques into their practice and, if they did not integrate them, why not.

Chapter 3

Methodology Introduction This study addressed the integration of mindfulness therapy techniques with psychodynamic therapy by psychodynamic therapists in the United States. An explanatory sequential mixed methods design was used. The methodology involved collecting quantitative data first and then explaining the quantitative results with in-depth qualitative data. The study posed eight research questions: 1. What was the prevalence of psychodynamic therapists who used mindfulness therapy techniques in their sessions? 2. What was the prevalence of psychodynamic therapists who integrated mindfulness therapy techniques and who were not aware of it? 3. What was the meaning of integrating mindfulness therapy techniques for psychodynamic therapists? 4. How did psychodynamic therapists define mindfulness therapy techniques? 5. Were psychodynamic therapists reluctant to disclose the integration of mindfulness therapy techniques in their practice?

6. How did psychodynamic therapists describe their decision to integrate mindfulness therapy techniques? 7. To what extent and in what way did the survey responses help to identify psychodynamic therapists who could be interviewed to further an understanding of the integration of mindfulness therapy techniques? 8. To what extent and in what way did qualitative interviews with psychodynamic therapists contribute to a more comprehensive and nuanced understanding of the integration of mindfulness therapy techniques? This chapter described the studyâ€™s research methodology and included discussions around the following areas: 1. rationale for research approach, 2. description of the research sample, 3. summary of information needed, 4. overview of research design, 5. methods of data collection, 6. analysis and synthesis of data, 7. ethical considerations, 8. issues of trustworthiness, and 9. limitations of the study. The chapter ended with a brief concluding summary.

Rationale for Mixed Methods Research Design Mixed methods research was primarily pragmatic since it was not committed to any one philosophy, but inquired from both quantitative and qualitative assumptions (Creswell, 2014). A pragmatic approach allowed the utilization of the appropriate methods, techniques, and procedures that would best fit with the needs of the research study. “Methods can be combined in creative ways to more fully or completely understand a research problem” (Creswell, 2014, p. 30). This approach looked at the what and how based on where I wanted to go with the information. This afforded me a freedom of approaches while I collected data and analyzed the results, which provided the best understanding of the research problem. “The problem is primary” in pragmatism (Bloomberg & Volpe, 2012, p. 29). Creswell (2014) defined mixed methods research as: An approach to inquiry involving collecting both quantitative and qualitative data, integrating the two forms of data, and using distinct designs that may involve philosophical assumptions and theoretical frameworks. The core assumption of this form of inquiry is that the combination of qualitative and quantitative approaches provides a more complete understanding of a research project than either approach alone. (p. 4) Mixed methods research has been a fairly new methodology that began about 25 years ago (Creswell, 2015). There have been common elements to mixed methods research that were easily identified, which included collecting and analyzing both quantitative and qualitative data in response to the research questions. A mixed methods research study

involved rigorous qualitative and quantitative methods, integration of the data, and an interpretation of this integration.

Rationale for an Explanatory Sequential Mixed Methods Design Creswell (2014) identified six specific types of mixed methods designs: 1. convergent parallel, 2. explanatory sequential, 3. exploratory sequential, 4. embedded, 5. transformative, and 6. multiphase. In order to accurately and fully answer the research questions proposed in this study, I thought that an explanatory sequential mixed methods design was the best option. This design included two phases. In the first phase, quantitative data were collected and analyzed, and in the second phase, qualitative data were collected in order to build upon the quantitative results. The quantitative results informed “the types of participants to be purposely selected for the qualitative phase and the types of questions that will be asked of the participants” (Creswell, 2014, p. 224). The first phase of this mixed methods phenomenological research project was quantitative, involving data collection through a survey. Creswell (2014) stated that a survey can provide “quantitative or numeric description of trends, attitudes, or opinions of a population by studying a sample of that population. From sample results, the

researcher generalizes or draws inferences to the population” (p. 155). A survey design was the preferred type of data collection in this study as it helped inform which participants were selected for the qualitative phase of this study. This survey was crosssectional and the data were collected via the Internet. The second phase of this mixed methods phenomenological research project was qualitative and helped inform and understand the quantitative data. “Qualitative research is an approach for exploring and understanding the meaning individuals or groups ascribe to a social or human problem” (Creswell, 2014, p. 4). While there were several qualitative approaches to choose from, the approach I used was phenomenology. Phenomenological research focused on “the lived experience of people to identify the core essence of human experience or phenomena” (Bloomberg & Volpe, 2012, p. 32).

Research Sample The inclusion criteria for this study required that participants were fully licensed therapists with a minimum of 2 years of formal psychodynamic education. Psychodynamic education included classroom education and/or weekly or biweekly consultation with a PhD-level licensed therapist with 4 or more years’ experience as a practicing psychodynamic therapist. The licensed therapists needed to have a minimum of ten direct client hours per week. They may or may not have used mindfulness practices, but must have had a basic understanding of the concept of mindfulness. Participant selection for this study first began with the quantitative sample. Nonprobability sampling, which used specific sample strategies versus random sampling, was

used in combination with purposeful sampling and snowball sampling (Rubin & Babbie, 2011). Purposeful sampling picked participants who would have expertise on the problem. In this study, to gain an understanding of the integration of mindfulness therapy techniques by psychodynamic therapists, it was important to select participants who had substantial knowledge of psychodynamic theory. The survey was sent to different psychodynamic institutes in the United States via an Internet link. Participants received the survey and were encouraged to share the link with other psychodynamic therapists they knew, which provided a snowball sample. All participants first went through the criteria checklist to make sure they qualified to take the survey. A minimum of 30 participants were recruited to complete the survey. The qualitative sample was selected based on the analyzed results of the quantitative data. As part of the quantitative survey, participants were asked if they were willing to do a voluntary qualitative follow-up interview. The qualitative sample was a purposefully selected criterion-based sample that helped to understand the phenomenon of integrating mindfulness therapy techniques into psychodynamic therapy. All participants in the qualitative sample stated they were willing to complete an interview. It was originally planned to have four in-depth interviews conducted based on the quantitative results. This was increased to ten interviews to provide a greater understanding of the phenomenon. Five interviews were conducted with participants who had integrated mindfulness therapy techniques into their therapy sessions. The other five interviews were conducted with participants who stated they did not use mindfulness

therapy techniques within their sessions, but according to the criteria on the survey, they met the definition of using mindfulness therapy techniques within their sessions.

Research Design The following list outlined the steps I used to carry out my research, followed by a more detailed discussion of each step. 1. Prior to collecting the data, literature was reviewed to determine potential aspects of mindfulness therapy techniques that were being used by psychodynamic therapists. The literature identified a shift from Buddhist psychology to a Western clinical practice of mindfulness. 2. IRB approval was obtained and I then proceeded to my proposal hearing. 3. Potential research participants in Phase One were contacted initially via email, and those who agreed to participate continued on to take the survey. 4. Potential research participants in Phase Two were confirmed via a brief phone screening and were then sent the consent form prior to the scheduled interview. 5. I initiated the first phase of my study, which entailed collecting and analyzing the quantitative data. The data were collected via an Internet survey that I designed; the survey was cross-sectional, which meant the data were collected at only one point in time. This survey included both demographic questions, as well as questions pertaining directly to gaining an understanding of mindfulness practices of psychodynamic therapists.

6. Based on the quantitative results, under the supervision of my dissertation chair, I selected ten participants for the second phase of my study. 7. The second phase consisted of collecting qualitative data through in-depth interviews and analyzing the data. The in-depth interviews provided a detailed account of how mindfulness therapy techniques were integrated into psychodynamic therapy sessions by therapists who utilized the techniques.

Data Collection This study had two distinct phases of data collection: rigorous quantitative sampling in Phase One, followed by purposeful sampling in Phase Two in order to triangulate the results. Triangulation, or using multiple data collection procedures, has been used by researchers in order to reduce the chances of misinterpretation (Bloomberg & Volpe, 2012; Johnson, Onwuegbuzie, & Turner, 2007).

Survey. The first phase of the study required participants to complete an Internet survey. One major benefit of online surveys was that they cost substantially less than a conventional mail survey and have higher response rates (Rubin & Babbie, 2011). â€œThe purpose of the survey is to provide statistical estimates of the characteristics of a target population (Fowler, 2009, p. 11). In this study, those estimates provided an understanding of the prevalence of psychodynamic therapists who integrated mindfulness therapy techniques into their sessions.

This survey was created and administered through Survey Monkey. Survey Monkey allowed for the survey to be created quickly and emailed to the participants for completion (Creswell, 2014). In order to establish validity in the survey, a test survey was administered to colleagues and/or committee members prior to participants taking the survey. This helped establish that the survey questions were gathering the information that they were designed to gather. Adjustments needed to the survey design were completed prior to sending the survey out to participants. Once a minimum of 30 completed surveys had been received, the data were analyzed. The results of the quantitative data directed the purposeful selection of participants for the second phase. Participants received a link to the survey via an email. This email described the study being conducted and provided a link to the survey. Once they entered the survey, it provided a checklist of inclusion criteria to qualify for the study (see Appendix A for a copy of the email). Once participants qualified to take part in the study, they were asked to read the informed consent and check “Accept” or “Reject” (See Appendix B for a copy of the informed consent for Phase One). If they did not provide their electronic signatures, they were not able to continue and were considered non-participants. The survey questions focused on participants’ basic knowledge of mindfulness techniques, if they personally practiced mindfulness skills in their everyday lives, if they taught their clients mindfulness techniques during sessions, and their psychodynamic training, as well as some basic demographic information. (See Appendix C for a copy of the survey questions.) Likert scaling allowed me to understand the extent of particular perspectives, this study included data collection on the extent of participants' use of mindfulness and/or

beliefs about mindfulness (Rubin & Babbie, 2011). The survey questions provided a structure and informed me of particular viewpoints of the participants, including their psychodynamic theoretical orientation. There were both open-ended and closed-ended questions. The open-ended questions allowed participants to elaborate on particular questions and the closed-ended questions were primarily for categorical or demographic information. The demographic information included gender, educational level, age, state of residence, and race. Participants were also asked if they were willing to conduct a follow-up, in-depth interview to provide more information to explain their survey responses. When the participants got to the final question, the questionnaire prompted them to submit the survey and concluded with a thank you for their participation. The data from the surveys were analyzed, in-depth interviews were then conducted with ten participants in order to obtain additional qualitative data that would further explain the survey results.

Interviews. Data collection in the qualitative phase was conducted using in-depth interviews. The questions for the interviews were designed as a follow-up to explain the quantitative survey data. Five interviews were based on participants who specifically integrated mindfulness therapy techniques into their therapy sessions. The other five interviews were conducted with participants who stated they did not use mindfulness therapy techniques within their sessions, but according to the criteria on the survey, they met the

definition of using mindfulness therapy techniques within their sessions. These participants were contacted via phone, using a brief interview script, to schedule their indepth interview. Participants also completed an informed consent for the second phase of the study (see Appendix D for a copy of the phone script and Appendix E for a copy of the informed consent for Phase Two). The interviews were semi-structured and audio recorded via GoToMeeting. The questions were open-ended in nature to help understand the phenomenon of integrating mindfulness therapy techniques into psychodynamic therapy sessions. There were two separate scripts used, one for participants who used mindfulness therapy techniques in their sessions and one for those participants who did not use mindfulness therapy techniques in their sessions. (See Appendices F and G for a copy of the script of the two semi-structured interview questions.) The five in-depth interviews of participants who used mindfulness therapy techniques in their sessions provided a detailed account of how this integration took place, including specific techniques being used and how these techniques were introduced with clients in their sessions. The five in-depth interviews with participants who did not use mindfulness therapy techniques in their sessions, but the criteria on the survey suggested that they did, provided a detailed account of the participantsâ€™ understanding of the concepts of mindfulness and any particular techniques being utilized in their sessions. All ten in-depth interviews provided a greater understanding of the participantsâ€™ psychodynamic theoretical orientation and their perception of integrating mindfulness therapy techniques into their psychodynamic practices.

Data Analysis Integration was a vital component of this mixed methods research. As Creswell (2015) has stated: â€œIntegration is the place in the mixed methods research process where the quantitative and qualitative phases intersect (or bump up against each other)â€? (p. 82). The integration process of this studyâ€™s design included a merging of the qualitative indepth interviews to explain the quantitative survey results. In the first phase, the quantitative survey data were collected and analyzed. Based on the results from the quantitative data, the second phase collected and analyzed qualitative data from targeted subjects to explain the survey results from the first phase. Survey Monkey was used to analyze the quantitative survey results. These results included the total number of completed and uncompleted surveys that were received. A table was developed that displayed the specific demographics of all of the participants, as well as statistical information including the mean, standard deviation, minimum, maximum, and percentage when appropriate. The results were reported for two separate groups. One group included participants who stated they specifically used mindfulness therapy techniques in their sessions; the other group included participants who stated they did not use mindfulness therapy techniques in their sessions. Response bias, which was the effect of non-responses on the survey estimates, was minimal based on the research design (Fowler, 2009; Creswell, 2014). By using survey software, the number of incomplete surveys was reduced. The survey software made responses to questions mandatory and therefore reduced the response bias.

Once the data were analyzed, data cleaning was conducted. Data cleaning was the process of eliminating possible errors (Rubin & Babbie, 2011). Although the likelihood of errors was low due to use of a software program to analyze the data, all analyzed data were reviewed to eliminate any possibility of errors. From the quantitative data collected, five participants from each group were selected to complete an in-depth qualitative interview. The quantitative results also aided in the development of new questions for the interview guide. If two groups had not been identified in the data analysis, all ten participants would have been participants who recognized mindfulness integration. The qualitative results were analyzed using NVivo software, a powerful software for analyzing qualitative data. The recorded interviews were transcribed through NVivoâ€™s transcription connection. Data analysis in the qualitative portion differed from the quantitative portion as analysis began immediately (Creswell, 2014). I began by looking through all data that were collected, including the reflective journal. All documents were read line-by-line and the data were hand-coded, i.e., organized by theme and then categorized. Themes were developed through the repetition of common concepts, and similar themes were grouped into categories. I kept a running list of categories as they emerged and grouped and re-categorized all similar topics. Memoing, which was a form of bracketing, was used throughout the research process and especially during data analysis. Memoing was a way to make notes throughout the project, as well as to keep others involved (Rubin & Babbie, 2011). Although memoing has been commonly used in grounded theory, it has been found to be

beneficial in any qualitative approach (Birks, Chapman, & Francis, 2007). Birks et al. (2007) used a mnemonic for the word "memo" to describe its functions, which included â€œmapping the research activities; extracting meaning from the data; maintaining momentum; and opening communicationâ€? (p. 70). Memoing was similar to using a reflective journal, but what made it different from a reflective journal was that a reflective journal recorded the affect of the process. Once the data had been coded, categorized, and interpreted, the results were written up, including passages of participant narratives, and various tables or graphs were developed to display the data and findings. The data were first analyzed inductively and then deductively. As Creswell (2014) has stated: Qualitative researchers build their patterns, categories, and themes from the bottom up and by organizing the data into increasingly more abstract units of information. Then deductively, the researchers look back at their data from the themes to determine if more evidence can support each theme or whether they need to gather additional information. (p. 186) This allowed me to provide a comprehensive set of themes while still maintaining a focus on the meaning being conveyed by the participants. In phenomenological research, the focus was on identifying significant statements that captured the meaning of the phenomena as experienced by the participant (Bloomberg & Volpe, 2012). The phenomena in this study were mindfulness therapy techniques and how psychodynamic therapists identified, defined, and utilized these techniques in their sessions. The coding

process produced a detailed description of the phenomena of mindfulness therapy techniques and the integration process used by the psychodynamic therapists. The final part of data analysis was interpreting the data. Interpretation was the process of understanding the data in relation to the purpose of the study (Creswell, 2014). These findings included personal interpretations and comparisons to past findings, and sometimes introduced new questions that needed to be asked. The intent of this study was to describe the phenomena of mindfulness therapy techniques in great detail as understood by the participants. This included specific techniques being used as well as potential barriers as to why these techniques have not been utilized. These findings were also discussed in relation to the literature reviewed.

Ethical Considerations In Phase One of the study, participants completed a survey via the Internet. When participants clicked on the link to the survey, they first answered some screening questions to make sure they qualified for the study. If they qualified for the study, the next screen was the informed consent. Once they clicked “Accept,” indicating that they understood the informed consent and they did not have any questions, it took them to the survey. The informed consent provided information on how they were protected as a subject in the study. As Bloomberg and Volpe (2012) have stated, “As researchers, we are morally bound to conduct research in a manner that minimizes potential harm to those involved in the study” (p. 111). Participants were informed of the purpose of the study, which was to explore the integration of mindfulness therapy techniques with

psychodynamic therapy by psychodynamic therapists in the United States. In Phase One of the study, the participants were told that their names and any identifying information would remain anonymous. They were informed that Survey Monkey would temporarily store their data until 30 completed surveys were submitted. After then, all data were exported into my personal documents. The data were stored on my computer; all computer files and the computer itself were password-protected. In Phase Two of the study, participants went through a brief phone screening. If they qualified to continue, an Internet link was sent to them with the Phase Two informed consent. If they clicked â€œAccept,â€? indicating that they understand the informed consent and did not have any questions, they proceeded to the interview via GoToMeeting. In the Phase Two consent form, participants were told that all interviews would be video- and audio-recorded. It was later discovered that GoToMeeting did not record the video of the participants, so the interviews were audio-recorded only. These interviews were transcribed by TranscribeMe, an NVivo affiliate. The transcriptionists were bound to a confidentiality agreement ensured by TranscribeMe. All transcripts were stored on a computer in a password-protected file. The informed consent let the participants know if there were any known risks or benefits. The risks involved were that participants may have felt somewhat anxious about expressing their ideas. Therapists, for example, could have questioned their ability to integrate mindfulness techniques adequately. The discomfort associated with this study was no more than would be experienced in daily life; participants had the option to withdraw at any time. The risks to this study were very minimal. All precautions were

taken to ensure the confidentiality of participants involved in both Phase One and Phase Two of the study. The information gained in this study helped understand the integration of mindfulness therapy techniques of psychodynamic therapists with their clients, which enhanced therapeutic outcomes. Participants were informed that information would not be destroyed until 5 years after results were published. Participants received a $10 eGift card from Amazon for completing the online survey. An additional $20 eGift card from Amazon was given to participants who completed the in-depth interviews.

Issues of Trustworthiness Credibility. Bloomberg and Volpe (2012) defined credibility as “whether the participants’ perceptions match up with the researcher’s portrayal of them” (p. 112). I strived for credibility in numerous ways by using bracketing. Tufford and Newman (2010) defined bracketing as, “A method used by some researchers to mitigate the potential deleterious effects of unacknowledged preconceptions related to the research and thereby to increase the rigor of the project” (p. 81). One way to bracket was through reflective journaling throughout the research process, which included monitoring potential biases and subjective perspectives. Ortlipp (2008) stated, “Rather than attempting to control researcher values through method or by bracketing assumptions, the aim is to consciously acknowledge those values” (p. 695). Journaling allowed me to track my thinking and reasoning throughout the process, it tracked all research activities, it provided a record of any alterations in methodologies or

analysis, and it recorded any other observations, insights, or experiences (Bloomberg & Volpe, 2012; Ortlipp, 2008). This journal also noted observations of participants during the interviewing process. Triangulation was used to validate my interpretations by using different sources of data, which included quantitative survey data and in-depth interviews. Presenting all data, which included anything negative or contradictory, also provided credibility. Negative or contradictory data challenged my expectations and findings to seek new understandings of the phenomena. Using rich, detailed descriptions helped the results become more realistic, which increased their validity (Creswell, 2014). Member checks allowed the participants to review my summaries and allowed for an accurate perception of what the participants were trying to convey (Bloomberg & Volpe, 2012). Finally, dissertation committee members reviewed notes and challenged my assumptions or perceptions.

Dependability. According to Bloomberg and Volpe (2012), dependability was defined as â€œwhether one can track the processes and procedures used to collect and interpret the dataâ€? (p. 113). One way to assure dependability was to be very thorough in the research process and to provide an audit trail. This audit trail was a detailed account of how the data were collected and analyzed. Checking transcripts for any errors made during transcription increased dependability (Creswell, 2014). I used memoing, which provided a constant comparison of the data coded, to keep the focus of the study. Another method

of assuring dependability was to have committee members or colleagues code some of the interviews. This process helped to reduce any potential biases and established consistency among raters (Bloomberg & Volpe, 2012).

Transferability. Bloomberg and Volpe defined transferability as â€œthe fit or match between the research context in other contexts as judged by the readerâ€? (p. 113). This study increased the transferability by providing in-depth descriptions of how the participants integrated mindfulness therapy techniques into their sessions or, if they did not integrate them into their sessions, an in-depth description of why they did not. These in-depth descriptions were interpreted based on a thorough literature review.

Limitations and Delimitations The delimitations included in this study were selecting participants who were licensed therapists with a minimum practice of ten direct client hours weekly and who had a formal education in a psychodynamic theory. The participants were male or female of any age. The participants had a basic knowledge of the concepts of mindfulness, but they did not need to be practicing mindfulness techniques. There were multiple limitations to conducting this study. One limitation was the sample size for both the quantitative and qualitative phases of this mixed methods phenomenological study. This study used 30 completed surveys and followed up with ten in-depth interviews. This was a relatively small sample size and therefore made

generalization a non-factor. Another limitation was my own bias, which I tried to minimize through bracketing. I have had an extensive history of mindfulness practices and therefore I may have projected expectations onto participants regarding outcomes.

The Role and Background of the Researcher For the most part, I am a novice at doing research. As a masterâ€™s student, I had a general introduction to both quantitative and qualitative methods in my first year. During my second year, I completed a masterâ€™s level thesis on life after foster care. This thesis was a qualitative descriptive study that used a snowball sampling technique. I conducted one semi-structured, audiotaped interview with 10 adults who had aged out of foster care. I analyzed the data to describe their experiences of aging out of the foster care system, and whether any independent living skills programs during foster care impacted their transition and/or their lives after foster care. I did not acquire any other formal research experience until I started my doctoral program at ICSW in 2010. In my first year, I completed two semesters of general research methodology. The following year, I took a semester of qualitative research and a semester of quantitative research. In both courses, we did small-scale projects to gain experience in both qualitative and quantitative research methodologies. Finally, in my fourth year, I had two semesters of dissertation seminar, during which we learned how to write a dissertation proposal.

Conclusion In summary, this chapter provided a detailed description of the research methodology for this sequential mixed methods phenomenological study. The intent of this study was to understand the integration of mindfulness therapy techniques with psychodynamic therapy by psychodynamic therapists in the United States. This was a two-phased study. In the first phase, I developed and administered a quantitative survey and collected data from a minimum of 30 participants. The results of the first phase informed the selection of 10 participants for in-depth interviews in the second phase of the study. The in-depth interviews explained the survey results from the first phase. The conceptual framework was based on a thorough literature review that shaped the research design and analysis. This chapter fully addressed the following areas: 1.

rationale for research approach,

description of the research sample,

summary of information needed,

overview of research design,

methods of data collection,

analysis and synthesis of data,

ethical considerations,

issues of trustworthiness, and

limitations of the study.

Chapter 4

Results Introduction The purpose of this explanatory sequential mixed methods study was to gain a deeper understanding of what it means to integrate mindfulness techniques into psychodynamic therapy. Research was conducted through a two-phased study consisting of an Internet survey in Phase One and in-depth interviews in Phase Two. Once the Phase One surveys were completed and analyzed, 10 participants from two distinct subgroups were selected to be interviewed in Phase Two. The first sub-group consisted of participants who had a high frequency of use of mindfulness techniques with their clients in session and a high rate of referring clients to learn mindfulness techniques outside of their session, which I labeled the aware sub-group. The second sub-group consisted of participants who had a low frequency of use of mindfulness techniques with their clients and a lower rate of referring clients to learn mindfulness techniques outside of their session, which I labeled the unaware sub-group. After the interviews were completed, the data were coded and analyzed using NVivo software and organized into themes. There were four themes identified from each sub-group; from these themes, six findings were identified from the two groups combined. This chapter will provide a very detailed account of the results from the Phase One sample, the Phase Two sample, and the mixed methods results, as well as a final conclusion summarizing the chapter.

Phase One Sample A total of 31 participants completed the survey. All participants met the criteria, which included having a minimum of 2 years of formal psychodynamic education, being a fully licensed therapist, having a minimum of 10 direct client hours weekly, and having some familiarity with the concept of mindfulness whether they practiced it or not. Of the 31 participants, five had formal education from the Institute for Clinical Social Work, three from Smith College, and two from Loyola. The remaining participants were educated at various colleges and institutes throughout the United States. Four participants noted that they also held a certificate in psychoanalysis. The predominant license held by 27 participants was a Licensed Clinical Social Worker (LCSW, LICSW, LISW-S, LMSW). Two participants were Licensed Clinical Professional Counselors (LCPCs), one was a Licensed Professional Counselor (LPC), and one was a Licensed Psychologist (LP). All participants had some familiarity with mindfulness concepts, two had very little familiarity, 13 had somewhat of a familiarity, and 16 had a great extent of familiarity. See Table 2 for a summary of participant criteria.

Table 2 Participant Criteria (n=31) Variable Formal Psychodynamic Education ICSW Smith College Loyola College Other Certificate in Psychoanalysis Licensed Therapist Licensed Social Worker Licensed Clinical Professional Counselor Licensed Professional Counselor Licensed Psychologist Minimum of 10 Direct Client Hours Weekly Familiar with Mindfulness Concepts Very Little Somewhat A Great Extent

n 31 5 3 2 21 4 31 27 2 1 1 31 31 2 13 16

(%) (100.00) (16.13) (9.68) (6.45) (67.74) (12.90) (100.00) (87.09) (6.45) (3.23) (3.23) (100.00) (100.00) (6.45) (41.94) (51.61)

The demographic survey asked participants to report their gender, educational level, age, state of residence, and race. The gender of the participants included 25 females, five males, and one other. The educational level included 19 participants at the masterâ€™s level, 10 at the PhD level, and two with All But Dissertation (ABD) status. Under the age category, the sample size only included 30 participants, as one participant did not provide this information. The mean age was 55.93 years old, the median age was 59 years old, the minimum age was 31 years old, and the maximum age was 73 years old. The participants resided in 10 states, including four from California, one from Florida, nine from Illinois, one from Maine, one from Maryland, one from New Jersey, nine from New York, two from North Carolina, one from Ohio, and one from Texas. The final demographic category was race. A total of 29 participants self-identified as

White/Caucasian, one identified as Asian/Pacific Islander, one identified as Hispanic/Latino descent, and one identified as Multiple Ethnicity/ Other. See Table 3 for a summary of participant demographics. Table 3 Participant Demographics (n=31) Variable Gender Female Male Other Education Level MA/MS PhD All But Dissertation (ABD) Age (n=30 valid, missing 1) Mean Median Minimum Maximum State of Residence California Florida Illinois Maine Maryland New Jersey New York North Carolina Ohio Texas Race Asian/Pacific Islander Hispanic/Latino Descent White/Caucasian Multiple Ethnicity/Other

25 5 1

(80.65) (16.13) (3.23)

19 10 2

(61.29) (32.26) (6.45)

55.93 59 31 73 4 1 9 1 1 1 9 2 1 2

(12.9) (3.23) (29.03) (3.23) (3.23) (3.23) (29.03) (6.45) (3.23) (6.45)

1 1 29 1

(3.23) (3.23) (93.55) (3.23)

There were 10 survey questions directly related to mindfulness practices. The first question was open-ended and asked how the participant defined mindfulness. There were five themes that emerged from coding: focus (61%), observation (45%), presence (39%), acceptance (26%), and non-judgment (23%). Two participants were not sure how to define mindfulness and one participant did not respond to the question. The second open-ended question asked participants to define mindfulness techniques. One or more of the five themes of focus, observation, presence, acceptance and non-judgment were included in 84% of the responses to define mindfulness techniques. Six participants also included the theme of practice in the definition of mindfulness techniques, four participants stated they were not sure how to define mindfulness techniques, and one participant stated that mindfulness techniques were an ancient resource. Examples of mindfulness techniques listed by participants included body scans, breath work, describing/labeling, loving-kindness, meditation, mindful savoring, mindful walking, observing thoughts and feelings, refocusing on the present, relaxation, self-hypnosis, tai chi, tensing and relaxing muscles, practice being fully present, and visualization. The third question asked participants if they personally practice mindfulness techniques. Twenty-three (74%) participants said they personally practice mindfulness techniques, two (6%) participants said they do not personally practice mindfulness techniques, and six (19%) participants said they either personally practice some or sometimes or they are not sure. The fourth question asked participants if they use mindfulness techniques when they are treating their clients. Twenty-three (74%) participants said they use mindfulness techniques when they are treating their clients, two

(6%) participants said they do not use mindfulness techniques when they are treating their clients, and six (19%) participants said they only use mindfulness techniques with their clients occasionally or they are not sure how to use mindfulness techniques with their clients. The fifth question asked participants for the primary theoretical orientation of their psychodynamic education. One (3%) participant has a classical orientation, four (13%) participants have an object relations orientation, seven (23%) participants have a self-psychology orientation, 15 (48%) participants have a relational orientation, and four (13%) participants identified as other. The four "other" participants identified their orientations as modern psychoanalysis, Jungian, integrationalist/eclectic, and Imago Relationship Therapy. The sixth question asked participants to check any of the following techniques that they use with their clients. All 31 participants marked active listening and mirroring as techniques they use with their clients. Empathy was used by 94% of the participants, free Association was used by 77% of the participants, evenly hovering attention was used by 74% of the participants, breath work was used by 48% of the participants, vicarious introspection and meditation were used by 45% of the participants, body scans were used by 39% of the participants, guided imagery was used by 32% of the participants, yoga was used by 13% of the participants, hypnosis was used by 6% of the participants, and other techniques were used by 13% of the participants, including validation, confrontation, interpretation, EMDR, dance therapy, dialogue with parts of the self, and cultivating observing self.

The seventh question asked participants to rate on a Likert scale how frequently they teach mindfulness techniques to their clients. Three (10%) participants stated they almost never teach mindfulness techniques to their clients, seven (23%) participants stated they very infrequently teach mindfulness techniques to their clients, 10 (32%) participants stated they somewhat infrequently teach mindfulness techniques to their clients, eight (26%) participants stated they somewhat frequently teach mindfulness techniques to their clients, two (6%) participants stated they very frequently teach mindfulness techniques to their clients, and one (3%) participant stated that mindfulness techniques were almost always taught to clients. The eighth question asked participants to rate on a Likert scale how frequently they refer clients to learn mindfulness techniques outside of the therapy session. Three (10%) participants stated that they almost never refer clients to learn mindfulness techniques outside of therapy, seven (23%) participants refer out very infrequently, nine (29%) participants refer out somewhat infrequently, seven (22%) participants refer out somewhat frequently, four (13%) participants refer out very frequently, and one (3%) participant refers out almost always. The ninth question asked participants to rate on a Likert scale how much concern it would cause them when they considered deviating from the psychodynamic frame. One (3%) participant stated that it caused a great deal of concern, one (3%) participant stated that it caused much concern, 11 (35%) participants stated that it caused them some concern, 14 (45%) participants stated that it caused them little concern, and four (13%) participants stated that it caused them no concern when they considered deviating from

the psychodynamic frame. The final question asked participants if they were not currently using mindfulness techniques with clients, to explain why not. The majority of the participants are currently using mindfulness techniques with clients. However, of the participants who are using it very minimally or not at all, three (10%) participants were either not sure if they were using mindfulness or they did not know how to use mindfulness, two (6%) participants were resistant to moving outside of the psychodynamic frame, two (6%) participants stated they were not directive in session, and one (3%) participant stated that they were trained as a psychoanalyst steeped in classical and self-psychology. At the end of the survey, participants were asked if they would be willing to conduct a follow-up, in-depth online interview to provide more information to explain their survey responses. Twenty-four (77%) participants said they would be willing to conduct a follow-up interview and seven (23%) participants stated that they would not be willing to conduct a follow-up interview. All participants who were willing to conduct a follow-up interview provided contact information. See Table 4 for participant survey results.

Table 4 Participant Survey Results (n=31) Variable Q1 How do you define mindfulness practice? Focus Observation Presence Acceptance Non-judgment Not Sure No Response

(%)

19 14 12 8 7 2 1

(61.29) (45.16) (38.7) (25.8) (22.5) (6.45) (3.23)

26 6 4 1

(83.87) (19.35) (12.90) (3.23)

Q3 Do you personally practice mindfulness techniques? Yes 23 No 2 Other 6

(74.19) (6.45) (19.35)

Q2 How do you define mindfulness techniques? Focus, Observation, Presence, Acceptance, and Non-judgment Practice Not Sure Ancient Resource

Q4 Do you ever use mindfulness techniques when treating your clients? Yes 23 (74.19) No 2 (6.45) Other 6 (19.35) Q5 What is your primary theoretical orientation of your psychodynamic education? Classical 1 (3.23) Object Relations 4 (12.90) Self-Psychology 7 (22.50) Relational 15 (48.39) Other 4 (12.90) Q6 Which of the following techniques do you use with your clients? Active Listening 31 (100.00) Mirroring 31 (100.00) Empathy 29 (93.55) Free Association 24 (77.42) Evenly Hovering Attention 23 (74.19)

Breath Work Vicarious Introspection Meditation Body Scans Guided Imagery Yoga Hypnosis Other

15 14 14 12 10 4 2 4

(48.39) (45.16) (45.16) (38.71) (32.26) (12.90) (6.45) (12.90)

Q7 How frequently do you teach mindfulness techniques to your clients? Almost Never 3 (9.68) Very Infrequently 7 (22.58) Somewhat Infrequently 10 (32.26) Somewhat Frequently 8 (25.81) Very Frequently 2 (6.45) Almost Always 1 (3.23) Q8 How frequently do you refer clients to learn mindfulness techniques outside of therapy? Almost Never 3 (9.68) Very Infrequently 7 (22.58) Somewhat Infrequently 9 (29.03) Somewhat Frequently 7 (22.58) Very Frequently 4 (12.90) Almost Always 1 (3.23) Q9 When you consider deviating from the psychodynamic frame, how much concern does it cause you? A Great Deal 1 (3.23) Much 1 (3.23) Some 11 (35.48) Little 14 (45.16) None 4 (12.90) Q10 If you are not currently using mindfulness techniques with clients, please explain why? Not Sure or Donâ€™t Know How 3 (9.68) Resistant to Moving outside of the Frame 2 (6.45) Not Directive in Session 2 (6.45) Trained As a Psychoanalyst 1 (3.23)

Two distinct sub-groups were identified from the survey results. The first, which I labeled the aware sub-group, were participants who had a great extent of knowledge of mindfulness, a high frequency of using mindfulness in their sessions with clients, and a high rate of referring clients to learn mindfulness techniques outside of their session. A total of 16 participants were identified as being aware, or 51% of the total sample. From these 16 participants, a sub-group of five was selected based on qualifying criteria and willingness to participate in an interview. Two out of these 16 participants declined to participate in Phase 2 of my study. In the aware sub-group, the average age of the participants was 61 years old, with the youngest participant being 49 years old and the oldest participant being 73 years old. There were four females and one male. All five came from different states: New York, Illinois, Maine, Texas, and Florida. All five participants were White/Caucasian. Three participants identified as having a relational theoretical orientation, one identified as selfpsychology and one identified as classical. Three of the participants had their PhD and two were at a masterâ€™s level (see Table 5). All five participants had a great extent of familiarity with mindfulness concepts and they all personally practiced mindfulness techniques. All five participants indicated they taught mindfulness techniques to their clients in session to some degree. Three participants taught mindfulness techniques to their clients in session somewhat frequently, one participant taught them almost always, and one participant taught them very frequently. All five participants indicated they referred their clients to learn mindfulness outside of their session to some degree. Two participants referred clients out very frequently, two participants referred clients out

somewhat frequently, and one participant referred clients out almost always (see Table 6). Table 5 Phase Two Participant Demographic Matrix for Aware Sub-group Participant Age by PIN number 30-Jim 65

Gender

State

Race

18-Jen

26-Bev

1-Aly

9-Lyn

Average Age = 61 Lowest age= 49 Highest age= 73

F= 4 (80%) M= 1 (20%)

New York White/ Caucasian Illinois White/ Caucasian Maine White/ Caucasian Texas White/ Caucasian Florida White/ Caucasian New White/ York= 1 Caucasian= (20%) 5 (100%) Illinois= 1 (20%) Maine= 1 (20%) Texas= 1 (20%) Florida= 1 (20%)

Theoretical Orientation

Education Level

Relational

Masters

Relational

PhD

Relational

PhD

SelfPsychology Classic

Masters

Relational= 3 (60%) SelfPsychology= 1 (20%) Classic= 1 (20%)

PhD= 3 (60%) Master's= 2 (40%)

PhD

Table 6 Phase Two Participant Mindfulness Summary for Aware Sub-group Participant by PIN number

Extent of Familiarity of mindfulness

Personally practice mindfulness techniques?

A Great Extent A Great Extent A Great Extent A Great Extent A Great Extent A Great Extent= 5 (100%)

18 26 1 9

How often do you refer your clients to learn mindfulness techniques? Somewhat Frequently Somewhat Frequently Very Frequently

How often do you teach mindfulness techniques to your clients? Somewhat Frequently Somewhat Frequently Somewhat Frequently Very Frequently

Almost Always

Y = 5 (100%)

Somewhat Frequently= 3 (60%) Almost Always= 1 (20%) Very Frequently = 1 (20%)

Very Frequently= 2 (40%) Somewhat Frequently= 2 (40%) Almost Always= 1 (20%)

Y Y

Very Frequently

The second group, which I labeled the unaware sub-group, were participants who may or may not have had a great extent of knowledge of mindfulness, but who had a low frequency of using mindfulness in their sessions with clients and a lower rate of referring clients to learn mindfulness techniques outside to their session. A total of 15 participants were identified as being unaware, or 48% of the total sample. From these 15 participants, a sub-group of five was selected based on qualifying criteria and willingness to participate in an interview.

In the unaware sub-group, the average age of participants was 59.2 years old, with the youngest participant being 37 years old and the oldest participant being 69 years old. There were four females and one male. Two participants were from New York, two participants were from North Carolina, and one participant was from Illinois. All five participants were White/Caucasian. Four participants identified as having a relational theoretical orientation and one participant identified as having a modern psychoanalysis theoretical orientation. Four participants were at a masterâ€™s level and one participant had a PhD (see Table 7). Of the five participants, three had a great extent of familiarity with mindfulness concepts and two participants had somewhat of a familiarity with mindfulness concepts. All five participants personally practiced mindfulness techniques. Three participants taught mindfulness techniques to their clients in session somewhat infrequently, and two participants taught mindfulness techniques to their clients in session very infrequently. Three participants referred their clients to learn mindfulness techniques outside of their session very infrequently and two participants referred their clients out somewhat infrequently (see Table 8).

Table 7 Phase Two Participant Demographic Matrix for Unaware Sub-Group Participant by PIN number 25-Ava

Age

Gender

State

Race

Theoretical Orientation

Education Level

Masters (ABD-PhD) Masters

31-Jan

New York

White/ Caucasian White/ Caucasian White/ Caucasian

Relational

12-Sue

North Carolina Illinois

13-Tom

New York

16-Meg

Aver age Age = 59.2 Lowe st age= 37 High est age= 69

F= 4 (80%) M= 1 (20%)

North Carolina New York= 2 (40%) North Carolina= 2 (40%) Illinois= 1 (20%)

White/ Caucasian White/ Caucasian White/ Caucasian = 5 (100%)

Relational

Modern PhD Psychoanalys is Relational Masters Relational

Masters

Relational = 4 (80%) Modern Psychoanalysis= 1 (20%)

Masters= 4 (40%) PhD= 1 (20%)

Table 8 Phase Two Participant Mindfulness Summary for Unaware Sub-Group Participant by PIN number

Extent of Familiarity of mindfulness

Personally practice mindfulness techniques?

A Great Extent A Great Extent Somewhat

Somewhat

Y and N

A Great Extent A Great Extent= 3 (60%) Somewhat= 2 (40%)

How often do you teach mindfulness techniques to your clients? Very Infrequently

How often do you refer your clients to learn mindfulness techniques? Very Infrequently

Very Infrequently

Somewhat Infrequently Somewhat Infrequently Somewhat Infrequently Somewhat Infrequently= 3 (60%) Very Infrequently= 2 (40%)

Very Infrequently

Y = 100%

Somewhat Infrequently Somewhat Infrequently Very Infrequently= 3 (60%) Somewhat Infrequently= 2 (40%)

Phase Two Sample Ten participants were interviewed for Phase Two of this study. Five participants were from the aware sub-group and five participants were from the unaware sub-group. All 10 interviews were audio recorded and transcribed. All transcripts were proofread and edited, and then coded through NVivo software. Each participant was given a PIN number and a corresponding three-letter pseudo name for confidentiality purposes. All participants had their own experience of the phenomena of the integration of mindfulness therapy techniques in psychodynamic therapy. Participants will be described based on

their experiences, starting with the aware sub-group and followed by the unaware subgroup.

Jim. Jim is a 65-year-old white male from New York. He completed his MSW in the late 1970s and began a psychoanalytic fellowship in the early 1980s. Jim described his psychoanalytic fellowship as good, stating, “It was, I would say, strictly Freudian, and then we moved into object relations, a little bit of self-psychology, and that was about it.” Jim had extensive professional experience both in private practice and in administration. He worked with various populations and specialties until: I was called in to be a teacher and a supervisor at CSAB, and by that time, relational psychoanalysis was a hot number, which I didn't know a lot about. Since I was sort of an old dinosaur, I learned a lot about relational psychoanalysis, and I really realized that I was doing that all along. Jim recalls his first experience of mindfulness as having “taken courses in TM, Transcendental Meditation, since I was very lost in my twenties, with the war in Vietnam and everything else going on.” Jim was trained in various mindfulness-based models such as dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT), and he “got more into Buddhist psychology.” Although he does not identify as a Buddhist, he says, “I use a lot of different types of theories and techniques. So I'm not strictly a psychoanalyst anymore. I do see myself as a psychoanalytic psychotherapist, of one persuasion or another."

Jim describes his personal experience with mindfulness: I'm probably an intermediate at mindfulness. I do various types of mindfulness, whether active, like when I'm taking a shower, or passive, when I'm in between patients, where I'll sit and focus on my breath and just be aware of whatever I'm experiencing. Pretty much the DBT model of observe, label, and then participate. His own personal experience influenced him to integrate what he was learning about himself into his sessions with his clients. He describes his experience and connection as follows: What started happening is some patients would talk about a part of themselves, and there was a dialogue we began to have with various parts, memories of parts of themselves. I found that I was doing that too, both back in my supervision and my analysis where, you might call it the inner child or parts of myself that was sad or angry, and being able to just witness and stay present. So, I began using that with some patients that were capable of doing that kind of internal split. I found it very, very helpful that they were able to move towards the reflective capacity, besides just being embedded in their feelings, thoughts, and desires. Jim introduces mindfulness to some of his clients in session, “depending on their degree of psychological insight, the strength of their ego function or sense of self.” He is more reluctant to introduce mindfulness with clients “who might have a substantial history of trauma, or who are on a severe level or borderline spectrum,” as he does not feel it is as successful. First, Jim does an assessment with a client, “so the first three or four sessions is getting to know the patient and engaging with them, developing a rapport,

mirroring, attuning, emphatic, and validating what's going on.” Then he would “ask them if they would do a mindfulness exercise and explain what's going to happen, and tell them essentially it's sort of like a grounding experience.” If his client is interested, Jim asks the client to “put their feet on the ground, hands on their lap, and just begin listening to and experiencing their breathing.” To Jim, integrating mindfulness therapy techniques into his sessions with clients is about “gaining the concept of how to be present with themselves and experience both the awareness, the containing, the holding environment of tolerating whatever comes into their consciousness, and learning to work it through and let it go.” Regarding the integration of mindfulness therapy techniques in psychodynamic therapy, Jim believes, “It's always been there, that in some ways, there is a correlation between psychoanalysis and mindfulness.” His experiences with psychodynamic theories and practices have changed over the years, but he thinks, “It's being integrated more and more into…or I hope to believe that it's being integrated into the frame, ‘You're just supposed to be a blank slate, and just interpret.’ I don't think many of us do that anymore.” This integration impacts transference and counter-transference, but he doesn’t try to control it. Rather, it is about “trying to manage it and be present with it."

Jen. Jen is a 49-year-old Caucasian female from Illinois and has her PhD. Jen “went to graduate school at Northwestern through the medical school at Northwestern downtown, which at the time was still psychodynamic.” She noted that although her

training all started as psychodynamic, there was a huge shift around her of programs moving toward short-term solutions and behavioral programs. Jen specialized in eating disorders and substance abuse and thought she needed “some symptom-focused intervention, too, for these populations, these people with a lot of impulses and behaviors.” This led to her interest in dialectical behavior therapy (DBT). As she started to learn more about this model of practice, she began integrating it into her psychodynamic approach. “I identified and integrated with the relational base, and so I do incorporate a lot of things into my psychodynamic frame that would include DBT, CBT behavioral recommendations and suggestions, and mindfulness,” states Jen regarding her practice. Jen declares that “having my own practice helps me teach the practice to my clients." She believes that “having experienced the different obstacles that come up in my own practice, I feel like I can speak to what those are when a client shares their experiences, usually of frustration with mindfulness.” When Jen assesses who may be appropriate for mindfulness, she says: The two things that I really push mindfulness for, I would say, is either anxiety or people with panic attacks or generalized anxiety, or people who have a lot of unrelenting self-criticism or other types of intrusive thoughts. A sample of her experience with a client would look something like this: Just notice, bring your attention inside your body and notice the place in your body where you feel the sensation of breathing most strongly. That can be in your

nostrils, in your chest, in your diaphragm, anywhere you notice the breath moving in and out. And then use that sensation as a focal point. Jenâ€™s primary reason for introducing mindfulness in a session is â€œhelping that person have both the understanding and the space to act in accord with their new understanding, if they're gaining that.â€? Jen is aware of both positive and negative impacts to the psychodynamic frame when introducing mindfulness techniques with clients in session. She shares an example of how that may look in a session: I always think of specific symptom-focused techniques as transitional objects. I think that giving a client something concrete to take with them can make the relationship feel more present with the client when they leave, like they're not alone, so I think it can solidify or strengthen the relationship. That's the positive side. I think the negative side is that if the clients feel they can have a transference, such that they feel like they've been given an assignment and they could pass it or fail it, or they might disappoint me if they don't do it. That kind of thing. So I try to be on the alert for that and we process that. Despite there being an impact, Jen feels it is in line with her psychodynamic beliefs, as she expresses: Personally, I don't see any contradictions, because I'm relational and my interest in the relational model is that you do what the client needs, and you do what the particular dyad needs. If that means mindfulness or that means directive intervention or symptom-focused interventions, that's perfectly compatible.

Bev. Bev is a 61-year-old Caucasian female from New England and has a PhD. She completed her master’s degree in the late 1970s from Smith College and later completed a PhD in sociology. She has had training in family therapy, social constructivism, and Jungian therapy. Bev has extensive training in meditation and states, “I think since 1987, I've been a meditator. I spent time in ashrams all over the world India, Tibet, China, and here in the U.S.” She acknowledges her self-practice influences her work with her clients, as she believes “the energy and the presence are there, and certainly are useful in working with people.” With a client she will direct them to: Find a comfortable position. Put your feet on the floor. Nothing crossed because the energy really needs to flow. And very slowly breathe deep, count to ten on the in breath, ten on the out breath, diaphragmatic breathing below your chest. The energy and presence consists of: Focusing on the breath, and then allow the conversation to arise out of the space in between, out of the silence, and the space in the middle of the room. I think the space in the middle of the room as kind of like a fire that we are contributing to with our breath, like fanning the flames of this fire. Bev recognizes that her own self practice has made her feel “more grounded, integrated, happy in my own life.” This inspires her to introduce techniques in session with her clients. Bev states, “What I do, I think, is a very eclectic mix of things. For people who are interested, I begin each session with a meditation.” Although Bev primarily uses meditation, there are times when she will utilize other techniques. She

says, “It really is based on what's happening. So I do use body scans when I feel like people have dissociated, or breath work when I notice that people are not breathing and trying to avoid feelings.” She knows that not all clients are able to embrace these techniques in session and believes this is because “it requires an intimacy that they're not ready for." Bev maintains that for a client to meditate in a session, “it's coming forward in a very different way. Yes, vulnerability, openness, in a very different way.” And not everyone is able or willing to engage with this technique. Given all the different types of training Bev has had in different practice models, she says, “If I were to think about where I've ended up, I think I'm very grounded in psychoanalytic theory.” Her belief about the integration of mindfulness into her psychodynamic practice is Developing the capacity to be alone in the presence of another person and just become comfortable with your integrated self in the presence of another person. I actually think it propels the process and fits pretty well. Bev does not have negative concerns with impacting the psychodynamic frame. Regarding the transference and countertransference, she asserts, “I actually think it levels the playing field in an interesting way. I think transference, countertransference is an integral part of every relationship you ever have.”

Aly. Aly is a 57-year-old Caucasian female from Texas who completed her master’s degree in the early 1990s. Aly went on to complete a post-graduate fellowship that was

psychoanalytic, as well as a 2-year psychodynamic psychotherapy training through a local psychoanalytic institute. Aly’s theoretical orientation is self-psychology along with some object relations, but she describes her background as “extremely Freudian psychoanalytic. I would read a lot of Jungian stuff, and I would attend Jungian seminars. I think I'm also influenced by that aspect of psychoanalysis, the Jungian approach.” Aly started practicing mindfulness in the mid-1990s, learning different variations through trainings and workshops. She states, “I've used it for years in my practice with my patients, whether it's at the individual session, where I'll use it for either their anxiety or helping them do some kind of defusing from some of their troubling stuff.” She claims, “I would have never thought about using these techniques if I wasn't practicing mindfulness myself.” Aly has many reasons why she uses mindfulness practice. One reason she uses it in session is because: It helps me stay in the moment. It helps me lower my anxiety, think more clearly, not carry it around and let it build up. So, it helps me be in a calmer, more present state. Then, secondly, allowing my clients to be introduced to mindfulness helps them get into their deeper sense of self. She introduces it to clients in session by “asking their permission, give them a little bit of education and introduction to mindfulness.” Aly might say, for example: Okay, this is the technique called mindfulness, and it's very well researched and utilized by a lot of therapists, and this is how it works. It's really like teaching

you how to be aware of your thoughts and your thought processes, and teaching you how to manage them in a different way. Then she will have her clients begin by “gently closing their eyes and beginning to tune into their body. I'll walk them through a progressive relaxation through their body.” Aly says, “My fundamental training and practice is psychodynamic.” But she also deems that may not be enough with many clients. She describes the integration as: So, you need to go in with the analytic view, with the inside, with the interpretation, pull back the projection. You need that along with, ‘Let me teach you how to separate yourself from this sadness and anxiety that you feel.’ I don't think it is safe, myself, to go into the world of mindfulness without understanding the psychodynamic underpinning of a client's symptoms. Aly believes mindfulness has a positive impact on the psychodynamic frame as she describes that impact in today’s practice: Hugely, it's all over the place now. Neuroscience is bringing psychoanalysis into a deeper phase. When the therapist is teaching mindfulness, they're teaching their client to be reflective, so you're forming attachment, you're developing the observing ego. You're helping them defuse from their symptoms, like anxiety or addiction or depression, and helping them to find different aspects of themselves. She also holds that it has a positive impact on transference because clients can, “stay more present with it, rather than acting it out or physicalize it.” Aly maintains this is true for countertransference as well, and describes her experience with it:

I know for countertransference, the more mindful I am as a therapist, the less likely I am to get hijacked by countertransference, the more likely I am to be able to observe it, interpret it, and actually use it in the room, rather than it's using me. So, staying in the present moment, being the observer, keeping my own anxiety down, I can be more of a compassionate observer and guide rather than, I'm getting sucked into this, and there's some projective identification going on here, or countertransference, or whatever.

Liz. Liz is a 73-year-old Caucasian female from Florida. She completed her master’s degree in the late 1960s and went on to complete analytic training as well as completing her PhD. Liz was introduced to meditation in the early 1970s. Over the years, she has “learned all kinds of, what we now call mindful techniques, for calming and all kinds of stuff. So, to the degree that certain ones have been beneficial, I will offer them to a patient or a client.” When introducing mindfulness in session with a client, Liz says, "Have you ever tried meditation or relaxation techniques for this?" and “I'll investigate and ask what has worked.” She shares an example: I ask you to sit in your chair, get completely relaxed, close your eyes, sit back and relax every body part. So, I would take you through every body part from the toes to the head, and tell you to be mashed potatoes and completely relaxed. I would tell you ahead of time what I was going to do. I would be having you relaxed and

go through every body part, then I will tell you to say a two-syllable word. Usually I'll start with peaceful, because that's what I've found people like. Liz believes mindfulness is a natural integration into psychodynamic therapy and states: I don't see a contradiction between that and the theory I'm trained in, because the theory I'm trained in is psychoanalysis, making the unconscious conscious and psychoanalysis for healing. I'm talking about psychoanalysis for healing. If it's healing and helpful and it's using psychoanalysis, I don't see a problem. Regarding the impact on the psychodynamic frame, she declares, “Psychoanalysis has changed, in part, because of this, and in part because of many other reasons, too, but this is one of them, and it's an important one.”

Summary of the aware sub-group. All five participants from the aware sub-group have a great extent of familiarity with mindfulness. All of them personally practice mindfulness techniques and regularly teach mindfulness techniques to their clients in session. The processes, techniques, and rationale for integrating mindfulness into their sessions vary to some degree, but the overall belief is that the integration is a beneficial component to their clients’ psychodynamic process. All participants in this sub-group refer their clients to learn mindfulness techniques outside of the sessions. The primary reasons for referrals is to help the client gain further practice of a specific technique and/or to learn a new technique in which the therapist is not trained. The types of referrals include meditation centers, workshops or seminars, Internet downloads, books, CDs, the mindfulness-based

stress reduction course (MBSR), yoga, a labyrinth, tai chi, phone apps, eye movement desensitization and reprocessing (EMDR), and acupuncture. All five participants thought that their clients were very receptive to the integration of mindfulness techniques into their sessions. The following are accounts from each participant in the aware sub-group on their process of using mindfulness techniques in session with their clients. Aly utilizes concepts of mindfulness to increase awareness, manage the thought process, become grounded, and become self-observing. She does this through teaching her client breath work, as well as focusing on the body, guided imagery and visualization, and relaxation techniques. As for the process of integration, Aly continuously assesses her clients and cautions, “you have to be very careful. You have to ask permission. You can’t assume and just go somewhere. You have to go very slow and feel it out because in untreated, unresolved, or unrecognized trauma, mindfulness can actually trigger the residuals and the pain, so you just have to be really aware and careful.” Jen utilizes concepts of mindfulness to regulate affect, manage self-criticism or intrusive thoughts, increase awareness, create space, and help with symptom management. She does this through teaching her clients breath work, focusing on the body, meditation, and validation. Jen shares an example of how mindfulness techniques can create space with an eating disorder client. She states, “This is that thing that happens inside me right before I binge. They’re being mindful of that and then they can build in much more freedom to make a different decision rather than binging.” Bev utilizes concepts of mindfulness to help a client feel more grounded, increase awareness, manage symptoms, and co-create safe space. She does this primarily through

teaching her clients meditation, along with body scans and breath work, and focusing on the breath. Bev generally starts each client session with meditation and states, “What ends up happening – it’s very powerful – people usually begin in the place where they usually leave. People who don’t do this process, they do doorknob conversations right from the start, so it just speeds things up. It gets things to be more meaningful, and focused, and really kind of authentic...integrated.” Jim utilizes concepts of mindfulness to help ground clients, increase awareness, increase their self-observing capacity, help clients tolerate uncomfortable feelings or emotions, help contain the clients, and help clients relax. He does this primarily through attunement, empathy, validation, breath work, and guided imagery or visualizations. Jim thinks that an important part of this process is assessing the client and developing rapport. If he is working with an eating disorder client and he assesses that the client is ready, he will “move them from awareness into containing, or tolerating.” I try to help them just to stay present with whatever they are feeling or thinking, and try to get to the underlying issues of what is it they’re desiring, wanting or needing. Then, the final phase is working it through.” Liz utilizes concepts of mindfulness to help clients with symptom management. She does this primarily through teaching her clients a body scan, guided imagery, and visualization. Liz acknowledges that there are many different types of mindfulness therapy techniques and that what works for one person may not work for another. She often asks her clients to use a two-syllable word during the relaxation and instructs them

“not to judge the feelings and thoughts at all, and just do your best to get back to this twosyllable word.” Liz adds that she will then process the experience with her clients. Four themes emerged from the aware sub-group. These themes were selfpractices influences integration, the process of integration, mindfulness therapy techniques, and progression of psychodynamic theories. All the participants in the aware sub-group noted that their own self-practice directly contributed to how or when they integrated techniques with their clients. Many of them noticed benefits in their own personal lives, ranging from greater awareness and being in the moment to “this altered state where all kinds of things happen.” Participants also felt more confident in teaching the techniques to their clients. All of the participants in this sub-group had a process for integrating the techniques into their sessions. An important component to the process for all participants was knowing their client. If it was a newer client, there was an assessment period and the therapist would generally ask permission prior to utilizing mindfulness techniques. If the therapist had an established relationship with the client, it was more acceptable to suggest or introduce a technique without necessarily asking permission, as it was implied. Participants would continuously assess their clients for engagement, receptivity, or resistance. The participants all acknowledged that the process of integration was beneficial for their clients. The specific mindfulness therapy techniques varied between the participants in this sub-group. A common factor among the techniques was having clients focus on something--their breath, their body, or a fixed point in the room. Most of the participants utilized different breathing techniques along with guided imagery or visualization,

meditation, progressive relaxation, and body scans. The participants focused on the clients gaining awareness to their body sensations, their internal dialogue or selfmessages, and their capacity to create space in order to process their inner conflicts. All participants noted a progression in psychodynamic theories and practice. Most of the participants had studied all the theories, starting with Freud, but identified as more relational. The general consensus of the participants was that if mindfulness techniques helps clients, then it is okay to use them. Mindfulness techniques are utilized to regulate affect, as well as enhance the ability of going deeper into the psychodynamic process. Table 9 lists all four themes and samples of significant statements that comprise each theme.

Table 9 Themes from the Aware Sub-group Theme 1: Self-Practices Influence Integration________________________________ I found that I was doing that, both back in my supervision and my analysis, so I began using it with some patients. Having my own practice helps me teach the practice to my clients. The energy and the presence are there and certainly are useful in working with people. I would have never thought about using these techniques if I wasn't practicing mindfulness myself. So, to the degree that certain ones have been beneficial, I will offer them to a patient or a client. _______________________________________________________________________ Theme 2: The Process of Integration________________________________________ Gaining the concept of how to be present with themselves and experience both the awareness, the containing, the holding environment of tolerating whatever comes into their consciousness, and learning to work it through and let it go. Helping that person have both the understanding and the space to act in accord with their new understanding. Focusing on the breath and then allow the conversation to arise out of the space in between, out of the silence, and the space in the middle of the room, Allowing my clients to be introduced to mindfulness helps them get into their deeper sense of self. You have to be very careful. You have to ask permission. You canâ€™t assume and just go somewhere. ________________________________________________________________________ Theme 3: Mindfulness Therapy Techniques__________________________________ Put their feet on the ground, hands on their lap, and just begin listening to and experiencing their breathing. Just notice--bring your attention inside your body and notice the place in your body where you feel the sensation of breathing most strongly.

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Find a comfortable position. Put your feet on the floor. Nothing crossed because the energy really needs to flow. And very slowly breathe deep, count to ten on the in breath, ten on the out breath, diaphragmatic breathing below your chest. Gently closing their eyes and beginning to tune into their body. I'll walk them through a progressive relaxation through their body. I ask you to sit in your chair, get completely relaxed, close your eyes, sit back and relax every body part. ________________________________________________________________________ Theme 4: Progression of Psychodynamic Theories_____________________________ It's being integrated more and more into--or I hope to believe that it's being integrated into--the frame. I don't see any contradictions because I'm relational and my interest in relational model is that you do what the client needs. Developing the capacity to be alone in the presence of another person and just become comfortable with your integrated self in the presence of another person. I actually think it propels the process and fits pretty well. So, you need to go in with the analytic view, with the inside with the interpretation, pull back the projection. You need that along with, "Let me teach you how to separate yourself from this sadness and anxiety that you feel." Psychoanalysis has changed, in part because of this, and in part because of many other reasons, too, but this is one of them, and it's an important one.

Unaware sub-group. Ava. Ava is a 37-year-old Caucasian female from North Carolina. She has her masterâ€™s degree and is currently ABD in a psychodynamically-oriented doctoral program. Regarding her psychodynamic education, Ava states, â€œThe theories inform how I see and understand what a person is bringing to the room. But my way of responding is typically out of the more relational or object relations theory of orientation.â€? Her mindfulness

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practice began around 2007 when “I worked at an agency, where I was hired to work on a SAMHSA grant. We were also looking at interventions that were effective for people in recovery from substance use.” This prompted Ava to learn mindfulness “to be able to lead that group and to help other people learn.” Ava describes her current practice as follows: Well, at this juncture I would say that my practice is not even a daily practice in terms of a sitting meditation, but I feel as it is in the context of mindfulness and particularly the present mindedness and acceptance. These tenets are really a part of my person, as a result of having taught the class for so long. I think that they just come to me as a way of being. Ava struggles with how to define mindfulness techniques in the session and states, “I don't explicitly do mindfulness, unless people ask, because I feel like that's an approach people are looking for” and “to drop into a meditation or a philosophy of thought feels different.” Ava isn’t sure if mindfulness can be integrated into psychodynamic therapy and thinks the difficulty is because “I think I prioritize my dynamic training over my mindfulness training.” As Ava examines the concept of mindfulness integration further and considers potential definitions, she states: I think some of these techniques, they're just the same thing, but they have different names applied to them. There might be some finer distinctions, like if we're thinking about evenly hovering attention, it definitely feels like it corresponds with awareness. I think that that definition is kind of loose at this

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juncture in our society and in clinical practice, because it's been used in so many different ways. Her assumption when she hears that other therapists are integrating mindfulness therapy techniques is, “What they mean is that it's a formalized practice, that they're asking their clients to meditate or do breathing exercises, or something much more explicitly mindfulness-oriented." Ava attests that the psychodynamic frame is impacted when mindfulness therapy techniques are integrated into a session. She proclaims that “introducing something that is not necessarily being introduced by the client, is more directive and potentially changes the direction.” Ava clarifies: I guess what I'm saying is I'm encountering these thoughts, maybe for the first time, and so I'm curious about the avenue I'm taking with my own responses. But I think that there's a subtle choice that has to be made for each individual person based on an assessment of what their needs are, what their sense of structure is, and ego function. Going back and forth with uncertainty, Ava declares, “But it seems like it would be very clear that some people could maybe benefit, whether or not it changed the frame.” Ava also believes it would impact the transference and countertransference and describes it as, Introducing any activity means that a person may feel there’s an expectation or a privileging of that activity, so I can imagine a client then expecting that it's going to work, or I don't even know what work would mean. It's an introduction of an

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expectation that can influence whether or not the client feels like it will influence their experience, and it would also influence mine.

Sue. Sue is a 67-year-old Caucasian female from Illinois and completed her master’s degree in the late 1970s. After getting out of school and starting to work, she acknowledges, “I was kind of rigidly adhering to more psychoanalytic training.” But now, “with life experience and more training, I'd say I'm kind of a combination of psychodynamic relational, self-psychology.” Sue’s first mindfulness training was about 3 years ago when she attended an 8-week mindfulness-based stress reduction (MBSR) class. She describes this experience as “extremely enlightening, and I think lifechanging for me in certain ways.” Sue adds, “What I found was that just in my own personal life, if I just allowed myself to sit with the feeling and it dissolved, at some point, maybe the same day, the solution to the problem seemed very clear to me.” She states, “It really made me think a lot about what I do with my clients and whether I could add some of what I had learned to it.” But integrating mindfulness therapy techniques into sessions proved to be more difficult for Sue. She declares, “I have to put a lot of energy into doing it. It's not easy for me, and there was something about changing the frame and treatment.” Integrating mindfulness therapy techniques is challenging for Sue. She shares: I just felt like the idea of going from my role as a therapist to a teacher was more directive where somehow the idea of breathing with a client felt too intimate. It

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just felt like I was really going to have to work hard to get my head around it, and I struggled with it because I could see how helpful it was to me. Despite the outcome, Sue discloses her experiences in session with clients: I've done it with a few clients in a very kind of casual way, and I'm not sure whether it was because of my own lack of confidence in it, or because of where they were, and I felt like it was okay, but it didn't go anywhere, and neither of them were interested. Well, neither of them asked about doing it in subsequent sessions. Sue grapples with the definition of mindfulness therapy techniques and refers to the difference in techniques such as active listening, mirroring, and empathy versus meditation or breathing, as: I think about mindfulness, like mindfulness with a capital 'M' and mindfulness with a small 'm.' And mindfulness with a small 'm' -- I could see that they could be considered mindfulness techniques. But mindfulness with a capital 'M,' which I guess makes me think more about the active experience of meditating. I wouldn't include that, mindfulness with a capital 'M,' if that makes any sense. Despite the uncertainty of the definition of mindfulness therapy techniques, Sue adds: I didn't really mention it before, but I often say to somebody who's struggling with a feeling, and starting to feel anxious about the feeling and trying to kind of analyze it away or talk it through, â€˜Can we just sit together with the feeling? Just sit there with it, and see what it feels like?â€™ That's actually something that I probably did not do very much of before I took the mindfulness-based stress

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reduction class. But I am more comfortable with doing that, because that doesn't feel like changing the frame. It feels very organic to what's happening between me and my client, so I guess I would say that when I hear people saying that they use mindfulness, I think about that. But then I wonder, maybe they're doing breathing, or maybe they're doing a compassionate meditation, or I don't know. Sue is mindful of the psychodynamic frame and references her early training to “be with the client, be where the client is, listen, focus, and pay attention to your own feelings. Don't bring in your own agenda, don't try to fix things.” Sue shares the potential benefits of integrating mindfulness therapy techniques into a session: Well, first of all, sometimes it can relieve immediate suffering. It can relieve somebody's immediate anxiety. Or if somebody is having a pain in their arm or their stomach or something, and just to be with it, it can literally relieve the feeling. Regarding the transference, Sue conveys, “There's something about, again, are they doing this because I'm telling them to do it, are they getting something out of it?” She says, “Maybe for some people it could be comforting in a sense that well, she knows something here, she's an expert, she's telling me what to do, and it seems like she knows what she's doing.” Regarding the countertransference, Sue says: So sometimes when I'm going in that direction with a client, I do think about, ‘Yeah, my therapist never did this with me.’ And I think it causes me some discomfort, not so much now, but in the beginning.

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Jan. Jan is a 69-year-old Caucasian female from New York and she has a PhD. She claims she has been “a psychoanalyst for a million years” and is “a modern psychoanalyst, which is the school of thought which emphasizes the hallmarks of modern analysis as understanding the way people turn aggression against themselves and learning how to help the patient externalize the aggression instead of attacking themselves.” In the 1970s or 1980s, she went to a meditation center a few times and then later attended a 10-day contemplative psychotherapy intensive course that included meditation. Jan describes her current practice as follows: “I periodically sit for 10 or 20 minutes and just focus on my breath.” Although mindfulness is infrequently used in session with her clients, Jan notes, “I might suggest it. I sometimes ask people to just focus on their breathing right in the room if they are very anxious, to try to get back inside their body, and to feel more grounded inside their body.” She professes she does not use it more frequently in session, because “I think I'm not grounded in it enough myself to have it be large enough in me and in my mind to use it any more with people. I just bring it in when it occurs to me.” Jan feels her lack of knowledge is a barrier to integrating mindfulness in her sessions with clients. She states, “I don’t know enough technically about mindfulness other than focusing on the breath and being in the moment.” Further, Jan says, “Not only do I not know, but I wish I did, because I would love to know more, how to bring it in.” Her openness and curiosity has her interested in deepening her understanding of this process. When asked if she feels integrating mindfulness therapy techniques impacts the

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psychodynamic frame, Jan says, “That's a good question, because that's the reason that I don't do it now, because I don't even know how to change the frame that I have.” Jan has two thoughts on the impact to transference and countertransference. First, “for me to bring up something, a different modality, they might feel it was nurturing, they might feel it was jarring.” Second, “I wonder if it would change the nature of the transference because the therapist is now taking a new role. And whether that would give the person a different feeling.”

Tom. Tom is a 62-year-old Caucasian male from New York. He completed his master’s degree in the late 1970s and then started analytic psychotherapy training, which he completed in the mid-1980s. Regarding his training, he declares, “I was classically trained in ego psychology, initially. I would say my orientation now is more along the lines of a relational or a self-psychological, moving towards relational approach.” He was introduced to mindfulness as follows: A few years ago, I did a study group with a friend of mine who specializes in trauma work and body work. The study group was a peer group, primarily, though he was the leader, and it was around the issue of mindfulness in practice and working with trauma as well. Tom understands mindfulness as reflection and attentiveness. He gauges his integration of mindfulness in sessions as, “It fluctuates in terms of my attentiveness to say the physical, because it's also not an aspect of my training, in a sense, to pay attention to that

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aspect of things--the body itself.” He says, “If I say that I'm using a mindfulness technique with someone, I think there are more ways people incorporate that, that I'm not as familiar with.” When asked about using techniques such as active listening, empathy, and evenly hovering attention, Tom says: That's very much a part of my practice, and that was something that I developed doing without a sense or any kind of understanding of what mindfulness is versus evenly hovering attention or whatever. I still feel naive or unfamiliar with how one terms this mindfulness versus 'this is helping to reflect what's going on inside.' So, that's why I get reluctant and say, ‘Oh, this is mindfulness practice,’ or, ‘This is something else,’ because I get a little confused about how that differs from helping someone look inside, which to a certain extent is then an attempt of the analytic process all along. When asked about the impact of integrating mindfulness therapy techniques into psychodynamic therapy, Tom believes that “the whole purpose, to me, in terms of thinking about psychodynamic work, would be that it would expand the whole idea of looking inward.” With regard to the impact of these techniques on transference and countertransference, “anything that happens within the session affects the relationship and how you're seen. So, there's that aspect of it, in terms of what will be experienced, how you will be experienced by the person. It also emphasizes and expands our checking in with ourselves to learn more regarding our reactions to the people we work with.”

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Meg. Meg is a 61-year-old Caucasian female from the Southeast. She completed her master’s degree in the mid-1990s, but it wasn’t until 2000 that she had a really strong interest in clinical work. Meg’s psychodynamic training came through “reading, educating myself, going to conferences, going to AAPCSW conferences, and studying with people that I respect over the years.” Meg recalls her first mindfulness experience as going on a residential retreat in the early 2000s. She has also taken the mindfulnessbased stress reduction course twice, various classes on mindfulness for professionals, and a four-month coach training course that integrated mindfulness techniques. Meg has been on several residential retreats and asserts, “I practice daily. I meditate every day.” When Meg is with clients she will “introduce this idea, I don't necessarily call it mindfulness, but I will introduce this idea of the possibility of paying attention on purpose to what is occurring with an attitude of kindness to help patients.” Although she does not integrate mindfulness therapy techniques regularly, “if someone is particularly agitated, I will encourage a pause and some deep breathing.” Meg defines mindfulness as “a kind of skill and capacity that helps us to be deeply attuned to the unfolding of moment-to-moment experience, including a sense of deep connection to one's body.” Meg believes: Mindfulness practices add a dimension to the treatment that in some way extends, enriches the work. It helps with embodiment. Speech is only one way of communicating. There are others. Non-verbal communication is really important in psychoanalytic treatment. As therapists, we see how our patients sit, how they

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move, how they hold themselves, their posture, their gaze, their eyes, there's all this communication that is non-verbal. And mindfulness practices open that up more. Despite her belief that mindfulness therapy techniques can enhance the psychodynamic process, Meg affirms that “holding to a psychodynamic frame requires great care” and “one needs to be judicious about the timing of introducing mindfulness.” She is mindful of this process and takes into consideration: Whether I feel the relationship can hold a suggestion from me, because analytically speaking, I don't tend to make suggestions in the way that I work except in this particular arena, where I'm introducing some kind of mind-body technique, which I think would help the person. I think whenever the therapist is bringing suggestions for ways of working, the frame can shift. In some sense, it's the therapist inserting herself and her own idea into the frame. I'm saying I have an idea, I'm not making the patient do it but I'm still inserting my idea into the energy flow. Meg put similar thought into the impact of transference and countertransference and adds: I think it can be either positive, or negative, similarly. Depending on the same factors, depending on timing and the nature, the strength of the relationship and the nature of the transference or countertransference at the time that the exercise is introduced.

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Summary of the unaware sub-group. Of the five participants interviewed, Ava, Sue, and Meg thought they had a great extent of familiarity with the concept of mindfulness. Jan and Tom thought the extent of their familiarity with the concepts of mindfulness was somewhat familiar. All five participants have had a regular self-practice of mindfulness at some point, but currently only Meg has a daily practice. Although infrequently, all of the participants have referred their clients to learn mindfulness techniques outside of the session at some point. All of their reasons for doing so were similar: helping their clients with regulation so they could practice outside of the session, and supplementing their psychodynamic work so they could learn new tools and skills and/or practices. The only specific types of referrals named by these participants were the mindfulness-based stress reduction course, a mindfulness-based cognitive therapist, yoga, and meditation. All of the participants in this sub-group believe that the integration of mindfulness therapy techniques is beneficial to their clients. Despite believing that the integration of mindfulness techniques was beneficial to their clients, all five participants were unclear as to how to incorporate this integration into their own practices. Some of the potential barriers that were named included lack of one’s own self-practice, lack of training or knowledge, uncertainty as to how to define mindfulness practice, and fear of deviating from the psychodynamic frame. Jan believes that having a regular self-practice would get her more focused, and then “once I’m seeing more of what’s happening with me, then I’m in a position to bring it in more with

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patients.” Regarding lack of training or knowledge, Sue says, “I wonder what they’re doing. I’m in a consultation group and occasionally we talk about mindfulness. There’s nobody there who does it really as a major component of their practice.” Defining mindfulness introduces a new aspect, i.e., a continuum of mindfulness practice. Participants from the unaware sub-group primarily agree that mindfulness techniques that require an active participation are different than mindfulness techniques that require a passive participation. Ava defines an active participation as a “formalized practice that they’re asking their clients to meditate or do breathing exercises or something much more explicitly mindfulness orientated.” Sue, Meg, and Ava would consider a passive mindfulness technique to be in line with basic psychodynamic techniques. Ava states, “I think some of these techniques, they’re just the same thing, but they have different names applied to them. There might be some finer distinction like if we’re thinking about evenly hovering attention, it definitely feels like it corresponds with awareness.” Tom and Jan feel they don’t know enough about mindfulness to label it. Tom stresses, “That’s why I get reluctant and say, ‘oh, this is mindfulness practice’ or ‘this is something else,’ because I get a little confused about how that does differ.” Finally, all five participants have concerns of how integrating mindfulness therapy techniques into psychodynamic therapy impacts the frame and if it is even okay to alter the frame. Four themes emerged from the unaware sub-group. These themes include: definition of mindfulness, influences of personal practice, barriers to integration, and impact on the psychodynamic frame. One of the primary themes that emerged from the

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unaware sub-group was how to define mindfulness. There seems to be a lot of confusion as to what is considered mindfulness and what is not. Most of the participants in this subgroup distinguished a continuum of mindfulness from passive to active. Passive mindfulness includes basic psychodynamic techniques and awareness, whereas active mindfulness techniques involves directing the client to engage in some form of activity such as breathing or meditation. All participants from this sub-group had an interest in mindfulness practices, based on their own personal experiences. They were all introduced to mindfulness at some point and have a continued interest in learning more about it. Their own personal experiences have influenced their belief that mindfulness techniques can be beneficial to their clients. All participants in this sub-group believed there were barriers to integrating mindfulness therapy techniques into their sessions. The main barrier to this sub-group was the participants' beliefs that they didnâ€™t know enough about mindfulness to integrate it into their sessions. Most participants would like to have more training and experience with mindfulness practices before they would feel comfortable integrating mindfulness with a client. Participants expressed a desire to have a clearer definition and understanding of mindfulness practices, as well as having concrete examples of how other therapists are integrating mindfulness techniques into their sessions. Another barrier, which leads to the final theme, is the impact on the psychodynamic frame. Most of the participants had concerns with how the psychodynamic frame would be impacted by integrating mindfulness techniques. Most of the participants were not comfortable with being directive or were not sure if integrating mindfulness techniques was possible.

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However, most of the participants did integrate mindfulness therapy techniques if they felt that it was â€œorganicâ€? or a natural part of the psychodynamic process. Nevertheless, most of the participants still felt hesitant to integrate mindfulness techniques, as it felt as if they were not keeping with the frame. Table 10 lists all four themes and samples of significant statements that comprise each theme. Table 10 Themes from the Unaware Sub-group Theme 1: Definition of Mindfulness_________________________________________ I think some of these techniques, they're just the same thing but they have different names applied to them. There might be some finer distinction. Evenly hovering attention definitely feels like it corresponds with awareness. I think, maybe, you think about mindfulness, like mindfulness with a capital 'M' and mindfulness with a small 'm.' And mindfulness with a small 'm' I could see could be considered mindfulness techniques, but mindfulness with a capital' M' makes me think more about the active experience of meditating. I still feel naive or unfamiliar with how one turns this mindfulness versus this is helping to reflect on what's going on inside. So, that's why I get reluctant and say, "Oh, this is mindfulness practice," or, "This is something else," because I get a little confused, in a way, about how does that differ from helping someone look more inside, which to a certain extent is then an attempt of the analytic process all along. ________________________________________________________________________ Theme 2: Influences of Personal Practice_____________________________________ I would say that my practice is not even a daily practice in terms of a sitting meditation, but I feel as if in the context of mindfulness and particularly the present mindedness and acceptance, these tenets are really a part of my person. Extremely enlightening, and I think life changing for me in certain ways. I practice daily, so I meditate every day. Theme 3: Barriers to Integration___________________________________________ I think I prioritize my dynamic training over my mindfulness training.

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I have to put a lot of energy into doing it and it's not easy for me, and there was something about changing the frame and treatment. I just felt like the idea of going from my role as a therapist to a teacher was more directive, where somehow the idea of breathing with a client felt too intimate. I think I'm not grounded in it enough myself to have it be large enough in me and in my mind to use it anymore with people. I donâ€™t know enough technically about mindfulness other than focusing on the breath and being in the moment. If I say that I'm using a mindfulness technique with someone, I think there are more ways people incorporate that, that I'm not as familiar with. Theme 4: Impact on the Psychodynamic Frame_______________________________ Introducing something that is not necessarily being introduced by the client, as it is more directive and potentially changes the direction of the therapy. I am more comfortable with doing that, because that doesn't feel like changing the frame. It feels very organic to what's happening between me and my client. The reason that I don't do it now is because I don't even know how to change the frame that I have. I wonder if it would change the nature of the transference because the therapist is now taking a new role. The whole purpose, to me, in terms of thinking about psychodynamic work, would be that it would expand the whole idea of looking inward. I think whenever the therapist is bringing suggestions for ways of working, the frame can shift.

Mixed Methods Results This study is a sequential explanatory mixed methods design, with a Phase One survey first, followed by in-depth interviews in Phase Two with the selected survey participants. The analyzed survey data were used to select the participants and the

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interviews were intended to further explain the survey questions. From the analyzed survey data, three findings were revealed. The findings from Phase One include the following: 1. Participants who frequently integrate mindfulness techniques into their sessions with clients have a high familiarity with the concepts of mindfulness, but having a high familiarity with the concepts of mindfulness does not directly impact the frequency of using mindfulness techniques with clients. 2. Participants who were not integrating mindfulness techniques into their sessions identified three barriers: they don’t know how, they are not directive with clients, and they are concerned with the impact of the psychodynamic frame. 3. All participants who defined mindfulness practice had similar definitions that fell into one or more of the following five themes: acceptance, focus, non-judgmental, observe, and present moment. In Phase Two, two groups of participants were interviewed and the data were coded and analyzed. In both the aware sub-group and the unaware sub-group, four different themes were identified. The themes from the aware sub-group include: •

self-practice influences integration;

•

the process of integration;

•

mindfulness therapy techniques; and

•

progression of psychodynamic theories.

The themes from the unaware sub-group include: •

definition of mindfulness;

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•

influences of personal practice;

•

barriers to integration; and

•

impact on the psychodynamic frame.

Although the themes from each group are different, there are some parallels or similarities of themes between the two groups. In the aware sub-group, the theme “selfpractices influences integration” parallels with the theme of “influences of personal practice” from the unaware sub-group. Both groups were influenced by their own personal practices, but the primary difference was that the unaware sub-group thought they needed to learn more about mindfulness and/or hesitated to integrate techniques because of other barriers. In the aware sub-group, the theme “the process of integration” parallels with the theme of “barriers to integration” from the unaware sub-group. Both themes are about integration, but one sub-group is describing how they integrate techniques and the other sub-group is explaining why they don’t integrate techniques. In the aware sub-group, the theme “mindfulness therapy techniques” parallels with the theme of “definition of mindfulness” from the unaware sub-group. In the first sub-group, participants describe the mindfulness techniques they use in session, whereas in the second sub-group, they are not sure how to define what would be considered a mindfulness technique. Finally, in the aware sub-group, the theme “progression of psychodynamic theories” parallels with the theme of “impact on the psychodynamic frame” from the unaware sub-group. Both sub-groups think there is a shift in the psychodynamic theories, but the unaware sub-group is more hesitant about the integration process due to fear of deviating from the frame.

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Despite the themes being different for each sub-group, there were also many similarities. Six findings were identified for the 10 participants as a whole: 1. Mindfulness is not clearly defined and the language, techniques, and practices overlap to include both Eastern and Western beliefs and/or practices. 2. Participants who are integrating mindfulness techniques are also practicing them. 3. Psychodynamic theories have changed over the years and continue to change and evolve. 4. There is an impact on the psychodynamic frame when mindfulness techniques are integrated in session, and mindfulness is beneficial to the psychodynamic community. 5. Integrating mindfulness into therapy sessions will impact the transference and countertransference. 6. Integrating mindfulness techniques is beneficial to clients. The findings for mixed methods are given below. â€˘

Survey responses provided an expanded and informed way to select participants with specific qualities to interview further.

â€˘

Qualitative interviews provided a detailed understanding of the meaning of integration of mindfulness techniques from participants who are using them and a detailed understanding of the barriers or reasons why other participants are not using them. This detailed description further explained the survey results.

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Conclusion This chapter provided a full summary of the results from this mixed methods study. It began with the results from the Phase One sample. These results included the screening criteria, demographics, and the answers to all the survey questions from 31 participants as well as the participants who were selected for the in-depth interviewing. The Phase Two sample included detailed profiles from each of the 10 participants. The results identified unique themes and/or barriers that the interviewed participants experienced. These themes were described in relation to their respective sub-groups, along with how they paralleled each other. Finally, the mixed methods results identified the findings from both the survey and the interviews that will be discussed in the next chapter.

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Chapter 5

Findings, Discussion, and Implications Introduction The purpose of this explanatory sequential mixed method study was to gain a better understanding of the integration of mindfulness techniques into psychodynamic therapy. Phase One was an Internet survey to explore the following research questions: •

What was the prevalence of psychodynamic therapists who used mindfulness therapy techniques in their sessions?

•

What percentage of psychodynamic therapists who integrated mindfulness therapy techniques was aware of it?

From Phase One, a total of 10 participants were selected from two different sub-groups to provide in-depth interviews that further explained the survey answers. Phase Two used a phenomenological research design and was based on the following research questions: •

What was the meaning of integrating mindfulness therapy techniques for psychodynamic therapists? (central qualitative question)

•

How did psychodynamic therapists define mindfulness therapy techniques?

•

Were psychodynamic therapists reluctant to disclose the integration of mindfulness therapy techniques in their practice?

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•

How did psychodynamic therapists describe their decision to integrate mindfulness therapy techniques?

Finally, the mixed methods research tied the whole study together, based on the following questions: •

To what extent and in what ways did the survey responses help to identify psychodynamic therapists who could be interviewed to further an understanding of the integration of mindfulness therapy techniques?

•

To what extent and in what ways did qualitative interviews with psychodynamic therapists serve to contribute to a more comprehensive and nuanced understanding of the integration of mindfulness therapy techniques? As stated in Chapter 1, mindfulness has been considered an umbrella term that

was composed of multiple techniques and/or meanings. Although mindfulness has been historically rooted in Eastern Buddhist psychology, in recent decades it has been integrated into Western psychology. This integration into Western psychology has evolved into different practice models, such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT), as well as different types of self-help books (Crane, 2009; Eifert & Forsyth, 2005; Germer, 2005; Mace, 2008; Siegel, 2010). Research was lacking in the literature related to the integration of mindfulness techniques into psychodynamic therapy, which was why this study was originally conceived. Although this study referenced Eastern Buddhist psychology, the primary focus was on the use of mindfulness therapy techniques in Western psychology and its integration into psychodynamic therapy. This is an important point to remember because the data

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collected were from participants who practiced from both Eastern and Western psychologies. Data were collected from the Internet survey, followed by in-depth interviews. The data were coded, analyzed, and organized by themes, which then resulted in the findings for each phase. The previous chapter began with a presentation of the Phase One results, which contained primarily statistical data analyzed through Survey Monkey. Then the data for Phase Two were organized in a narrative of participant profiles from both the aware and unaware sub-groups, followed by the main themes from each sub-group. Finally, the chapter ended with the findings from Phase One and the overall findings from both sub-groups in Phase Two. This chapter will present and discuss Phase One findings, Phase Two findings, and mixed methods sequential application. Next, there will be a full discussion on the theoretical implications of integrating mindfulness techniques into psychodynamic therapy. Then the original study assumptions will be reexamined and the validity and limitations of the study will be discussed, as well as the implications for clinical social workers. Finally, recommendations for future research will be presented.

Phase One Findings and Discussion The prevalence of psychodynamic therapists who use mindfulness techniques in their sessions is relatively high, but it varies in the frequency of use. Of the 31 participants, 90% state that they use mindfulness techniques in their sessions to some degree. Only 10% of the participants state they do not use mindfulness techniques in

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their sessions at all. However, of that 90%, a total of 55% use mindfulness techniques infrequently, whereas 35% use them frequently. The following two findings further explain the prevalence of mindfulness use for these participants.

Finding #1. Participants who frequently integrate mindfulness techniques into their sessions with clients have a high familiarity with the concepts of mindfulness, but having a high familiarity with the concepts of mindfulness does not directly impact the frequency of using mindfulness techniques with clients. Thirty-five percent of the participants indicate that they integrate mindfulness techniques somewhat frequently, very frequently, or almost always. Of that 35%, a total of 82% of the participants have a great extent of familiarity with mindfulness. Only 6% of the participants have very little familiarity with the concepts of mindfulness. On the other hand, 90% of the participants state that they are aware of integrating mindfulness techniques into their therapy sessions with their clients, whether frequently or infrequently. There are no participants with a higher frequency of integration who indicate they do not have any familiarity with mindfulness concepts. This finding suggests that participants who utilize mindfulness techniques frequently have a greater understanding of what mindfulness is and how to use these techniques. The survey also indicates that the majority of participants (90%) personally practice mindfulness techniques, which likely contributes to their familiarity with mindfulness concepts. The degree to which they personally practice these concepts was not clear on the survey, with only 16% clearly noting that they only practice some or sometimes.

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In trying to understand why participants are not integrating mindfulness techniques with a higher frequency, it was evident that fear of deviating from the frame is not a significant reason. Only 6% of the participants state they have much or a great deal of concern with deviating from the psychodynamic frame. There is minimal research on the effects of mindfulness practices on the therapist (Davis & Hayes, 2011), and nothing was found to indicate if there was a correlation between a therapistâ€™s self-practice and the frequency of integration.

Finding #2. Participants who were not integrating mindfulness techniques into their sessions identify three barriers: they donâ€™t know how, they are not directive with clients, and they are concerned with the impact of the psychodynamic frame. Of the participants who identify barriers, 6% state they do not know how to integrate techniques, 3% state they are not directive enough to use techniques, and only 10% state they have a concern with how integration will impact the psychodynamic frame. The barrier of not knowing how to integrate techniques is consistent with literature that discusses mindfulness integration. One reason therapists do not know how to integrate techniques may be the struggle with how to define mindfulness. Hayes and Wilson (2003) state: The task of developing a more adequate account of mindfulness is made more difficult by several features of the current literature. First, different methods and processes are described with the same term. More troublesome, mindfulness is

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treated sometimes as a technique, sometimes as a more general method or collection of techniques, sometimes as a psychological process that can produce outcomes, and sometimes as an outcome in and of itself. (p.161) Another reason participants might not know how to integrate mindfulness techniques is that they lack training. The barrier regarding a therapist not feeling they are able to be more direct with their clients is likely a personality trait of the therapist and not a barrier of the integration technique. The barrier of concern with deviating from the psychodynamic frame is also found in literature. Although in favor of the integration of psychodynamic therapy with mindfulness techniques, Gold (2014) states that psychodynamic methods traditionally â€œhave not aimed at or been particularly useful in finding or changing the behavioral, experiential, or environmental consequences that inhibit progress in therapy and that maintain the patientâ€™s problemsâ€? (p. 28). There have been a number of studies conducted on the integration of psychodynamic theories and different behavioral techniques, but studies specific to the integration of mindfulness techniques are still lacking (Stewart, 2014). The percentage of psychodynamic therapists who integrate mindfulness techniques and are aware of it was difficult to determine. The majority of the participants indicate that they use various techniques that may be considered mindfulness, but that was not explored further in this survey. The following finding will further explain the difficulty of identifying a percentage of therapists who are unaware of using the techniques through understanding the definition of mindfulness.

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Finding #3. All participants who defined mindfulness practice had similar definitions that fell into one or more of the following five themes: acceptance, focus, non-judgmental, observe, and present moment. The participantsâ€™ definition of mindfulness practice includes five themes: focus, observation, presence, acceptance, and non-judgment. Germer (2005) identifies awareness, present moment, and acceptance as three key interdependent elements of mindfulness techniques. Germer further states that observation would be a component of achieving awareness and focus would be a component of achieving the present moment. When the next question expanded to include the definition of mindfulness techniques, participants added specific techniques that were practiced in order to achieve the five themes. The mindfulness techniques being used in sessions includes meditation, hypnosis, guided imagery, yoga, breath work, body scans, EMDR, cultivating the observing self, and dance therapy. Shapiro and Carlson (2009) note that mindfulness can be both a process and an outcome that â€œinvolves both knowing and shaping the mindâ€? (p. 4). The 10% of participants who state that they do not utilize mindfulness techniques in sessions with their clients indicate that they use techniques such as active listening, mirroring, free association, evenly hovering attention, and empathy. These are all known psychoanalytic techniques. Active listening and mirroring were used by 100% of the participants. Given the struggle with defining mindfulness as suggested above by Hayes and Wilson (2003), there is not a clear understanding of what would be considered a

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mindfulness technique and what would not be considered a mindfulness technique from the survey alone.

Phase Two Findings and Discussion This study sought to understand what the meaning of integrating mindfulness techniques is for psychodynamic therapists. Two different sub-groups were interviewed based on the frequency of integration with their clients and the frequency of referring clients out to learn mindfulness techniques. The aware sub-group has a high frequency of integration with their clients and a high frequency of referring clients out to learn mindfulness. The unaware sub-group has a lower frequency of integration with their clients and a lower frequency of referring their clients out. The participants in the aware sub-group report having a regular self-practice, whereas most of the participants in the unaware sub-group do not. Some participants received their training in Eastern Buddhist psychology and some received their training in Western psychology, regardless of which group they were in. The data presented in the previous chapter identified four different parallel themes between the two groups. The themes from the aware sub-group include: •

self-practices influences integration;

•

the process of integration;

•

mindfulness therapy techniques; and

•

progression of psychodynamic theories.

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The themes from the unaware sub-group include: •

definition of mindfulness;

•

influences of personal practice;

•

barriers to integration; and

•

impact on the psychodynamic frame.

Each participant experienced this meaning a little bit differently within each group, but the experiences from participants in the aware sub-group were generally quite different from the experiences of participants in the unaware sub-group. The following findings are identified from the themes. These findings will provide a more detailed account of how the participants understand the integration of mindfulness techniques with their clients. These findings will also answer the following sub-questions: 1. How do psychodynamic therapists define mindfulness therapy techniques? 2. Are psychodynamic therapists reluctant to disclose the integration of mindfulness therapy techniques in their practice? 3. How do psychodynamic therapists describe their decision to integrate mindfulness therapy techniques?

Finding #1. Mindfulness is not clearly defined and the language, techniques, and practices overlap to include both Eastern and Western beliefs and/or practices. The general consensus in the Western world is that mindfulness is about being in the present moment (Crane, 2009; Davis & Hayes, 2011; Eifert & Forsyth, 2005; Germer,

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2005; Hayes & Wilson, 2003; Kabat-Zinn, 2009; Mace, 2008; Sauer et al., 2011; Shapiro & Carlson, 2009; Siegel, 2010) and includes components such as the following: •

Just observing, trying to create an observing self within themselves to witness their thoughts, their emotions, their body sensations (Aly).

•

Paying attention in the moment to what is occurring without judgment, with a sense of compassion towards the self (Meg).

•

A way of being present, being aware of your body and of yourself in the room, on the earth (Bev).

•

A kind of skill and capacity that helps us to be deeply attuned to the unfolding of moment to moment experience, including a sense of deep connection to one’s body (Meg).

After conducting a practice review, Davis and Hayes (2011) state, “The term ‘mindfulness’ has been used to refer to a psychological state of awareness, a practice that promotes this awareness, a mode of processing information, and a characterological trait” (p. 198). The multiple variations of the word mindfulness continue to promote confusion and a lack of continuity in the therapeutic application of mindfulness. It may be helpful to develop a consistent definition and language for use in Western psychology in order to provide a uniformed understanding and practice. Participants share their understanding of mindfulness in Western psychology: •

I was at the first international mindfulness conference with Kabat-Zinn. It was amazing to see him and hear him talk about his background. I think it was physics at MIT, and he decided to do this research on meditation and mindfulness

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practices, and people thought he was crazy. That was a long time ago, and he’s not crazy. So it became a science, and I think it’s partly because of him and how he put it all together. For him, MBSR is a very clear technique and science, and the people who are studying in the Western world, I think, are doing it in a scientific way. They’re looking at people’s brains and all kinds of things, and I think it does make it more palatable to everyone in our world (Bev). •

This is an exercise of the mind versus this represents a philosophy (Aly).

•

The way it’s been Westernized, it has been taken out of a religious context (Jen).

•

A lot of literature for consumers talks about that. They point out – this came from Buddhism, but we’re using it in the West. Psychology is using this, neuroscience is using this. This doesn’t have to be a philosophy or a religion. This is just a way of exercising your mind and exercising your thinking in a different way than you’re used to doing, learning a thinking technique. They present it in a very Western way (Aly).

•

I think it is pretty non-sectarian in its presentation (Meg).

The current trend in Western psychology, according to Grossman and Van Dam (2011) is “to define and operationalize mindfulness as a relatively stable trait in a manner that takes little account of the development and contextual aspects inherent in the Buddhist formulation” (p. 221). Delineating the differences between Eastern mindfulness practice and Western mindfulness practice may actually lessen the confusion. Germer (2005) uses the term therapeutic mindfulness when mindfulness is used in the therapeutic arena. Defining and operationalizing specific terms when integrating mindfulness into the

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therapeutic setting can allow for a standardized curriculum for training, as well as the development of effective measurement tools. Lin and Seiden (2014) state: The best-known operational definition, “paying attention in a particular way; on purpose, in the present moment, and nonjudgmentally,” was proposed by Jon Kabat-Zinn (1994), who has been largely responsible for popularizing mindfulness for Western psychologists. (p. 2) If one is using this operationalized definition, then it would be more in line with the understanding that one achieves mindfulness through the use or practice of mindfulness techniques. This would suggest that mindfulness techniques are concrete skills that can be measured and practiced. Germer (2005) introduces a continuum of a level of practice in which mindfulness is cultivated. At one end of the continuum is every day mindfulness, whereas one acknowledges mindful moments through disengagement from their daily activities with breathing or awareness. At the other end of the continuum are people who spend considerable amounts of time meditating. These techniques are also referred to as informal and formal practices, which refers to everyday practices and meditation, respectively. This fits well into the continuum of moving from informal practices or techniques to formal practices or techniques. Defining techniques on a continuum provides a form of measurement as one moves from one end to the other. Ava shares her thoughts on how she interprets these concepts, “I think it’s a super useful thing to think about, the explicit versus implicit and explicit meaning the formalized training versus just the way of being.”

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Using the continuum of practice with mindfulness techniques, most of the basic psychodynamic techniques fall under the informal practice end of the continuum. For example, active listening, evenly hovering attention, and empathy are all techniques that therapists are trained in and/or require conscious awareness to implement. Therefore, many therapists are unaware that they are already implementing mindfulness techniques. Aly describes this phenomenon: I think a lot of analysts have been using a lot of these techniques with tracking their clients, with attuning to their clients, with resonating with their clients, keeping their clients in the room, keeping their clients in the moment and maybe we didnâ€™t realize, 'oh thatâ€™s neuroscience, thatâ€™s mindfulness.' But now we are getting more and more labels for that. (Aly) Therefore, defining a continuum of practice of mindfulness techniques provides a language and understanding of the therapeutic integration process. Most participants in the unaware sub-group identify not knowing how to integrate mindfulness techniques into their sessions as one of their barriers. Operationalizing and defining mindfulness in Western psychology for therapeutic mindfulness would eliminate this barrier and allow more therapists to utilize and integrate mindfulness techniques into their sessions.

Finding #2. Participants who are integrating mindfulness techniques are also practicing them. Participants in the aware sub-group have extensive training in meditation and/or mindfulness techniques. They are either practicing regularly or currently practice

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sporadically with having had regular practices in the past. The participants in the unaware sub-group are primarily still learning mindfulness techniques or do not have a regular practice, except for one participant who does meditate daily. The findings indicate that the participants who are integrating mindfulness techniques also have selfpractices. In contrast, participants who are not integrating mindfulness techniques typically do not have self-practices. The participants who do have self-practices from this sub-group identify barriers as to why they are not integrating mindfulness techniques with clients. Ava expresses her belief regarding the outcomes of self-practice: So if Iâ€™ve learned to practice and how to practice myself, then it is part of who I am as a clinician. And so, whether or not Iâ€™m choosing to specifically sit down and have a person meditate, those tenets might be informing how I relate to a person. (Ava) This is consistent with findings from a study carried out at the University of North Carolina that confirms the assumption that the more one practices mindfulness (also called state mindfulness), the more likely it is that this will become a way of being, referred to as trait mindfulness (Malinowski, 2015). This suggests that mindfulness becomes a way of being, which would then naturally be integrated with clients to some degree. Little research has been done regarding client outcomes of therapists who meditate (Davis & Hayes, 2011). However, in one study conducted in Germany, it was found that â€œafter nine weeks of treatment, clients of trainees who meditated displayed greater reductions in overall symptoms, faster rates of change, scored higher on measures

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of well-being, and perceived their treatment to be more effective than clients of nonmeditating trainees" (Davis & Hayes, 2011, p. 203).

Finding #3. Psychodynamic theories have changed over the years and continue to change and evolve. All of the participants acknowledge and recognize the changing of psychodynamic theories over the years. Psychodynamic theory, which is rooted in psychoanalytic theory, began with Freudâ€™s classical theory. Classical theory is not interactional and relies on strict neutrality from the therapist (Frank, 1992). The therapist is supposed to be a blank slate who provides interpretations. This eventually evolved into object relations theory, which shifts the focus from libidinal drive to the internalization of objects, in relation to self and others. Self-psychology began when Kohut recognized that interpretations based in classical theory were not adequate in his clinical work. Selfpsychology is based in the idea that psychological development is dependent on the quality of the relationship with significant others. Kohut identified the function of significant others and developed the term selfobject. This term implies that early developmental relationships provide necessary function for the development of psychological health. This primary importance on others and the quality of their interaction with the developing child is not recognized in classical theory. Relational and other contemporary theories continue to focus on the relationship with the client, and they add an additional dimension to the importance of the relational dynamics throughout development and throughout life. Most of the participants in this study were trained in all

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of the different psychodynamic theories through their degree program or psychoanalytic training; if they had not been trained in all the theories, they learned them at a later date. Ava describes her education at Smith College: They really want us to understand that when we are talking about drive theory, or ego psychology, or object relations, they want us to know how they are distinct from one another. So they have us learn the theories, and write papers from each perspective that really employ the language of the specific theory and it very clearly separates one from another. (Ava)

Finding # 4. There is an impact on the psychodynamic frame when mindfulness techniques are integrated in session, but mindfulness is found to be beneficial to the psychodynamic community. All participants will agree that there is an impact on the psychodynamic frame when integrating mindfulness techniques into a session. Participants from the aware subgroup are consistent that the impact is positive in nature and benefits the psychodynamic community. Although participants from the unaware sub-group also believe that the impact is primarily positive, most have a fear of deviating from psychodynamic frame and therefore were unsure and how to integrate these techniques. Sue wonders, “What would my psychoanalytic supervisors from years ago think about this? You know, like, is this okay? I’m veering out of the Bible, sort of thing.” None of these participants explicitly states that they are reluctant to disclose that they are integrating mindfulness techniques, but some do express how they try to remain loyal to the frame. These

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participants tend to justify ways in which the integration will not be considered a deviation from the frame. For example: •

It does break the frame asking a patient… I don’t feel inside myself that I’m breaking the frame, because I’ve known her for 3 years, it is okay. It feels organic. I feel inside myself that this is right, and somehow I know she’s going to say yes. It has to do with being in the room with a patient and working with the material that is rising up in the room within myself, within the patient, between us and utilizing what occurs in the moment as the material. In some sense, organic, as a kind of mindfulness, means it’s being very present in the moment, very attuned and trying to follow multiple threads that are occurring in each of us and between us. That’s what I mean by organic. (Meg)

•

From an ego psychology perspective, clients using mindfulness would be, perhaps, like an ego supported intervention. So it wouldn’t be deviating from the frame necessarily because it would be the thing that we would be choosing to do, because it would be helpful given their particular psychic structure. But if we were operating out of a relational object relations perspective, a mindful breathing that I’m doing could be co-regulating. In that case it wouldn’t be a deception of the frame, it will just be a part of the relationship and the work that we were doing. (Ava)

This lack of understanding of the integration process into psychodynamic therapy will be further discussed in the theoretical implications section.

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The participants believe that with changes in psychodynamic theories over the years, the integration of mindfulness techniques is a natural fit. Stern (2014) shares: Although my gradual, growing involvement in the world of mindfulness felt natural, I experienced some tension and concerns about how it was being perceived in the local psychoanalytic community, in which I had been deeply involved for more than 30 years. Would I be seen as moving too far from the 'mainstream?' Would my referral base be affected by a shift in reputation? But I live and work in a psychoanalytic community that has become increasingly tolerant. In this community I have encountered broad support, considerable curiosity, and opportunities to teach about the integration of mindfulness in treatment, as well as some expression of skepticism about my utilization of mindfulness in clinical work. (p. 147) These participants assert that mindfulness techniques will enhance the work of psychodynamic therapy, which in turn will benefit the psychoanalytic community. The following examples from participants support this belief: •

Using these mindfulness tools can really enhance psychodynamic work (Aly).

•

The whole purpose, to me, in terms of thinking about psychodynamic work would be that it would expand the whole idea of looking inward (Tom).

•

Mindfulness and meditation have such a long tradition that the aims of those two practices are very much the same as psychotherapy. They just have followed a different prescription for how to get the same place. The way I look at it, I think the two can only enhance each other (Jen).

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Finding #5. Integrating mindfulness into therapy sessions will impact the transference and countertransference. Participants agree that the integration of mindfulness techniques into their sessions with clients does impact the transference and countertransference dynamics. Many believe that when anything new is introduced by the therapist, it changes the course of therapy, therefore impacting the transference. However, this can be either positive or negative, depending on the client. For example, if the therapist integrates a mindfulness technique to help regulate affect, it is often felt that leads to deeper work with the client. Most participants feel their personal awareness leads to positive countertransference outcomes. The following examples include both positive and negative potential impacts on the transference and countertransference dynamics: â€˘

â€˘

I think it feels controlling or patients are compliant or they will go along with it (Sue).

â€˘

I think it can be positive, or negative, depending on timing and the nature --the strength of the relationship and the nature of the transference or countertransference at the time that the exercises are introduced (Meg).

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•

I think that introducing recommendations means that the person can feel like they have to do them in order to please the therapist or that they’re going to do them wrong or they did not do them enough (Jen).

•

It’s an introduction of an expectation that can influence whether or not the client feels like it will influence their experience, and it would also influence mine (Ava).

•

My experience is that almost no matter what you do, people’s transferences are what they are. Unless you do something unbelievable wild, most of the time people are pretty much in the state of the way that they are viewing me (Jan).

Although this study does not explore the impact on transference and countertransference further, research by Frank (1992) asserts that this must be a consideration when introducing new techniques. Frank (1992) states that “determining whether or not to introduce action techniques is a clinically complex matter, and much depends on the status of the transference analysis, which retains centrality (p. 71). In addition, he maintains: Although the therapist reveals him/herself differently in the expanded role associated with action techniques, perhaps revealing more in that sense, it should be noted that such revelations typically are quite limited. The techniques themselves are usually brief and structured, roughly following an established form, and the therapist, basically following a protocol, can introduce formal material without necessarily revealing much information about his/her inner experience. (Frank, 1992, p. 61)

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Frank’s research referred to action techniques from a cognitive behavioral practice, but a formalized mindfulness technique is considered an action technique and therefore this research is applicable.

Finding #6. Integrating mindfulness techniques is beneficial to clients. Participants from the aware group think that mindfulness techniques are beneficial to their clients and these techniques fit well with their psychodynamic practice. The participants from the unaware group also think that mindfulness techniques are beneficial to their clients, but they express barriers to the integration process. Despite participants’ beliefs that teaching mindfulness techniques is beneficial to the therapeutic outcomes of their clients, this was not explored further in this study. Participants shared numerous beliefs as to what these benefits are, but these beliefs were formed from their opinion or feedback that clients had given them. Some of the potential benefits of their clients' experiences as expressed by the participants include: •

To be aware of your thoughts and thought processes and teaching you how to manage them in a different way (Aly).

•

If you can learn to relax your body, you’re going to naturally automatically begin to lessen your experience of anxiety (Aly).

•

It has helped her access different aspects of herself, different forgotten or exiled or hidden traumas, pain, memories (Aly).

•

I found with certain clients who experienced a lot of rumination and a lot of anxiety, that it might be very helpful (Sue).

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•

Opening up more ability for them to talk about things, or to be aware of something (Tom).

•

I think when patients are deeply traumatized, sometimes language is not enough. Mindfulness practice adds a dimension to the treatment that in some way extends, enriches the work. It helps with embodiment (Meg).

•

Particularly with trauma clients, a lot of times they have their memories in bodily form, and just talking doesn’t get to it (Jen).

•

I think mindfulness can be quite helpful for people who have difficulty with affect (Ava).

•

I sometimes asked people to just focus on their breathing, right in the room, if they are very anxious, to try to get back inside their body and to feel more grounded inside their body (Jan).

Participants express that mood/affect regulation is a primary reason to integrate mindfulness techniques in session. Participants utilize mindfulness techniques to help regulate or ground their clients in order to deepen the therapeutic process. The following examples are particular to mood/affect regulation: •

If someone is particularly agitated, I will encourage a pause and some deep breathing (Meg).

•

If somebody is coming for treatments and clearly needs some help with affect regulation, or they need more ego supportives from an ego-psych perspective, I might consider integrating a more formal teaching, like a mindfulness teaching, at

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that juncture, because it would be what they needed in order to move the work further along and to help them develop the capacity to bear the work itself (Ava). Overall, mindfulness techniques can broaden and enhance the treatment process. According to Frank (1993), “A therapeutic process that can directly facilitate alternative forms of adaptive behavior, while advancing insight, at times can empower the therapeutic process” (p. 541). Participants describe different ways mindfulness techniques can be integrated into the session, such as breath work, body scans, meditation, guided imagery and visualization, and progressive relaxation. The following examples provide specific techniques and/or outcomes: •

Mindfulness is helping them to be able to step back and just be a witness to whatever they are experiencing within themselves or around themselves (Jim).

•

They really are gaining the concept of how to be present with themselves and experience both the awareness, the containing, the holding environment of tolerating whatever comes into their consciousness, and learning to work it through and let it go (Jim ).

•

I do a lot of trauma work. If someone has been abused as a child, I might have them go into a very relaxed state. From that relaxed state, I say, “Can you see this little girl who was you? Is she looking at you? What does she look like? What is she wearing? How do you feel? Would do you want to say to her? What is she need from you?” I’ll just use that active imagination to help them connect with, and from their adult self, go back and reconnect with their child (Aly).

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•

The fact of our impermanence as living beings, I think is really important. And I think it’s very connected to the ultimate analytic goal of coming to peace with what is. I think that’s what we help our patients do. There is transformation and growth, of course, but there are also things that do not change in our lives, in our patients’ lives, that they ache when they first come in to change. And I think part of the growth and therapeutic process involves feeling a sense of this mess of life is okay (Meg). Growing amounts of research supports the benefits of mindfulness practices on,

“Mental health symptoms, such as stress, anxiety, some personality disorders, chronic pain, and substance abuse (Sauer et al., 2011, p. 2). Sauer et al. (2011) assert that not only does mindfulness influence the emotional state through a neurological base, but that, “Mindfulness training – according to neuroplasticity paradigm – may actually influence the structural composition of the brain” (p. 2). They believe it is critical to understand that the process of mindfulness is not about lessening the symptoms, but changing one’s relation and/or attitude towards the symptom. Kostner (2014) reinforces this notion in regard to psychological suffering and says, “We learn that we can look at these thoughts and feelings unflinchingly and then unhook from them” (p. 63). This can be particularly beneficial in working with clients who have experienced trauma, as many participants noted, as it can help regulate difficult emotions, step back and observe what they are feeling, and take them to a deeper level within themselves to process the trauma itself.

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Mixed Methods Findings and Discussion Finding #1. Survey responses provided an expanded and informed way to select participants with specific qualities to interview further. Interviewing participants provides a deeper and more informed understanding of the integration of mindfulness techniques into psychodynamic therapy sessions with clients. A survey alone limits the capacity to expand on and understand a participantâ€™s response. Unlike a survey, interviewing allows for a deeper discussion and the ability to explore questions further. Having two distinct sub-groups of participants adds another dimension to this study. It not only enhances the understanding of the integration of mindfulness techniques used by therapists who regularly integrate them into their sessions, but it provides a perspective from therapists who infrequently integrate mindfulness techniques into their sessions. This alternative perspective provides an understanding of unique barriers to this particular sub-group, as well as themes between the two sub-groups. From these themes and/or barriers, a number of findings were discovered, which contributes to a greater understanding for other psychodynamic therapists and the psychodynamic community as a whole.

Finding #2. Qualitative interviews provided a detailed understanding of the meaning of integration of mindfulness techniques from participants who are using them and a detailed understanding of the barriers or reasons why other participants are not using them. This detailed description further explained the survey results.

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The interviews with participants contribute to a more comprehensive understanding through personal accounts and specific examples of how they are integrating mindfulness techniques into their sessions with clients. Participants share their experiences and what this means to them and their psychodynamic theory or orientation. Having both a sub-group of participants who frequently integrate techniques and a sub-group of participants who infrequently integrate techniques identifies barriers as to why more therapists may not be integrating mindfulness techniques in their sessions. The unaware sub-group of participants are clear that they feel these techniques are beneficial to their clients but are not integrating them more because of either not knowing how to define the techniques, not knowing how to do specific techniques, or not knowing how to integrate them into their sessions to align with their theoretical orientation. Interviewing allows for a deeper understanding of the questions that were asked on the survey.

Revisiting Assumptions from Chapter One It is beneficial to revisit the seven assumptions from Chapter One. This study was based on the researcherâ€™s professional experiences and background and the assumptions were presented at the onset. The seven assumptions identified at the beginning of the study are summarized below based on the analysis of this studyâ€™s findings. â€˘

Assumption #1: The therapists integrating mindfulness therapy techniques are also practicing them. This is found to be true and is described under Finding #2.

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•

Assumption #2: Teaching mindfulness therapy techniques to the client will enhance the client’s therapeutic outcomes. This is found to be true and is described under Finding #6.

•

Assumption #3: Therapists who integrate mindfulness therapy techniques into psychodynamic therapy believe it will be beneficial to the psychoanalytic community. This is found to be true and is described under Finding #4.

•

Assumption #4: Some therapists who integrate mindfulness therapy techniques are not aware they are doing so because they have not put a label or language to the techniques. This is found to be true and is described under Finding #1.

•

Assumption #5: Integrating mindfulness therapy techniques into psychodynamic therapy will impact the transference/countertransference dynamics. This is found to be true and is described in Finding #5.

•

Assumption #6: Therapists utilize mindfulness therapy techniques to regulate their client’s mood/affect prior to deepening the treatment. This is found to be true and is described in Finding #6.

•

Assumption #7: Therapists utilize mindfulness therapy techniques to enhance the treatment process. This is found to be true and is described in Finding #6.

Summary of Interpretations of Findings Phase One had the following three findings: 1. Participants who frequently integrate mindfulness techniques into their sessions with clients have a high familiarity with the concepts of mindfulness,

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but having a high familiarity with the concepts of mindfulness does not directly impact the frequency of using mindfulness techniques with clients. 2. Participants who were not integrating mindfulness techniques into their sessions identify three barriers: they donâ€™t know how, they are not directive with clients, or they are concerned with the impact of the psychodynamic frame. 3. All participants who defined mindfulness practice had similar definitions that fell into one or more of the following five themes: acceptance, focus, nonjudgmental, observe, and present moment. Phase Two had six findings, which included the following: 1. Mindfulness is not clearly defined and the language, techniques, and practices overlap to include both Eastern and Western beliefs and/or practices. 2. Participants who are integrating mindfulness techniques are also practicing them. 3. Psychodynamic theories have changed over the years and continue to change and evolve. 4. There is an impact on the psychodynamic frame when mindfulness techniques are integrated in session, but mindfulness is beneficial to the psychodynamic community. 5. Integrating mindfulness into therapy sessions will impact the transference and countertransference. 6. Integrating mindfulness techniques is beneficial to clients.

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The mixed methods findings included the following: â€˘

Survey responses provided an expanded and informed way to select participants with specific qualities to interview further.

â€˘

These findings were discussed fully and the mixed methods findings and discussion integrated the benefits of using both quantitative and qualitative research together to expand the understanding of the phenomenon.

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Chapter 6

Conclusions and Recommendations The purpose of this explanatory sequential mixed methods study was to explore the integration of mindfulness therapy techniques into psychodynamic therapy. The conclusions from this study follow the research questions and the findings and therefore address four areas: 1. Theoretical and clinical implications; 2. implications for clinical social work; 3. social implications; and 4. validity and limitations. The following discussion of the conclusions is gathered from this research and is proceeded by the researcherâ€™s recommendations and a final reflection of this study.

Theoretical and Clinical Implications All of the participants believe the integration of mindfulness techniques into their sessions with clients is beneficial, but some fear what deviating from the psychodynamic frame could mean or are uncertain how to integrate the techniques. Others have little concern of deviating from the psychodynamic frame, as they believe it is a natural and/or complementary to integrate mindfulness techniques. The overall belief of the participants is that integrating mindfulness techniques into sessions enhances the therapeutic process

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for clients, but the psychodynamic theories do not endorse this integration. It would make sense that as things are changing in our world, the acceptance of integrating mindfulness techniques into psychodynamic therapy would continue to grow. Participants share their views of current changes and why integration is necessary in the following examples: •

There’s so much more that we know about neuroscience and the brain, and there is a lot of literature about it and people are reading about it (Sue).

•

There are two actual people in the room, and you can’t fit those two people neatly into either a theory or intervention or anything. So I think you have to have the flexibility. In my opinion, that’s what it really means to be psychodynamic, to be open to being impacted by what the client needs, whatever that is (Jen).

•

Patients, family members, and the culture have taught psychoanalysts that there is more to the world than the old-fashioned psychoanalysis, and so psychoanalysis had to change—feminism, their culture, everything. The whole field has gotten more interpersonal, interactive, engaged, relational, but some of that, I have to say, has to do with feminism and the fact that…I had no women supervisors, I had one woman analytic teacher. Now, women have taken over the field. Women are more talky, interactive, and engaged (Liz).

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I think of bodywork, I think of trauma work, I think of the neuro work, I think of different aspects of affect regulation and other aspects of the field that are not new, but are becoming a focus of things for the community to deal with or to utilize (Tom).

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I tend to think that we’re people who are in conversation with people. I do believe there is an evolution of theory happening where people are beginning to move out of the frames, because frames are constraining and interfere with process, and so I think it’s kind of a radical shift (Bev).

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Hopefully, we are moving toward some form of convergence, where there are many ways of helping a person come to their own awareness, like making conscious the unconscious. It doesn’t need to be just through infantile neurosis and regression, where you must develop this severe neurosis toward your therapist (Jim).

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People who are analytically trained, especially who have gone through Institute training and maybe many years ago, they carry a lot of very strict rules in their heads (Meg).

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Once we become more seasoned clinicians, we’re not going to necessarily be practicing from a strict orientation alone. We’ll be integrating our orientations a bit and we’ll be drawing from different theories as we think about clinical practice (Ava). As described earlier in the literature review, there are four modes of integration

that have been identified. These modes include technical eclecticism, common factors, assimilative integration, and theoretical integration. There have been proposals and discussions of different perspective integration models between psychodynamic theories and various other models or theories (Castonguay, 2011; Frank, 1992; Germer et al., 2005; Gold, 2014; Lin & Seiden, 2014; Stewart, 2014), but there has been minimal

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agreement regarding implementing these integration proposals. Castonguay (2011) states this is because “at various times, the boundaries that separate different knowledgeable communities have been described as impassable, and the views about psychopathology and therapy prevailing within each of them have been perceived as irreconcilable (p. 125). This makes the most sense when referring to a theoretical integration. Stricker and Gold (n.d.) define theoretical integration as “the synthesis of novel models of personality functioning, psychopathology, and psychological change out of the concepts of two or more traditional systems (p. 4). This study is not proposing this type of integration but will address the other three types of integration. Frank (1992) acknowledges that “one observes that psychoanalysis is undergoing a paradigm shift in which the very subject matter of the mind is being reframed from that narrowly defined as intrapsychic to a broader view including the interactional, interpersonal field” (p. 59). Participants in this study acknowledge that a paradigm shift is indeed underway and are in support of it. Specific types of integration were not explicitly addressed in this study, but based on the participants' responses, I will compare them with the appropriate integration mode. The first mode, common factors integration, assumes that all psychotherapies share certain factors that contribute to a client’s therapeutic process, regardless of one’s theoretical orientation and/or practice model (Stricker & Gold, n.d.). Lin and Seiden (2014) see mindfulness as a “trans-theoretical clinical process” that “is seen as a state of psychological freedom that helps the individual to embrace, move toward, and come to terms with his or her distress” (p. 2). They link

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this to research done by Dunn, Callahan, and Swift (2013) and Martin (1997), who have proposed mindfulness as a common factor. Mindfulness as a common factors mode is supported in this study. In creating a clear definition of mindfulness as a therapeutic practice, participants identify basic psychodynamic techniques as a mindfulness practice. These may also be considered common factors, as active listening and empathy are not exclusive to psychodynamic therapy. When a therapist is attuned to a client, the therapist is being mindful, but this is also viewed as a common factor to being an effective therapist. The research correlates that the more therapists practice mindfulness techniques themselves, the more likely that mindfulness will become a trait of who they are. These traits that become a part of who they are, are also in the sessions with their clients, which enhances the therapeutic relationship, another common factor. According to Lin and Seiden (2014), “The advantage of this common factors integration, then, is to increase the number of these curative factors, common and unique, to which the patient systemically may be exposed” (p. 4). The other two modes of psychotherapy integration, technical eclecticism and assimilative, are very similar in structure. Technical eclecticism utilizes techniques and interventions from two or more psychotherapeutic systems, but does not subscribe to a dominant theoretical school (O’Hara & Schofield, 2008; Stricker & Gold, n.d.). In contrast, assimilative integration uses a single theoretical structure while incorporating attitudes, practices, perspectives, and techniques from other schools (Castonguay, 2011; O’Hara & Schofield, 2008; Stricker & Gold, n.d.). Because psychodynamic theories

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have a dominant theoretical school of thought, technical eclecticism would not necessarily be a good choice of integration. Participants in this study are all rooted in psychodynamic theory; therefore, assimilative integration would be the best way to integrate mindfulness techniques while still maintaining a firm psychodynamic perspective. Stricker and Gold (n.d.) propose an assimilative psychodynamic model of psychotherapy integration. This model “relies heavily on contemporary psychodynamic theories of personality structure, psychopathology, and psychological change, while freely using methods and interventions from other therapeutic systems” (p. 5). Findings from this study support this model of integration, utilizing mindfulness techniques in conjunction with the psychodynamic theory. Stricker and Gold’s (n.d.) summary below reinforces the responses of the participants regarding their process of intervention and affirms the need for this type of integration: The assimilative use of active interventions is based primarily on the therapist’s ongoing assessment of the patient’s psychodynamic status. This evaluation includes an emphasis on the tone of the therapeutic relationship and alliance, as well as consideration of the most pressing conflicts, defenses, self and object representations, and emotional states with which the patient is struggling. Active methods are chosen and are suggested with two or more simultaneous and compatible objectives in mind: (1) to promote changes in the person’s current functioning that (2) will impact on central intrapsychic and characterological processes as well. (p. 6)

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There are a growing number of integrationalists in support of integrating psychodynamic work with mindfulness-based psychotherapies, particularly from a relational view (Stewart, 2014). Frank (1992) stated, “Compared to a strict blank-screen view, an interactional model conceptualizes the psychoanalytic situation in a way more compatible with psychotherapy integration” (p. 60). In contrast to earlier psychodynamic theories, contemporary theories are more likely to “describe the mind as a longitudinally developing, open system, wherein psychological conflicts and structures can change or develop in response to interactions with the outside world (Gold, 2014, p. 29). Stricker and Gold (n.d.) attest that there is a growing number of studies being conducted regarding psychodynamic integration, which will be needed to support and implement integration techniques.

Implications for Clinical Social Work This study has great implications for clinical social work. As social workers, we rely on ethical standards of practice to follow and guide our work. This study researches the integration of mindfulness techniques into psychodynamic therapy, which is currently lacking in empirical evidence. Mindfulness-based practices have sufficient research supporting the benefits of using these techniques, but integrating these techniques into psychodynamic therapy has limited research. The findings in this study indicate that integrating mindfulness techniques into psychodynamic therapy may benefit both the clients and the psychodynamic community. This study also identifies barriers to this

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integration, which include the lack of a standard definition of mindfulness in therapeutic practice, and the uncertainty of how to integrate these techniques into the therapy session. The term therapeutic mindfulness, as used by Germer (2005), would include any use of mindfulness in the therapeutic arena. By adapting this concept for Western psychology, it enables researchers to work toward an operational definition, including a continuum of mindfulness practice, which allows for the development of standardized ways to measure the use of these concrete mindfulness techniques and/or practices. Operationalizing and standardizing mindfulness concepts will allow for the development of training curricula and more effective research studies, which then increases the validity of mindfulness techniques in psychodynamic therapy as evidence-based.

Social Implications The social implications for this study are the benefits that will be gained by our clients and our society as a whole. People come to therapy for a multitude of reasons, but they are generally looking to alleviate some form of discomfort in their life that is likely causing impairment with their day-to-day functioning. The more effective the therapy they receive, the more likely they will improve their daily functioning. This improved functioning allows them to better contribute to society. Integrating mindfulness techniques into psychodynamic therapy teaches clients a way to regulate or cope, that they can replicate and practice outside of therapy. These techniques lead to greater insight, acceptance, self-regulation, and a greater capacity to function, as well as the ability to enhance relationships and interpersonal interactions.

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Validity and Limitations In addressing the validity and limitations, I am revisiting the issues of trustworthiness and the limitations as I outlined in the methodology section. The issues of trustworthiness include credibility, dependability, and transferability. Credibility is whether or not the participantsâ€™ perceptions match up with the way I portray them (Bloomberg & Volpe, 2012). Dependability allows one to track the processes and procedures from my study, and transferability is the match between my research context and other contexts as judged by the reader (Bloomberg & Volpe, 2012). Credibility is established in this study through the use of bracketing, triangulation, member checks, and my dissertation committee members. My use of journaling throughout the research process was one way in which I bracketed. Journaling allowed me to track my thinking and reasoning and to track all my research activities while keeping a record of my observations, insights, and experiences. Triangulation was used by collecting different sources of data, which in this study included a quantitative survey and qualitative interviews. I presented all the data, whether positive or negative, as a way to challenge my expectation and findings. Member checks were used, which allowed participants to review my summaries of their information. The majority of the participants provided feedback regarding their individual information, which was then incorporated into the results. Finally, I regularly use the dissertation committee members to review my notes and provide me with feedback regarding my assumptions and/or perceptions.

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I created an audit trail to ensure dependability in this study. This audit trail included the use of a detailed journal that describes my process and procedures regarding data collection and analysis. To decrease bias during the interviews, I did not express my opinion at any time, nor did I share my personal or professional background. Once the interviews were transcribed, I reviewed each transcript for any errors that may have been made during the transcription. I also sent my committee chair transcribed interviews to decrease my bias in the coding process. Transferability is established in this study through the use of in-depth descriptions by the participants. These in-depth descriptions were then interpreted based on a thorough literature review. There were two main limitations I noted in the methodology section. The first limitation is the sample size of the study, which was very small. There were 31 participants in the quantitative survey and there were 10 participants in the in-depth interviews. A larger sample size in the quantitative phase would have allowed for a greater selection of participants in the quantitative phase. A larger sample size in the qualitative phase would have allowed a greater number of in-depth interviews for each of the groups, which may have provided additional findings and/or an even deeper understanding of the process of integrating mindfulness techniques into psychodynamic therapy. The second limitation is my own personal bias. Given my extensive history of mindfulness practices, I worried about influencing the potential outcome of this study. I did minimize my biases through bracketing, and I did not allow my opinions to be a part of the interviews.

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Another limitation was my research sample. The sample was primarily White/Caucasian females with a mean age of 56 years old for both the surveys and the interviews. This study could be expanded to include greater diversity of race, gender and age, which may provide further depth and reveal other potential barriers. The state of residence also limited the sample, as all the participants interviewed were primarily from the East coast, with a couple of participants from the South and Midwest. Interviewing participants from the West and/or expanding the regions could greatly broaden the understanding of how integration may look from a regional standpoint.

Future Research There are numerous areas that this study identifies where future research is needed. The first area is with the definition and concepts of mindfulness. This area needs to be solidified in order to develop and standardize measurement tools to further research the effects of mindfulness techniques. Then, further research can be conducted on the impact of mindfulness techniques on the transference and countertransference within psychodynamic therapy. Another area of research is on the outcomes for clients. This research needs to be done from a client perspective, which may be more difficult to establish. More research is also needed on how a therapist's self-practice influences the therapist's work and client outcomes.

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Researcher Reflections As this study comes to a close, I want to reflect on the process I traveled. I began this journey with a hope of gaining an understanding of how psychodynamic therapists integrate mindfulness techniques into their sessions with clients to begin to expand the discussion on psychotherapy integration. I believe participants provided an understanding of that integration and so much more. Having participants from two distinct sub-groups reinforced the struggles many are having with their own integration process and provided a foundation to expand for future research. My hope is that research in the area of psychodynamic integration will continue to be explored to enhance the therapeutic outcomes for our clients.

Conclusion The purpose of this explanatory sequential mixed methods study was to gain a better understanding of the integration of mindfulness techniques into psychodynamic therapy. This chapter answered all the original research questions from Phase One, Phase Two, and the mixed methods approach. It then fully described the findings and implications of the study for Phase One, Phase Two, and for mixed methods with the primary focus on the use of mindfulness therapy techniques in Western psychology. The assumptions from Chapter One were then revisited, followed by theoretical and clinical implications. Next, the validity and limitations were discussed and the implications for clinical social work and social implications were addressed. Finally, areas of future research were suggested. The study revealed that the integration of mindfulness

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techniques in psychodynamic therapy is beneficial, but further research is needed to fully develop an evidence-based integrative practice.

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Appendix A Copy of Recruiting Email

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Professionals, My name is Barb Jochum and I am a Ph. D. candidate in social work at the Institute of Clinical Social Work in Chicago. I am conducting a research study for my dissertation in which I am interested in learning about experiences using mindfulness techniques in psychodynamic therapy. Are you familiar with mindfulness? Even if you do not use mindfulness in your practice, I am hoping you will take the time to fill out a survey on this topic via Survey Monkey, which will take around 30 minutes for you to complete. To qualify for this study, you should possess formal psychodynamic education, be a fully licensed practicing therapist and have some familiarity with mindfulness. I will provide you with a $10 eGift card from Amazon to compensate you for your time. If you have questions, please contact me directly at 320-980-2145 (cell phone) or bjochum@icsw.edu (email). Click on the following link to proceed to the survey __________________________________. Thank you for your interest.

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Appendix B Informed Consent for Phase 1

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Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research Exploring the Integration of Mindfulness Techniques in Psychodynamic Psychotherapy: Phase 1 I,

, acting for myself agree to take part in

the research entitled: Exploring the Integration of Mindfulness Techniques in Psychodynamic Psychotherapy. This work will be carried out by Barbara Jochum (Principal Researcher) under the supervision of Dr. James Lampe (Dissertation Chair). This work is being conducted under the auspices of the Institute for Clinical Social Work; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232. Purpose The purpose of this study is to address whether mindfulness therapy techniques are being used in psychodynamic therapy by psychodynamic therapists in the United States. There are many psychodynamic therapistsâ€™ that claim they are integrating mindfulness therapy techniques into their practice, but it is unclear as to what this integration looks like. This study seeks to understand how mindfulness therapy techniques are currently being integrated into the psychodynamic therapy sessions, if they are and how this could be beneficial to the psychoanalytic community. Procedures used in the study and duration This is Phase 1 of a two Phase study. In this phase, participants will complete an online survey consisting of around 30 closed and open-ended questions. This survey will include both demographic questions, as well as, questions pertaining directly to gaining an understanding of mindfulness practices of psychodynamic therapists. The time involved

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should not exceed 30-60 minutes. Data will be confidential and will be destroyed after 5 years. I will keep all information on a password-protected document. At the completion of the survey, you will be asked if you would like to participate in Phase 2 of the study, which is an interview about the same topic. If you are ultimately not selected for Phase 2, I will make the information collected during Phase 2 available to you at the completion of the study. Participants will receive a $10 Amazon eGift card for completing the online survey. Benefits There are no known benefits to the participants for participating in this study. Costs There are no known costs to the participants to participate in this study. Possible Risks and/or Side Effects Privacy and confidentiality are risks to any study, including this one. Survey Monkey will be temporarily storing their data until 30 completed surveys have been submitted, at which point all data will be exported into my personal documents. However, the risk is very minimal. There are no other known risks related to your participation in this study. Privacy and Confidentiality The names of the participants will remain anonymous, all transcribed interviews and notes will be locked in a cabinet, and all computer files will be password protected, as well as, the computer being password protected. Data that is collected will not be destroyed until five years after results are published. Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness. I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw. If I have any questions about the research methods or consent form, I can contact Barb Jochum at this phone number: (320) 980-2145 or Dr. James Lampe at this phone number:

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773-665-1380. In addition, I can email Barb Jochum at this email: bjochum@icsw.edu or Dr. James Lampe at this email: jlampe@icsw.edu. If I have any questions about my rights as a research subject, I may contact John Ridings, Chair of Institutional Review Board; ICSW; 401 South State Street; Chicago, IL 60605; (312) 935-4232. Signatures I hereby consent to participate in the above described research project. I am 18 years of age or older. I have received a copy of this consent form for my records. I have all my questions answered. I understand that a copy of the online consent form may be printed prior to clicking the “I agree” button. If I am unable to print a copy of the consent form, I may obtain a copy by contacting Barb Jochum at (320) 980-2145 or by sending an e-mail to bjochum@icsw.edu. I understand that by clicking the “Accept” button, I will be giving my consent to participate in this study. If you consent to be in this study, click "Accept" If you do not consent to be in this study, click "Reject" □

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Reject

Revised 1 Feb 2014

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Appendix C Survey Questions

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Thank you for your interest and willingness to complete my survey! Please follow the prompts as directed and answer all of the questions. This survey should take around 30 minutes to complete. Once you finish it will ask you to provide your email address in order to receive a $10 eGift card from Amazon. Screening Questions 1. I have had ____ years of formal psychodynamic education. (if 2 or more move forward) 2. Where did you study psychodynamic theory and practice? Please explain: __________________________________________________________________ __________________________________________________________________ ______________________________________ 3. Are you a fully licensed therapist? Yes/NO (if yes move forward) 4. What type of license do you hold? (check all that apply) LCPC LCSW LICSW LMFT LMHC LPCC CADC Other: _________________________ 5. I currently have _____ direct client hours weekly (if 10 or more move forward) 6. How familiar are you with mindfulness concepts? A Great Extent (4) Somewhat (3) Very Little (2) Not At All (1) (we will build logic to move potential participant forward or send them a thank you but you donâ€™t qualify for this study message) Demographic Questions 1. What is your gender? Male/Female/Other 2. What is your highest education level? DSW PsyD PhD MA BA Other: ______________ 3. I am ____ years old. 4. What state do you reside in?

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5. Are you of Hispanic or Latino origin? Yes/No 6. What is your race or ethnicity? (please circle one) American Indian or Alaskan Native American or Pacific Islander African American Caucasian Mixed Other Survey Questions 1. How do you define mindfulness practice? If you are not sure, just say so: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________ 2. How do you define mindfulness techniques? If you are not sure, just say so: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________ 3. Do you personally practice mindfulness techniques? Yes/No 4. Do you use mindfulness techniques when treating your clients? Yes/No 5. What is your primary theoretical orientation of your psychodynamic education? Classic Objection relations Self-psychology Relational and other contemporary theories Other 6. Which of the following techniques do you use with your clients? (check all that apply) Evenly hovering attention Active listening Mirroring Meditation Hypnosis Guided imagery Yoga Breath work Body scans Free Association

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Vicarious Introspection Empathy Other(s): __________________________________________________________________ _________________________________________________________________ 7. How frequently do you teach mindfulness techniques to your clients? Almost Never Very Infrequently Somewhat Infrequent Somewhat Frequently Very Frequently Almost Always 8. How frequently do you refer clients to learn mindfulness techniques outside of therapy? Almost Never Very Infrequently Somewhat Infrequent Somewhat Frequently Very Frequently Almost Always 9. When you consider deviating from the psychodynamic frame, how much concern does it cause you? A Great Deal Much Some Little None 10. If you are not currently using mindfulness techniques, please explain why: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ____________________________________ 11. Would you be willing to conduct a follow-up, in-depth online interview, to provide more information to explain their survey responses? Yes/No 12. If yes, please provide your telephone number and a time to contact you 13. If you would like a $10 eGift card from Amazon, please provide you email address:__________________

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Appendix D Script for Brief Screening Interview

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Script for Brief Screening Interview After a potential participant participates in Phase 1 of my study and indicates they want to participate in Phase 2, a brief screening interview will take place for select participants. This will be conducted by phone in order to ascertain their appropriateness for the study. This screening interview is likely to reflect a similar conversation as the following:

“Thank you so very much for completing my survey and volunteering to participate in this next phase of my research! There are a few things I need to confirm before we move forward. I’m looking to better understand the use of mindfulness techniques as they occur in therapy sessions whether the clinician identifies using them with clients or not. I have to confirm you have a license to practice and have had some formal training in psychodynamic education. Would you be willing to be interviewed once for up to 90 minutes via GoToMeeting? Are you okay with being audiotaped and videotaped? Great!” “In an effort to minimize any risk to you for participating, I’d like to ask you about some things Is there anything that you can think of that might deter you from participating or providing me with honest answers? Then our next step is to talk about the consent form for Phase 2. I am going to read through the consent form for phase 2 and then I will send you a link to Survey Monkey where you can “Accept” or “Reject” your consent. Once I go through the transcripts and have a summary of the interpretations, I will email you a copy. Would you be willing to read through it and verify that the information is accurate? Great, let’s set a date and time for the GoToMeeting!”

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Appendix E Informed Consent for Phase 2

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Leave box empty - For office use only

, acting for myself agree to take part in

the research entitled: Exploring the Integration of Mindfulness Techniques in Psychodynamic Psychotherapy. This work will be carried out by Barbara Jochum (Principal Researcher) under the supervision of Dr. James Lampe (Dissertation Chair). This work is being conducted under the auspices of the Institute for Clinical Social Work; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232. Purpose The purpose of this study is to address whether mindfulness therapy techniques are being used in psychodynamic therapy by psychodynamic therapists in the United States. There are many psychodynamic therapistsâ€™ that claim they are integrating mindfulness therapy techniques into their practice, but it is unclear as to what this integration looks like. This study seeks to understand how mindfulness therapy techniques are currently being integrated into the psychodynamic therapy sessions, if they are and how this could be beneficial to the psychoanalytic community. Procedures used in the study and duration This is Phase 2 of a two Phase study. In this phase, participants will complete an in-depth interview. These in-depth interviews will provide a detailed account of how mindfulness therapy techniques are integrated into psychodynamic therapy sessions. The time involved should not exceed 60-90 minutes. The interviews will be conducted via GotoMeeting and will be recorded and transcribed. Data will be confidential and will be destroyed after 5 years. I will keep all information on a password-protected document. I

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will make the information collected during Phase 2 available to you at the completion of the study. Participants will receive a $20 Amazon eGift card for completing the in-depth interview. Benefits There are no known benefits to the participants for participating in this study. Costs There are no known costs to the participants to participate in this study. Possible Risks and/or Side Effects Privacy and confidentiality are risks to any study, including this one. However, the risk is very minimal. The NVivo transcriptionist will have access to all raw data. The video recorded interviews will be imported into NVivo and then through their software they access the data to transcribe the interviews. Once NVivo provides the transcribed documents, they will be saved onto my computer in a password protected file. There are no other known risks related to your participation in this study. Privacy and Confidentiality The names of the participants will remain anonymous, all transcribed interviews and notes will be locked in a cabinet, and all computer files will be password protected, as well as, the computer being password protected. Data that is collected will not be destroyed until five years after results are published. Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness. I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw. If I have any questions about the research methods or consent form, I can contact Barb Jochum at this phone number: 320-980-2145 or Dr. James Lampe at this phone number: 773-665-1380. In addition, I can email Barb Jochum at this email: bjochum@icsw.edu or Dr. James Lampe at this email: jlampe@icsw.edu.

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If I have any questions about my rights as a research subject, I may contact John Ridings, Chair of Institutional Review Board; ICSW; 401 South State Street; Chicago, IL 60605; (312) 935-4232. Signatures I hereby consent to participate in the above described research project. I am 18 years of age or older. I have received a copy of this consent form for my records. I have all my questions answered. I understand that a copy of the online consent form may be printed prior to clicking the “I agree” button. If I am unable to print a copy of the consent form, I may obtain a copy by contacting Barb Jochum at (320) 980-2145 or by sending an e-mail to bjochum@icsw.edu. I understand that by clicking the “Accept” button, I will be giving my consent to participate in this study. If you consent to be in this study, click "Accept" If you do not consent to be in this study, click "Reject" □

□

Reject

Date Revised 1 Feb 2014

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Appendix F Interview Guide 1

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I’d like to thank you again for taking the time to meet with me. Again, my name is Barb Jochum and tonight I’ll be interviewing you for Phase 2 of my study on mindfulness integration. Remember, I am audio and video taping this session. Do you have any questions for me before we begin? For Mindfulness Integration 1. Is there anything you’d like to add to your initial survey responses? 2. Tell me a little bit about yourself and more about your psychodynamic training/theoretical orientation. If Yes to Question 18 on the survey 3. How does your own mindfulness self-practice influence the integration of mindfulness techniques with your clients? If Yes to Question 19 on the survey 4. Can you walk me through the step by step process of how you integrate mindfulness techniques? 5. Can you provide any concrete examples of when and how you’ve integrated mindfulness techniques into your practice? 6. How receptive are your clients to the suggestion or application of mindfulness techniques? Can you provide any specific examples? 7. In what circumstances would you refer a client out to learn mindfulness versus implementing the technique in session? In response to Question 24 on the survey 8. In what way do you think the psychodynamic frame is impacted by integrating mindfulness techniques in session? 9. In what way do you think the transference/countertransference is impacted by integrating mindfulness techniques in session? 10. Do you have any final thoughts or comments?

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Appendix G Interview Guide 2

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I’d like to thank you again for taking the time to meet with me. Again, my name is Barb Jochum and tonight I’ll be interviewing you for Phase 2 of my study on mindfulness integration. Remember, I am audio and video taping this session. Do you have any questions for me before we begin? For Non-Mindfulness Integration 1. Is there anything you’d like to add to your initial survey responses? 2. Tell me a little bit about yourself and more about your psychodynamic training/theoretical orientation. If Yes to Question 18 on survey 3. You stated that you personally use mindfulness self-practice, but use it infrequently with clients. Can you explain this? If No to Question 19 on survey 4. You stated that you do not use mindfulness techniques, but you indicated on number 21 that you use __________________________________ (write in the mindfulness techniques checked by the participant) If these are not mindfulness techniques, then what are they? 5. Some professionals have defined or compared _________________________ (write in the mindfulness techniques checked by the participant) as mindfulness techniques. What are your thoughts on this? 6. When you use ________________________ (write in the mindfulness techniques checked by the participant) with clients, how receptive are they? 7. When you hear of another psychotherapist saying that they integrate mindfulness into their psychodynamic practice, what thoughts come to mind? 8. In what circumstances would you refer a client out to learn mindfulness? 9. In what way do you think the psychodynamic frame could be impacted by integrating mindfulness techniques in session? 10. In what way do you think the transference/countertransference could be impacted by integrating mindfulness techniques in session? 11. Do you have any final thoughts or comments?

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