The Application Of Yoga To Counselor Training

TEACHING SELF-CARE THROUGH MINDFULNESS PRACTICES: THE APPLICATION OF YOGA, MEDITATION, AND QIGONG TO COUNSELOR TRAINING

JOHN CHAMBERS CHRISTOPHER is a professor of counseling psychology in the Department of Health & Human Development at Montana State University and a senior staff psychologist at MSU’s Counseling Center. He is the recipient of the 2003 Sigmund Koch Early Career Award by the Society of Theoretical and Philosophical Psychology of the American Psychological Association. He specializes in cultural psychology and theoretical and philosophical psychology. He has written on the cultural, moral, and ontological underpinnings of theories of psychological well-being, moral development, and psychotherapy. He also maintains a private psychotherapy and consultation practice, Habits of the Heart.

SUZANNE E. CHRISTOPHER is an associate professor of community health in the Department of Health and Human Development at Montana State University. She received her doctorate in the Department of Health Behavior and Health Education from the University of North Carolina School of Public Health. Her primary work is conducting community-based participatory research, and she is currently funded by the American Cancer Society for a multiyear women’s health project with the Apsáalooke (Crow) nation.

TIM DUNNAGAN is an associate professor within the Department of Health and Human Development at Montana State University. During AUTHORS’ NOTE: Correspondence concerning this article should be addressed to John Christopher, Montana State University, 221 Herrick Hall, Bozeman, MT 59717; e-mail: [email protected]. Journal of Humanistic Psychology, Vol. 46 No. 4, October 2006 494-509 DOI: 10.1177/0022167806290215 © 2006 Sage Publications

494

John Chambers Christopher et al.

495

the past 18 years, he has been involved in a variety of health interventions within worksites and communities as a practitioner, director, and evaluator/researcher on topics such as welfare reform, fetal alcohol syndrome, obesity, fall prevention, diabetes prevention, employee job satisfaction, college student health enhancement, health care costs containment, underaged drinking, and impaired driving. During the past 12 years, he has focused his efforts in the areas of worksite- and community-based health theory and program intervention development, implementation, and evaluation.

MARC SCHURE is a public health promotion specialist at the Gallatin City–County Health Department in Bozeman, Montana. He recently received a master’s degree in health education and promotion from Montana State University, where he worked on a multistate research and education project promoting healthy eating, physical activity, and positive body image. He also holds a bachelor’s in cultural anthropology and a master’s in continuing and adult education from the University of Wisconsin–Madison. Currently, he is working on local and state public health promotion issues and systems improvement.

Summary Faculty in counseling training programs often give voice to the importance of self-care for students during the training period and into practice after training is completed. However, few programs specifically address this issue in their curricula. To address this perceived need, a course was developed to provide students with (a) personal growth opportunities through selfcare practices and (b) professional growth through mindfulness practices in counseling that can help prevent burnout. A focus group assessed course impact on students who reported significant changes in their personal lives, stress levels, and clinical training. Keywords:

mindfulness-based stress reduction; MBSR; self-care; meditation; yoga; qigong, stress prevention and control; therapist training

The notion of burnout is broadly applied within American society but was originally coined to refer to the physical and emotional exhaustion that can occur for human service providers. Consequences of burnout are serious for individuals experiencing burnout, their

496

Teaching Mindfulness Practices

coworkers, and their clients (Jackson & Maslach, 1982; Jackson, Schwab, & Schuler, 1986). Workers in the health care sector are particularly vulnerable to stress overload and burnout (Harris, 2001; Moore & Cooper, 1996; Sharkey & Sharples, 2003; Wall et al., 1997). According to Moore and Cooper (1996) mental health professionals, in particular, are subject to severe levels of stress because of working in an emotionally exhaustive environment. Consequently, learning to deal with stress and burnout is a critical dimension of professional development. Self-care practices are self-initiated behaviors that promote good health and well-being (Bickley, 1998). Although mainstream, accredited counseling training programs often emphasize the need for self-care strategies to prevent burnout, the demands of the curricula and clinical training often leave little room for directly teaching these strategies. Self-care is typically presented to the student as an individual responsibility and is not taught directly through the curricula. We believe that the quality of training programs is compromised if the rhetoric of practitioner growth, development, and self-care is not matched by specific means for trainees to learn and practice methods of self-care. Learning self-care techniques can assist counseling students in the long term and can affect their educational and training experiences (Baker, 2003; Weiss, 2004). More so than in other disciplines, counseling students experience moments of strong personal emotions that accompany “human suffering and mortality” (Rosenzweig, Reibel, Greeson, Brainard, & Hojat, 2003). Students preparing to go into counseling have additional demands compared to most graduate students as they face the stress and challenge of self-development for clinical work. These demands and stressors may have harmful effects on students’ effectiveness and success by reducing their capacity for attention, concentration, and decision making, all critical skills to becoming an effective counselor (Shapiro, Shapiro, & Schwartz, 2000). A perceived need in counselor training led the first author to develop a graduate course entitled Mind/Body Medicine and the Art of Self-Care. The goals of the course were to familiarize students in an accredited counseling program with mindfulness practices and their relevance for counseling and to provide students with methods for self-care and the prevention of burnout. The underlying philosophy behind the course is that of Buddhist mindfulness as interpreted through the Mindfulness-Based Stress Reduction

John Chambers Christopher et al.

497

(MBSR) Program developed by Jon Kabat-Zinn (1990) and implemented at the University of Massachusetts Medical Center in 1979. Mindfulness is based on cultivating awareness “with the aim of helping people live each moment of their lives—even the painful ones—as fully as possible” (Kabat-Zinn, 1993, p. 260). Although mindfulness is an ancient concept that has a rich textual background (e.g., Bhiku Soma, 1949; Buddhaghosa, 1976; Goleman, 1977; Govinda, 1969; Gunaratana, 1992), MBSR attempts to communicate the essence of contemplative practice in a nonsectarian, generic form that can appeal to a broader American audience not inclined toward Eastern religious-philosophical traditions. Although mindfulness can often lead to states of relaxation, the ultimate goal of mindfulness differs from relaxation training. The intent of relaxation exercises is to replace a less desirable mental and physical state such as stress, anxiety, fear, or pain with a more desirable state such as calm, peace, or relaxation. In mindfulness practices, the goal is instead to be present to whatever our experience is at the moment. As Kabat-Zinn (1993) puts it, “Acknowledging present-moment reality as it actually is, whether it is pleasant or unpleasant, is the first step towards transforming that reality and your relationship to it” (p. 261). The extensively researched MBSR program has been used with more than 10,000 medical patients and has been found to be beneficial for a variety of medical conditions including chronic pain, heart disease, gastrointestinal disorders, anxiety, depression, and extreme skin conditions (Kabat-Zinn, 1982; Kabat-Zinn & Chapman-Waldrop, 1988; Kabat-Zinn et al., 1992, 1998; Kabat-Zinn, Lipworth, & Burney, 1985). Mindfulness practice has the potential to transform counseling trainees in a number of ways including becoming less reactive to stress-related or anxiety-provoking events such as when clients are in crisis or are discussing painful emotions. Counseling students can also conceivably gain new ways of relating to their emotional life that include awareness and tolerance. Instead of responding with defensiveness and reactivity, contemplative and mindfulness disciplines can assist counselors to become more present and connect more intimately with themselves, their clients, and their supervisors (Epstein, 1995; Lesh, 1970; Magid, 2002; Rubin, 1996; Safran, 2003). Unlike some researched mind/body practices, such as Benson’s generic form of meditation known as the Relaxation Response,

498

Teaching Mindfulness Practices

Kabat-Zinn’s 8-week MBSR program was based on a variety of different practices. Research bears out the importance of providing people with multiple practices. For instance, Kabat-Zinn, Chapman, and Salmon (1997) found that individuals who experience anxiety somatically (e.g., physical symptoms such as gastrointestinal distress) prefer meditation, whereas those who experience anxiety cognitively (e.g., racing thoughts) prefer yoga. Therefore, different practices are available in MBSR to best meet the physical, affective, and cognitive needs of the individual.

RESEARCH ON MINDFULNESS PRACTICES IN TEACHING Given that counseling programs focus on personal growth and development, we were surprised to find no published studies that looked at the application of mindfulness practice to counseling curricula or students. Studies, however, have been conducted that evaluate MBSR as a tool for helping undergraduate college students and nursing and medical students cope with stress. Results from a controlled study of undergraduate students showed that MBSR participants had statistically significant decreases in levels of depression and anxiety and had a greater sense of control and adaptability skills (Astin, 1997). Shapiro, Schwartz, and Bonner (1998) examined the impact of an 8-week MBSR program on medical and premedical students and found similar reductions in state and trait anxiety and overall psychological distress, including depression. They also found an increase in scores on a measure of spiritual experiences and an increase in scores on an empathy measure. Another controlled study of medical students found a significant decrease in total mood disturbance among participants as compared to the control group (Rosenzweig et al., 2003). Using quantitative and qualitative methods, Bruce, Young, Turner, Vander Wal, and Linden (2002) found that an 8-week MBSR program for nursing students decreased psychological symptoms and, to a lesser degree, physical symptoms and increased health-related quality of life and sense of coherence. The nursing students also reported enhanced awareness of their physical, emotional, and mental responses to stress, new abilities to let go of stress, and decreased feelings of being rushed, confused, and disoriented.

John Chambers Christopher et al.

499

DESCRIPTION OF THE COURSE Unlike the above studies, the course we developed and describe in this article is not a supplemental 8-week program but a semesterlong elective course integrated into the curriculum that not only teaches techniques for stress reduction but also directly addresses the issue of how mindfulness practice and transformation can be integrated into the students’ clinical work. The two primary goals of personal and professional growth were operationalized through six course objectives: (a) to provide students with techniques and skills for self-care, (b) to foster students’ understanding of indigenous traditions of contemplative practice from both Eastern and Western cultures, (c) to foster students’ awareness of mind/body medicine and contemporary attempts to adapt contemplative practice to health care, (d) to foster students’ awareness of mind/body research regarding the effectiveness of contemplative practice in behavioral medicine, (e) to begin to foster students’ awareness of ethical considerations in the application of mind/body medicine, and (f) to foster students’ awareness of the impact of culture and cultural understandings of well-being on the counseling process. Consequently, the course is interdisciplinary in nature, drawing on source materials from religious studies, psychological and medical anthropology, behavioral medicine, cross-cultural psychology, and psychiatry. The course entails both academic and experiential learning. The experiential component of the class was loosely based on Kabat-Zinn’s (1990) MBSR program. During the first 75 minutes of a 2 hour and 15 minute class taught twice a week, students were taught and practiced hatha yoga, meditation, and the body scan (a type of conscious relaxation exercise that stresses the goal of awareness instead of relaxation). In addition, the students were taught qigong, an ancient Chinese practice for cultivating health. Students chose a practice, such as meditation, yoga, qigong, or tai chi, and engaged in practice sessions for a minimum of 45 minutes a day, 4 days of the week, outside of class. Students were paired up and met once a week to process their practice activity during the semester. The academic aspect of the course included an introduction to readings about the mindfulness practices (including authors indigenous to the specific traditions and contemporary Western interpreters), recent applications to psychotherapy and behavioral medicine, and current research. Students presented four 15-minute

500

Teaching Mindfulness Practices

overviews of self-selected empirical research on aspects of mind/ body medicine (e.g., contemplative practice, meditation, yoga, the relaxation response, tai chi chaun). Twice during the semester each student was responsible for cofacilitating the discussion of the readings for that day. A major component of the course was an intellectual and experiential journal, providing students with the opportunity to process and discuss both their reaction to the ideas and concepts in the readings and discussions and also their reactions to the contemplative practices. Journal writing had to total a minimum of 60 typed pages during the semester.

PARTICIPANTS Participants in this study were first and second year master’slevel graduate students in mental health counseling, school counseling, and marriage and family counseling enrolled in an elective graduate course entitled Mind/Body Medicine and the Art of SelfCare. Focus group data were collected from 11 participants. The age of the participants ranged from the early 20s to mid-50s. Eight participants were female and three were male.

METHOD To assess the impact of this course, one of the coauthors who is not the course instructor conducted a focus group near the end of the semester. Focus group research is a qualitative data-gathering method that allows researchers to gain a variety of perspectives (Patton, 2002) and has been shown to be a useful tool in gathering evaluative data from students (Christopher, 2000). Focus groups allow participants to hear each others’ comments and either disagree or build on what has previously been said. As Morgan (1988) aptly describes, “The hallmark of focus groups is the explicit use of the group interaction to produce data and insights that would be less accessible without the interaction found in a group” (p. 12). The interactive framework allows participants to use each other’s thoughts to generate new ideas and insights and the group moderator can probe for clarification and depth. In addition, these groups give students the opportunity to have an open forum for discussion and give them a sense of having an impact on their education. Focus groups allow researchers to

John Chambers Christopher et al.

501

gather data on multiple individuals at one time, in a relatively quick and inexpensive manner. A moderator’s guide was developed by the moderator largely based on the descriptions provided through a six-volume focus group instructional series (Morgan & Krueger, 1998). The guide listed the purpose of the focus group, probing ideas, group control and facilitation techniques, and questions for discussion. For this project, ground rules were developed by the students after the moderator asked, “What rules would you like to have in place so that we can have a productive discussion?” Ground rules such as listening to others’ opinions and ideas, being open to the fact that there are no right or wrong answers, and agreeing to keeping the discussion confidential were examples of the students’ ground rules. These rules are similar to the suggested ground rules presented by researchers who engage in focus group research (Morgan, 1998; Templeton, 1994). The questions were open ended and included, “Why did you take this course?” “What is the first thing that comes to mind when you consider the course?” “What do you like most about the class?” “What do you like least about the class?” “Discuss the strengths and weaknesses associated with the class organization.” “Would you like to make any other comments?”

ANALYSIS The focus group was tape-recorded, and field notes were taken during and immediately after the session was completed. The tape was transcribed verbatim by a trained graduate assistant. Inductive content analysis was used to identify the primary themes in the data (Patton, 2002; Strauss & Corbin, 1990). The researchers used the transcribed sentences as the unit of analysis. The level of analysis was across cases that allowed the thematic grouping of the responses to be similar for all the students. All authors read the transcript and developed and discussed themes until agreement on all themes was reached. After completing the analysis, the researchers cowrote the results section.

RESULTS It was evident that students found the class to be of highquality and a valuable experience that helped them to grow

502

Teaching Mindfulness Practices

personally and professionally. Suggestions were made about how the course could be improved; however, none of the themes demonstrated any problems of substance associated with the class. Results are presented by question asked. Why Did You Take This Course? Students responded that they wanted to learn more about the mind-body connection, that they wanted to learn how to manage their stress, and that they wanted to learn how to use relaxation techniques with clients. Students mentioned that they had heard about mind-body practices or that they had tried some practices (e.g., yoga) but wanted a more in-depth experience. Several students mentioned that they took the class for themselves because they had heard that they would practice self-care techniques in the class. One student stated that he initially took the course because he thought it would be easy and was surprised that he experienced significant growth through his efforts: I was hoping it would be something to breeze by and the reality is it was probably my most difficult course and not so on a requirement level but I think on an internal level, because as I learned to have to slow down and pay attention to my body and through meditation and awareness, all of this stuff came to my consciousness that maybe through busyness and activity and attending to others that I wasn’t intending to. It forced me to kind of take a deep breath, an internal look at some things that I might have avoided.

He laughed and said, “It kind of backfired on me.” What is the First Thing That Comes to Mind When You Consider the Course? The students described different types of changes that they experienced as a result of taking the course. Specifically, physical, emotional, mental, and spiritual changes were mentioned. They indicated that it was refreshing to have a class that was taught in a nontraditional format. Students also described being more patient, aware, conscious, and able to focus. One student described what she meant by being able to focus: Well, just basically what I was saying about being able to recenter myself and just taking a couple minutes to do that. Focusing on

John Chambers Christopher et al.

503

things that, you know, are in the present, and not necessarily stressing out about things that are in the future or things that have already happened, um, just focusing on what’s real instead of letting the stress overwhelm me.

The students talked about significant changes that they experienced as a result of the class, leading the moderator to probe further into that area. Several students gave direct examples of how this class facilitated personal changes and how these changes influenced their therapy with clients. I feel like . . . really being able to be present with myself . . . truly present with myself and then being able to take that into the therapeutic environment where I can really be with the client. You know, I really don’t know how to put words around it, but I do think there’s some spiritual component to the therapeutic process, and I’m not going to attempt to try to tell you about my understanding of it, but I do think that that component of presence allows that to be possible.

Another student noted: I really became aware of how disconnected I can be from myself, especially, all of these extrinsic motivations, until I’m here and I start breathing, um, I suddenly realize the difference, and the difference being that I’m in this completely defensive, like get out of my way type of mode, I’m closed up. I’m not greeting the world at all, I’m more looking at, I’m like, are you in my way, and I get around them and hurry to class. I still do that, I still catch myself doing that, but after practice, um, I can greet the whole world a lot more openly than to see it as an obstacle and to bring that with my clients is amazing.

What Do You Like Most About the Class? There were several comments about the instructor. Students enjoyed his manner, the fact that he was emotionally present and available, that he walks the talk, and that he was willing to deviate from the syllabus to teach areas the students were interested in learning about. One student commented, I really value, he really walks his talk and that’s, when I think about the people that have really influenced me over my life, it’s those people, you know, that, because, you pick that up and carry it with you.

The students also brought up that they enjoyed the readings.

504

Teaching Mindfulness Practices

What Did You Like Least About the Class? Students differed on their preference for the number of practices that should be reviewed during the semester. Some students would have preferred trying out more types of practices, whereas others liked learning fewer practices in more depth and detail. Another area where students had differing opinions was in the journal writing assignment. As mentioned above, students were required to journal 60 typed pages during the semester about reactions to course readings and about their personal practice. Some students did not like journal writing, most did not like having a certain number of pages that they had to write, and some did not like having to type their journals on the computer. Others disagreed on these topics, receiving a lot of benefit from journaling. One of the students who had trouble with the journal assignment stated: I felt that what I was writing was very real and I got really angry and resentful and actually I almost went to go and talk to [the instructor] and say this is real stuff and so what’s important, do you want quality or do you want quantity? Because these are my real experiences and I can’t put it into, maybe this isn’t going to take four pages, but I will certainly write what I experience and maybe it takes two.

The students also had differing opinions about having to give presentations on four scientific articles during the semester. Some thought it was too many presentations, some did not like that they had to be scientifically based, and some had trouble finding research-based articles on topics covered in this course. Others disagreed. One student explained the potential future benefit of this part of class: I think that if we are looking to integrate this into the practice with the public, it will be met with skepticism, and given that this is an academic course, first of all, I think it has an important place in this course. But furthermore, in convincing perhaps the clinic that we work for, that hey, I want to bring this mindfulness meditation to working with people with depression, you’re going to need to back it up besides just kind of the hippy-dippy ‘cause it feels good type of mentality. So to actually have that empirical approach and say, look at these articles, this is what’s it’s proven to be, why are we not trying this? I think that’s, that’s a lot [of] money in the bank.

John Chambers Christopher et al.

505

Discuss the Strengths and Weaknesses Associated With the Class Organization Students responded that the course was not tightly organized. This was good for some and not good for others. For one student, this structure impeded the student’s ability to feel properly prepared for class. For others, the structure seemed to fit into the course objectives and seemed well matched with the goal of staying present. One student commented, “I think it kind of extended the practice of being present in the moment and by not cutting things off, if there was a good conversation, there was depth there, we stuck with it.” Would You Like to Make Any Other Comments? Lastly, students were given the opportunity to provide any other feedback or comments. The first comment was based on the fact that this class might not be taught every year. Students thought that would be “a big error.” There was considerable agreement concerning this topic. There was also much agreement with the idea of making this course, which is an elective, a requirement for all of the counseling students. One student summed up her feelings: In a lot of ways, I feel like this was the most important class I’ve taken, just learning to be present in a different way. It has huge implications in the counseling area. I’ve taken a lot of different yoga classes in the past and you focusing on the poses and I’ve never been given a base of how to breathe. And I’ve noticed that when I’m in session and it’s a new thing and it’s kind of nerve wracking, I have this new control over my body where I can like, take a breath, and it’s a different kind of breath than I’ve ever knew how to take, and feel like, oh, I feel calmer now, and I feel centered, and in control of my body and I can be present to this person instead of being anxious inside. It’s just huge.

DISCUSSION Students reported that Mind-Body Medicine and the Art of Self-Care was a high-quality, rigorous, relevant course that had a significant impact on their personal and professional lives. Students overwhelmingly gave praise for this course and the instructor. They indicated that they took this course to learn about the

506

Teaching Mindfulness Practices

mind-body connection, self-care techniques, and ways of applying these techniques with clients. The reasons given by students closely match the curricular goals of the course. We found that student feedback reflected the intended benefits of the course. Students expressed that the course positively influenced them in a variety of personal and professional ways. A number of students indicated having a greater awareness or consciousness of themselves and/or their clients as a result of the course. Students also expressed an ability to focus more and stay more in the present than before taking the class. Such acquired abilities are desired effects of MBSR programs (Kabat-Zinn, 1990). Many students also reported feeling better equipped, both emotionally and mentally, to deal with daily stress in their lives. These positive impacts support similar results from related studies with university students (Astin, 1997; Bruce et al., 2002; Shapiro et al., 1998). Students also talked about significant changes experienced as a result of taking the class, particularly around working with clients. Concepts covered in this course and contemplative experience through course practices changed how students conceptualize and pursue the therapeutic process. The fact that students have had such experiences within the context of a university course confers relevance for the role of these practices in counseling curricula and other higher education based endeavors (Tisdell, 2003). Our findings most strongly support the value of these types of courses on students training to be caregivers (i.e., therapists and other health professionals). In most university courses, it is uncommon to hear students talk about significant and substantial changes within and across a variety of life domains because of taking a course. It is also worth mentioning that students valued this course enough to commit to four additional sessions of practice each week outside of class time. Taking this course resulted in positive outcomes with personal functioning and also influenced students’ capacities and abilities within clinical environments. The perceived weaknesses of the course were not consistent across students and were primarily related to preferences in teaching style and course assignments such as journal writing and presentations. Such variability in student preferences within the classroom setting can be associated with preferred learning styles and degrees of comfort in performing certain tasks or assignments. Yet given the fact that students needed to regularly

John Chambers Christopher et al.

507

schedule extra time outside class for practice, perhaps such negative reactions were more indicative of feeling generally overloaded. Additional research could elucidate the deeper meaning of these reactions. Given the summary of this course’s evaluation and results from related studies, we feel that college programs would benefit from incorporating similarly structured courses into counseling curricula. The first author is willing to share the course syllabus with interested parties.

REFERENCES Astin, J. A. (1997). Stress reduction through mindfulness meditation. Effects on psychological symptomatology, sense of control, and spiritual experiences. Psychotherapy and Psychosomatics, 66, 97-106. Baker, E. K. (2003). Caring for ourselves: A therapist’s guide to personal and professional well-being. Washington, DC: American Psychological Association. Bhiku, S. (1949). The way of mindfulness. Colombo, Ceylon: Vajirma. Bickley, J. (1998). Care for the caregiver: The art of self-care. Seminars in Perioperative Nursing, 7, 114-121. Bruce, A., Young, L., Turner, L., Vander Wal, R., & Linden, W. (2002). Meditation-based stress reduction: Holistic practice in nursing education. In L. Young & E. Virginia (Eds.), Transforming health promotion practice: Concepts, issues, and applications (pp. 241-252). Victoria, Canada: F. A. Davis. Buddhaghosa, A. (1976). The path of purification: Visuddhimagga. Berkeley, CA: Shambhala. Christopher, S. E. (2000). Student-based focus groups: One component in course evaluation. Journal of Staff, Program, & Organization Development, 17, 7-16. Epstein, M. (1995). Thoughts without a thinker. New York: Basic. Goleman, D. (1977). The varieties of the meditative experience. New York: E. P. Dutton. Govinda, L. A. (1969). The psychological attitude of early Buddhist philosophy. New York: Samuel Weiser. Gunaratana, H. (1992). Mindfulness in plain English. Boston: Wisdom. Harris, N. (2001). Management of work-related stress in nursing. Nursing Standard, 16, 47-52. Jackson, S., & Maslach, C. (1982). After-effects of job related stress: Families as victims. Journal of Occupational Behavior, 3, 63-77. Jackson, S., Schwab, R., & Schuler, R. (1986). Toward an understanding of the burnout phenomenon. Journal of Applied Psychology, 71, 630-640. Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation:

508

Teaching Mindfulness Practices

Theoretical considerations and preliminary results. General Hospital Psychiatry, 4(1), 33-47. Kabat-Zinn, J. (1990). Full catastrophe living. New York: Delta. Kabat-Zinn, J. (1993). Mindfulness meditation: Health benefits of an ancient Buddhist practice. In D. Goleman & J. Gurin (Eds.), Mind/body medicine (pp. 259-276). New York: Consumer Reports Books. Kabat-Zinn, J., Chapman, A., & Salmon, S. E. (1997). Relationship of cognitive and somatic components of anxiety to patient preference for different relaxation techniques. Mind/Body Medicine, 2, 101-109. Kabat-Zinn, J., & Chapman-Waldrop, A. (1988). Compliance with an outpatient stress reduction program: Rates and predictors of program completion. Journal of Behavioral Medicine, 11, 333-352. Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8, 163-190. Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., et al. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936-943. Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, M. J., Cropley, T. G., et al. (1998). Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosomatic Medicine, 60, 625-632. Lesh, T. V. (1970). Zen meditation and the development of empathy in counselors. Journal of Humanistic Psychology, 10, 39-74. Magid, B. (2002). Ordinary mind: Exploring the common ground of Zen and psychotherapy. Somerville, MA: Wisdom. Moore, K., & Cooper, C. (1996). Stress in mental health professionals: A theoretical overview. International Journal of Social Psychiatry, 42, 82-89. Morgan, D. L. (1988). Focus groups as qualitative research. Beverly Hills, CA: Sage. Morgan, D. L. (1998). Planning focus groups. In Focus group kit (Vol. 2). Thousand Oaks, CA: Sage. Morgan, D. L., & Krueger, R. A. (1998). The focus group kit (6 vols.). Thousand Oaks, CA: Sage. Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Rosenzweig, S., Reibel, D. K., Greeson, J. M., Brainard, G. C., & Hojat, M. (2003). Mindfulness-based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine, 15, 88-92. Rubin, J. B. (1996). Psychotherapy and Buddhism: Toward an integration. New York: Plenum. Safran, J. D. (Ed.). (2003). Psychoanalysis and Buddhism: An unfolding dialogue. Sommerville, MA: Wisdom. Shapiro, S., Schwartz, G., & Bonner, G. (1998). Effects of mindfulnessbased stress reduction on medical and premedical students. Journal of Behavioral Medicine, 21, 581-599.

John Chambers Christopher et al.

509

Shapiro, S., Shapiro, D., & Schwartz, G. (2000). Stress management in medical education: A review of the literature. Academic Medicine, 75, 748-759. Sharkey, S., & Sharples, A. (2003). The impact of work-related stress of mental health teams following team-based learning on clinical risk management. Journal of Psychiatric and Mental Health Nursing, 10, 73-81. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage. Templeton, J. F. (1994). The focus group: A strategic guide to organizing, conducing and analyzing the focus group interview. Chicago: IrwinProfessional. Tisdell, E. J. (2003). Exploring spirituality and culture in adult and higher education. San Francisco: Jossey-Bass. Wall, T., Bolden, R., Borrill, C., Carter, A., Golya, D., Hardy, G., et al. (1997). Minor psychiatric disorder in NHS trust staff: Occupational and gender differences. British Journal of Psychiatry, 171, 519-523. Weiss, L. (2004). Therapist’s guide to self-care. New York: BrunnerRoutledge.