23 Journal of Religion and Health ISSN 0022-4197 J Relig Health DOI 10.1007/s10943-013-9679-0 Meditation Awareness Training (MAT) for Improved Psychological Well-being: A Qualitative Examination of Participant Experiences Edo Shonin, William Van Gordon & Mark D. Griffiths 1 23 Your article is protected by copyright and all rights are held exclusively by Springer Science +Business Media New York. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your work, please use the accepted author's version for posting to your own website or your institution's repository. You may further deposit the accepted author's version on a funder's repository at a funder's request, provided it is not made publicly available until 12 months after publication. ORI GIN AL PA PER Meditation Awareness Training (MAT) for Improved Psychological Well-being: A Qualitative Examination of Participant Experiences Edo Shonin • William Van Gordon • Mark D. Griffiths  Springer Science+Business Media New York 2013 Abstract Mindfulness-based interventions are reported as being efficacious treatments for a variety of psychological and somatic conditions. However, concerns have arisen relating to how mindfulness is operationalized in mindfulness-based interventions and whether its 'spiritual essence' and full potential treatment efficacy have remained intact. This qualitative study used interpretative phenomenological analysis to examine participant experiences regarding the acceptability and effectiveness of a newly designed secularized intervention called meditation awareness training (MAT) that follows a more traditional Buddhist approach to meditation. Participants (with issues of stress and low mood) reported experiencing improvements in psychological well-being due to receiving MAT. The wider implications are discussed. Keywords Meditation  Mindfulness  Meditation awareness training  Psychological well-being  Interpretative phenomenological analysis Introduction The last 30 years have witnessed increased interest in meditative and mindfulness techniques within the Western health setting (Arias et al. 2006). In a recent survey (n = 2,007) of attitudes towards meditation, the Mental Health Foundation (MHF) found that 86 % of British adults acknowledged that they would be healthier by learning to 'live in the moment' (p. 12, MHF 2009). There is a growing consensus that meditation and mindfulness have treatment efficacy for a broad range of both psychological and somatic conditions. Meta-analyses for the treatment efficacy of mindfulness meditation typically shows moderate to strong effect sizes (d [ 0.5) for issues as wide-ranging as chronic pain, fibromyalgia, cancer, sleep disorder, stress, anxiety and depression (Grossman et al. 2004; Baer 2003). E. Shonin (&)  W. Van Gordon  M. D. Griffiths Division of Psychology, Nottingham Trent University, Burton Street, Nottingham NG1 4BU, UK e-mail: e.shonin@awaketowisdom.co.uk 123 J Relig Health DOI 10.1007/s10943-013-9679-0 Author's personal copy Meditation is a spiritual and introspective process involving elements of both concentration and analysis, and is a process of becoming aware of and of training the mind (Dalai Lama 2001). To different extents and in different forms, meditation is practiced by the majority of world religions. However, within the Western health setting, it is Buddhist or Buddhist-derived techniques that have experienced the greatest popularity (Arias et al., 2006). Buddhist meditation stems from a 2,600-year-old philosophical doctrine expounded by Sakyamuni Buddha throughout India. Contemporary mental health practices generally integrate forms of Buddhist meditation known as concentrative meditation (Sanskrit: samatha), insight meditation (Sanskrit: vipasyana) as well as mindfulness meditation. For the purposes of this paper, the term 'mindfulness meditation' (MM) is used to distinguish this particular derivative of meditation from the traditional Buddhist practice that is more commonly known simply as 'mindfulness'. Clinical techniques based on MM are typically group-orientated and are generally delivered in the form of an 8-week course. Within the United Kingdom, the National Institute for Health and Clinical Excellence advocates the use of MM in the form of mindfulness-based cognitive therapy (MBCT) (Segal et al. 2002) for the prevention of relapse in adults with recurrent depression (NICE 2009). Mindfulness-based stress reduction (MBSR; Kabat-Zinn 1990), which might be seen as a precursor to MBCT, is practiced at over 240 hospitals and clinics worldwide (Baer, 2003) with over 19,000 participants having completed the programme since 1979 (Center for Mindfulness 2009). More recently, mindfulness-based relapse prevention (Bowen et al. 2009) has been developed as a group programme for preventing relapse following rehabilitation for substance use disorders. Mindfulness techniques are also widely utilized in numerous one-toone therapeutic modes such as dialectic behaviour therapy (Linehan 1993) and acceptance and commitment therapy (Hayes et al. 1999). MM is described in the psychological literature as having a non-judgmental awareness of the present moment (Kabat-Zinn 1990) and a receptive attention to present events and experience (Brown and Ryan 2003). Emphasis is placed on cultivating awareness of breath, bodily and thought processes. Such contemporary contextualizations of MM appear to be in reasonable accord with traditional Buddhist perspectives of mindfulness. Within the Buddhist setting, mindfulness is generally taught and practiced as part of a framework known as the four establishments of mindfulness (consisting of mindfulness of (i) body; (ii) feelings; (iii) mind and (iv) phenomena) (Walshe 1995). In many respects, MM appears to be an attempt to introduce the Buddhist practice of mindfulness into the clinical setting in a secular manner. Mindfulness in Buddhism Within Buddhism, mindfulness is practiced within a framework of mutually supportive and interrelated practices. A key example is a fundamental tenet known as the 'noble eightfold path' in which mindfulness features as just one aspect (the seventh aspect) and is known as 'right mindfulness'. Within the framework of the noble eightfold path, right mindfulness (Sanskrit: samyak-smriti) arises interdependently with the 'right' practice of each of the other seven components. In addition to the noble eightfold path, numerous other teachings central to all Buddhist schools also help guide and support mindfulness practice. For example, meditation upon and a deep understanding of the four noble truths is an integral condition of being able to cultivate mindfulness correctly. Likewise, the development of J Relig Health 123 Author's personal copy mindfulness depends upon a deep internalization and realization of the three dharma seals of: (i) impermanence, (ii) non-self and (iii) suffering. Within Mahayana Buddhism, the establishment of mindfulness is intrinsically linked with the gradual realization and practice of the three doors to liberation comprising: (i) emptiness, (ii) signlessness and (iii) desirelessness. Emptiness (Sanskrit: sunyata), for instance, refers to the profound yet highly subtle awareness that realizes that all phenomena are absent of inherent existence. Buddhist teachings explicate that a practitioner cannot come to anything that resembles a full awareness of the present moment unless they have some grounded understanding of the true and absolute mode in which the present moment exists. Mindfulness is also considered within Mahayana Buddhism to be both product and cause of each of the practices of the six perfections of: (i) generosity; (ii) ethical discipline; (iii) patience; (iv) joyful perseverance; (v) concentration and (vi) wisdom. The term nonjudgemental awareness is frequently used in the psychological literature as a means of defining MM. However, Buddhist teachings advocate that the ability to remain mindful of the present moment in a non-judgemental manner will simply not be established without highly developed or transcendent qualities of patience (Sanskrit: kshanti) or outside of a system of ethical discipline (Sanskrit: sila) that helps to avoid distraction and loss of awareness caused by latent cognitive and behavioural tendencies. The primary purpose of the foregoing is not to present an in-depth account of mindfulness as it is applied within Buddhist philosophy (for a more in-depth perspective, see Kang and Whittingham 2010), but to briefly outline some basic principles of Buddhist practice in order to provide a degree of insight into the context of traditional mindfulness practice. The most salient point is that within Buddhism, mindfulness is practiced only within the context of an array of complementary practices and perspectives. This is in contrast to methods such as MBCT and MBSR in which mindfulness (in the form of MM) is taught in isolation of many (or any) of the practices which are traditionally assumed to be vital for its cultivation. Kang and Whittingham (2010) describe mindfulness within the Buddhist context as a richer process when compared with its utilization within psychological settings. Singh et al. (2008) refer to the dangers of reducing mindfulness into a technical or psychotherapeutic construct as opposed to a means for lasting spiritual growth. Concerns have therefore arisen relating to whether the 'spiritual essence' and full potential treatment efficacy of mindfulness have remained intact in its clinically orientated and Westernized form (Singh et al. 2008; Howells et al. 2010; McWilliams 2011). Qualitative Enquiry Qualitative analysis of service-user experiences complements the more efficacy-driven quantitative approach by providing meaningful insight into the acceptability of a given intervention (Fitzpatrick et al. 2010), as well as the mechanisms that may underlie a particular outcome. Qualitative data for MM techniques are sparse in comparison with empirical evidence, and most qualitative studies have been limited to techniques such as MBSR and MBCT for only a limited range of mental health issues such as depression or anxiety. There has also been very little in the way of attempts to understand how participants might respond to (and experience) a secularized yet more traditional Buddhist approach to meditation and mindfulness. Interventions based on meditation or mindfulness emphasize the role played by participants in terms of their understanding and the significance of their experiences (Williams J Relig Health 123 Author's personal copy et al. 2011). With its roots embedded within phenomenology and hermeneutics, in addition to its adherence to a robust ideographic stance and iterative analytic process, interpretative phenomenological analysis (IPA) is deemed to be a suitable technique to analyse such experiences because it accepts that there is 'no clear and unmediated window' (Eatough and Smith 2006; p. 118) into the life of participants. The practices of meditation and mindfulness are subtle and are experienced differently by each individual. Nevertheless, certain common milestones and reference points have been identified (Dalai Lama 2001) which may not be immediately recognizable to an individual who is relatively new to the practice. IPA relies upon the analyst interpreting the participant's interpretation of their world (Smith and Osborn 2003), and therefore, lends itself to a rich co-construction of the meaning of meditators experiences by analysts who are themselves experienced in meditation. This double-hermeneutic process is deemed to be a unique strength of IPA (Parke and Griffiths 2012) and allows for findings to be reflexively interpreted within the context of the wider literature without losing sight of the importance that individuals assign to their experiences. Thus, IPA emphasizes the significance of 'meaning making' and the individual's perception of their reality. As stated by Eatough and Smith (2008), a principal motive for the development of IPA ''was the articulation of a qualitative approach to psychology which was grounded in psychology'' (p. 180). Therefore, the current study was exploratory, and aimed to address the aforementioned knowledge gaps by following IPA methodology in order to examine participant experiences and views in respect of the acceptability and effectiveness of a newly designed secularized yet more traditionally congruent 8-week group-based programme called meditation awareness training (MAT). The qualitative analysis was embedded within a controlled pilot trial that assessed the effects of MAT to psychological well-being in an opportunity sample of higher education students (pre–post measures of stress, anxiety, depression, dispositional mindfulness, negative affect and positive affect). Methods Participants A sub-sample consisting of seven females and three males was drawn from the intervention arm of the main study group. Most participants enrolled on the programme as a means of improving issues relating to stress or low mood whilst a small number enrolled primarily for the purpose of learning more about the practice of meditation and mindfulness. Given the intricacy and profundity of the iterative analytic process, the relatively small sample size (n = 10) was deemed to be conformant to IPA guidelines (Smith et al. 2009). Ages ranged from 20 to 42 years (mean age = 30.1 years), 70 % of participants were of 'White British' ethnicity and the average number of years in education was 15.7 years. Participation was voluntary and participants were screened to ensure the absence of any prior meditative experience and current psychopathology. Programme Description MAT is delivered over an 8-week period and follows a comprehensive approach to meditation whereby mindfulness is an integral part but does not form the exclusive focus of the programme. In addition to mindfulness, MAT incorporates practices that would be traditionally followed by meditation practitioners including (for example) techniques J Relig Health 123 Author's personal copy aimed at cultivating generosity, patience and compassion. MAT also integrates techniques that encourage the participant to investigate and come to an understanding of complex concepts such as impermanence and emptiness. These practices are taught via seminars and workshops and are integrated into a graded series of guided meditations. Participants attend weekly 2-h group workshops and are provided with a programme booklet and a CD comprising guided meditations in order to encourage them to introduce the practice into their normal daily routine. MAT is facilitated by experienced meditators, and prior to commencing the programme, participants are asked to confirm they understand and agree to the level of commitment required. On a four-weekly basis, each participant is invited to attend a one-to-one support session with the programme facilitators. This aspect of the programme is consistent with a Buddhist approach to meditation whereby, particularly in the beginning stages, it is considered vital that the practitioner engages in regular discussion and receives feedback from an experienced teacher or guide. Procedure Participants were invited to attend one-to-one support sessions (50-min duration) in the third and seventh week of the course. The one-to-one support sessions included a semistructured interview that covered key topics that had been selected for their relevance pursuant to a detailed literature search. Table 1 outlines the main topics covered by the interview schedule along with an example of the type of open-ended questions used to elicit responses. In order to elicit participant responses in as natural a manner as possible, the facilitators used their discretion to choose the most appropriate point to intersperse each of the interview questions into the one-to-one support sessions. These sessions followed an approach that is traditionally used between meditation teacher and student (sometimes referred to as 'Dharma sharing'). The student is not prescribed a set of 'answers' to their particular issues with the training. Rather, the role of the teacher is more one of facilitating a process of guided discovery in terms of how best to develop and apply the various meditation methods and techniques taught as part of the programme. The objective is to draw out a form of understanding or wisdom (Sanskrit: prajna) that can be shared by both teacher and student alike. Therefore, whilst not a session of individual therapy per se, the sessions inherently utilize many of the principles which, according to contemporary Table 1 Summary of topics and example questions Topic Example question Overall evaluation of the course Can you tell me what your expectations of the course were and how the course might have differed from these expectations? Development of awareness Do you feel you are more aware as a result of the course? If so, in what ways? Impact of the course Has the course had any significant impact on you? If so, please describe? Course facilitators Do you feel the course leaders played an important role in facilitating these changes? If so, please describe your experiences in this respect. Acceptability of the course Based on your experiences of the course in what settings and for what type of person do you feel the course would be most suitable? Continuing the practice Do you think you are likely to experience any challenges in terms of continuing with the practice after the end of the course? If so, please explain? J Relig Health 123 Author's personal copy understandings of best practice, are deemed to be important for maintaining a healthy 'therapeutic environment' (e.g. the use of a non-directive approach and core conditions such as active listening, unconditional positive regard, accurate empathy, genuineness and congruence (Wells 1997). Consistent with the IPA interview recommendations of Smith et al. (2009), the semi-structured interviews followed a Socratic questioning approach and were administered in a manner that encouraged participants to express themselves freely with allowance for the facilitator to prompt for additional clarification as required. The overlaying of the one-to-one support sessions with a semi-structured interview was deemed to be conformant to IPA guidelines which are non-prescriptive and provide a flexible framework that can be adapted according to the aims and parameters of the research (Smith et al. 1999). Data Analysis The one-to-one support sessions were audio recorded, transcribed verbatim and analysed following standard IPA guidelines (Smith et al. 2009; Smith and Osborn 2003). Transcripts were read several times and line numbered. An electronic spreadsheet was then used for annotation and coding to allow the identification of emergent themes. Preliminary themes were clustered into higher order categories (Eatough and Smith 2006) and a table compiled accordingly. This initial process of analysis was repeated by a second member of the research team as a form of 'independent audit' (Smith 1996). The interpretative process is not intended to be objective (Yardley 2008) and so rather than control for error in the first researcher's coding, this step was undertaken in order to verify the rationality and transparency of the first researcher's analysis. The entire analytical process, from reading the raw data through to the compilation of a master theme table was repeated in iterative fashion until a degree of gestalt was achieved (Smith 2004). Validation Guidelines such as following a paper-trail approach and grounding in examples were followed to maximize validity (Yardley 2000). The validation process also involved sending a summary of themes and interpretations to two of the study's participants and requesting their feedback accordingly (Creswell 2007). Results Analysis of the transcripts generated the master and subordinate themes as outlined in Table 2. Interpretations of these themes along with example verbatim excerpts and any relevant idiographic detail are then presented. Theme 1: Development of Awareness Participants reported a growth in 'present moment awareness' as a result of undertaking MAT. This was often expressed in terms of feeling joy due to being aware of the 'here and now' but also as a feeling of calm. For example: ''I am really enjoying it-it's like when you remember [to be aware of the present] you are showered with peace and calm'' (Participant 8) J Relig Health 123 Author's personal copy The development of awareness could be indicative of participants' experiencing increased levels of contentment due to consciously engaging a mindful attention-set and abandoning unproductive or ruminative thought processes that were largely preoccupied with future conjectures or past occurrences. Most participants commented on the importance of using the breath as a means of 'anchoring' themselves in the present moment. For example: ''When it just gets too much I try and remember to breathe. No, I mean, I'm always breathing but I try and know it if that makes sense'' (Participant 1) Participants reported that when they first began to practice, it appeared that they had more of a 'racing mind' than at baseline. Rather than an actual decrease in mindfulness, participants appeared to acknowledge or suggest that this perception was in fact a result of them beginning to become more aware of the 'wild' nature of their cognitive and emotional processes that had hitherto remained largely unobserved. All ten participants reported a growth in 'spiritual awareness' as well as a greater appreciation of 'life in general'. In some cases, this was expressed explicitly as in the case of Participant 1: ''I like it because although it's non-religious-it has some real spiritual depth''. Others expressed this more circuitously by explaining that they felt the course had inspired a form of 'reawakening'. The development of both aspects of awareness (subordinate themes 1a and 1b) was experienced positively by participants and had the effect of reducing emotional distress. Participants highlighted the importance of increased thought awareness that seemed to enable them to recognize and transform any destructive or maladaptive cognitive processes 'before the thoughts got out of control'. All ten participants commented on the 'challenges of being aware' (subordinate theme 1c) which were primarily related to the intensity of the course as well as the aspiration to maintain a regular practice of meditation outside of the weekly group sessions. During the first one-to-one support session, participants commented on the need to 'set aside enough time' in order to adhere to their practice routine. The adoption of such a rigid approach to meditation may have resulted in feelings of guilt in the event of missing a personal-practice session. For example: ''Why didn't I do it? I know I would have felt so much better if I had done it'' (Participant 2) Table 2 Summary of master and subordinate themes Master theme Subordinate themes Development of awareness Present moment awareness Spiritual awareness Challenges of being aware Importance of the traditional course design Importance of support practices Importance of course facilitators Increased sense of personal agency and well-being Gaining a sense of acceptance Developing emotion-focussed coping strategies Improved mood and positive affect Interactions with others Group structure Relationships J Relig Health 123 Author's personal copy However, during the second one-to-one support session and towards the end of the 8-week programme, participants appeared to view their practice less as an activity that they needed to prescribe time for, and more as a process to be applied to all situations in which they found themselves. For example: ''I don't really like the idea of making things too regimented ......... At the start of the course I found the best time to practice was on the bus with the CD and my i-Pod. More recently though, like when I'm with friends, I've suddenly remembered to practice and it's actually been quite profound, quite joyful, and without too much effort on my part'' (Participant 1) Theme 2: Importance of the Traditional Course Design All ten participants recognized the 'importance of the support practices' (subordinate theme 2a) that provided the context for their meditation and mindfulness practice. In particular, they seemed to place a great deal of value on internalizing a preliminary understanding of impermanence that was taught by way of insight meditation techniques. For example: ''Even more reason to actually get on with it and live in the moment because you don't have time to wait until tomorrow, do you?'' (Participant 3) ''When you know that things are always changing, then you have to ask yourself what is the point of holding on so tightly'' (Participant 8) Participants found the concept of 'emptiness' less easy to digest but seemed to understand its importance. For example: ''I get the gist of what [emptiness is] about but it's difficult to put into words ......... you try and search for yourself and you kind of begin to understand what it might be like to be nowhere and everywhere at the same time'' (Participant 1). When discussing elements of MAT that related to cultivating love and compassion, some participants explained that the growth in awareness of their own 'inner environment' also led to a greater appreciation and sensitivity towards the needs of others. For instance: ''I was aware I was angry but I was also aware of a 13-year-old girl who needed some support'' (Participant 4) The role of the facilitators (subordinate theme 2b) was described as 'essential' and their execution of the role as 'inspiring'. The role model provided by the course facilitators appeared to be integral to the advancement of participants' meditation practice. All participants seemed to be enthused in this respect. For example: ''[The facilitators'] practice is really inspiring yet so down to earth, and so warm and natural-like how it should be'' (Participant 1) There seemed to be a positive association between participants who reported feeling equipped to continue with the practice after the course and those who reported being inspired by the example of the facilitators. Participants also seemed to welcome the facilitators' awareness and sensitivity to the type of issues they were experiencing as a result of undertaking the programme. J Relig Health 123 Author's personal copy Theme 3: Increased Sense of Personal Agency and Well-being This third theme relates to the different types of perceptual and emotion-focussed coping strategies that participants reported experiencing. All ten participants reported an increased sense of acceptance (subordinate theme 3a) as a result of receiving MAT. This was primarily expressed as an acceptance of any anxious, depressive or mood-related dispositional tendencies. For example: ''A lot of my thoughts are feelings of anger [and] frustration ...... I should just accept that some things do annoy me and should go from that point'' (Participant 7) ''[I] learned to accept what [feelings] are and then deal with them then'' (Participant 10) However, in the majority of cases, this was also expressed as what seemed to be a broader acceptance of 'self' in general. This was perhaps best exemplified by observations such as ''I know who I am now'' (Participant 8) and ''I'm beginning to accept myself'' (Participant 5). Furthermore, an increased sense of general 'contentment' was expressed by all ten participants. This was attributed by most participants to their growing ability to ground themselves 'in the present' (Participant 5). Interestingly, whilst a greater sense of acceptance seemed to permeate into all areas of participant's lives, in some cases, it did not extend to a full acceptance of them dedicating more time towards personal or meditative development. For example: ''It's difficult to do because I am so used to being concerned with everybody else'' (Participant 10). All ten participants reported examples of how MAT improved emotion-focussed coping strategies (subordinate theme 3b). Participants reported that being more mindful enabled them to be 'less emotionally closed off' and 'more balanced' (Participant 9). Participants indicated that this transformation was driven by a change in perceptual focus due to observing and analysing their emotions more as an objective onlooker. For example: ''I see myself with my different thoughts and problems and I just observe them and watch my mind'' (Participant 6) Participants also reported improvements in mood and positive affect (subordinate theme 3c) which included more profound states of 'joy', 'calm' and 'equanimity'. For example: ''I just find such joy in my life now. Too much to express actually'' (Participant 9) ''I could feel myself becoming anxious but ...... I was remembering to be aware and to breathe. In fact it was like my anxiety was cradled in a feeling of calm'' (Participant 5) This excerpt by Participant 5 was typical of the experiences of most participants and paradoxically appeared to suggest that they experienced a sense of well-being even in the presence of distressing emotions. Theme 4: Interactions with Others The group structure of the programme (subordinate theme 4a) was positively regarded by all ten participants. Words such as 'enjoyable' and 'comforting' were used to describe the group experience. Nonetheless, whilst seeming to draw comfort from the group-based J Relig Health 123 Author's personal copy structure of the course, most participants expressed concerns that others appeared to be progressing at a faster rate. For example: ''I seem to have slipped back whilst others in the group seem to be doing really well'' (Participant 6) Although encouraged by the course facilitators not to do so, participants recounted that comparing their progress against that of their peers actually motivated them to practice with greater resolve. Furthermore, participants explained that MAT had resulted in a greater autonomy within relationships (subordinate theme 4b) as well as an appreciation that taking time for themselves was a valuable if not indispensable activity. For example: ''[I now] think differently about my relationships... I have already begun to realise that the only way I can give my best to others is to take care of myself'' (Participant 6) Most participants seemed to reach a heightened awareness of the potential effects of their words and actions and the need for sensitivity in this respect. For example: ''I was aware how a throw away comment could really affect a relationship'' (Participant 10) Participants also reported being more 'tuned in' to the emotions and needs of others. This greater sensitivity towards others seemed to occur as a natural by-product of being more mindful of the present moment but also due to making a conscious effort in the practices of deep listening, generosity and compassion that were taught in the programme. Discussion The IPA resulted in the emergence of four overarching themes: (i) development of awareness; (ii) importance of the traditional course design; (iii) increased sense of personal agency and well-being and (iv) interactions with others. In accord with findings of recent qualitative research into MBCT (Griffiths et al. 2009), participants in this study reported developing greater awareness as a result of MAT and attributed this to an improvement in psychological well-being. Brown and Ryan (2003) suggest that a change towards a more present-orientated attentional positioning can help to remove layers of discursive thought that can obscure or filter the clarity and vividness of experience. A greater perceptual distance from cognitive processes appeared to serve as a coping strategy making it easier for participants to observe any distressing thoughts as passing phenomena. Whilst these developments in awareness were experienced positively, such outcomes were not without their challenges. These principally related to the degree of commitment required, and similar challenges have also been reported by participants of MBCT (Williams et al. 2011). The second theme to emerge from the data set was that participants appeared to welcome and place importance on the traditional design of MAT whereby mindfulness was taught in conjunction with numerous supporting practices. References to the structure and acceptability of the programme were most frequently made in relation to discussion surrounding the growth in spiritual awareness that all participants reported having experienced. Although the programme was secular, participants appeared to appreciate its 'depth of meaning' and the fact it was grounded in a traditional and (therefore) 'tried and tested' approach to meditation. Although some participants approached MAT as a tool for personal development or as a means of better managing a specific issue such as stress, all J Relig Health 123 Author's personal copy participants seemed to enjoy having the freedom to use the programme as a vehicle for spiritual development. Whilst Mackenzie et al. (2007) reported an increase in general spirituality in cancer patients receiving MBSR, spiritual awareness is not explicitly cited in the majority of qualitative studies of MM techniques. In a study examining pre–post rates of healthcare utilization by inner-city MBSR participants, Roth and Stanley (2002) refer to increases in spirituality in terms of broad concepts such as greater trust or a larger sense of purpose. Thus, the experiencing by MAT participants of meditative insight into more specific properties such as impermanence and emptiness appears not to be an experience shared by participants of MM techniques. The significance of this observation becomes apparent when viewed in the light of the Buddhist contextualization of mindfulness. Buddhist sutras that directly discourse on mindfulness include the Anapanasati sutra and the Satipatthana sutra. Such sutras specifically refer to the investigation of phenomena as paramount to the establishment of mindfulness. After having built up a basis of meditative calm and stability via the practice of concentrative meditation, MAT participants are taught to make a slight adjustment to their meditation in order to investigate phenomena by engaging a subtle mode of meditative analysis (vipasyana meditation). Vipasyana translates from the Sanskrit as 'superior seeing' and can be directed to provide insight into the impermanent and empty nature of both self and reality. Bien (2006) posits that regular meditative insight into impermanence can lead to reduced self-absorbtion and a greater appreciation of the preciousness of life as it exists in the present moment. Thus, meditative insight is not only assumed to improve psychological well-being but is also an essential component for the ongoing development of mindfulness. Associated with the more traditional design of the programme, 'authenticity' arose as a subordinate theme and related to the motivation participants received as a result of being inspired and assured by the practice of the course facilitators. This subordinate theme highlights an additional notable disparity between the conventional technique of MM and more traditional practices of mindfulness and meditation. Within all Buddhist vehicles, transmission from an authentic guide or 'dharma teacher' (Sanskrit: guru) is deemed to be of paramount importance. For instance, Tsong-kha-pa (1402), a revered Tibetan Buddhist saint and philosopher, uses terms such as 'thoroughly pacified', 'serene' and 'disciplined' to describe the qualities of a suitable teacher. Unsurprisingly, the role of teachers facilitating MM courses in the clinical setting is necessitated by convention to take on a different format. Here, modes such as MBSR and MBCT are more often guided by facilitators from a clinical background whose experience of mindfulness may be limited to completion of a single 8-week course with as little as 1-year's post-course practice (MHF 2009). Although recent years have seen attempts to disseminate good practice guidelines and assessment criteria for MM teachers (Crane et al. 2012), there are still no nationally agreed standards in terms of credentials and aptitude for such teachers and there is no centralized professional accrediting body to perform a regulatory role. The growing evidence for MM approaches substantiates their efficacy, yet as such techniques experience greater demand, it becomes crucial to ensure that course facilitators are suitably and experientially qualified. The term 'experientially' is to be emphasized here because proficiency in mindfulness practice can only be accomplished by fully integrating it as a way of life (Naht Hanh 1999), rather than something that can be turned 'on and off' as part of a profession (or to advance within a profession). Thus, Tsong-kha-pa's cautionary note written in 1402 certainly holds true ''... those who have not disciplined themselves have no basis for disciplining others'' (p. 71). J Relig Health 123 Author's personal copy The third theme identified in the analysis related to participants' experience of an 'increased sense of personal agency and well-being'. Findings suggest that MAT led to an improved acceptance and awareness of the consequences of actions and choices. Participants also reported a greater acceptance of any negative emotions as well as a broader acceptance of self in general. Such improvements in acceptance have been identified in previous qualitative analysis of MM techniques (e.g. Fitzpatrick et al. 2010) and are thought to lead to a reduction in issues such as anxiety (Wells 1997). A greater understanding and acceptance of any distressing thoughts or emotions appeared to act as a form of emotion-focussed coping strategy. Whilst this finding is similar to observations that have been made in qualitative studies of MM (e.g. Cohen-Katz et al. 2005; Morone et al. 2008), the arising of profound states of joy, peace and calm during meditation are less commonly reported. This could be because MAT integrates concentrative practices designed to arouse a state of 'tranquil abiding' (samatha). Samatha serves as a stable basis for vipasyana meditation and the insight arising from vipasyana meditation appeared to feedback into and further intensify participants' experiences of meditative calm. Most participants reported that meditative calm arose simultaneously with distressing emotions such as anxiety. This observation could be related to the notion that positive and negative affect represent two orthogonal dimensions (Tellegen et al. 1999). The fourth and final theme related to participants' interactions with others. Consistent with its more traditional design, MAT encourages participants to support each other in their practice. Support has been posited to be an important benefit resulting from the group structure of MM approaches (Allen et al. 2009; Fitzpatrick et al. 2010). The group setting may serve to normalize any new experiences that occur as part of learning meditation. Participants of MBCT have used the word 'family' to describe the group experience (Imel et al. 2008) and Williams et al. (2011) suggest that the group setting may result in a de-stigmatisation effect for participants with a common mental health condition. Consistent with MAT's more traditional design, participants appeared to engender a compassionate motivation for practice. Participants are taught to direct this meditativeborn compassion towards both themselves and others. Increased self-compassion has been linked with increases in life satisfaction and adaptive psychological functioning (Neff et al. 2007). Self-compassion due to becoming more aware of the nature and causes of distressful cognitive and emotional states is likely to result in increased empathy and sensitivity towards others. This increase in compassion (towards others) may help to reduce maladaptive self-obsessing and Pace et al. (2009) have associated compassion-orientated meditation with reductions in innate immune and distress responses to psychosocial stress. As with all qualitative techniques, findings are unique to the current sample and should be considered in the light of the limitations of the study. The practice of bracketing-off (Husserl, 1999) any fore-knowledge or preconceived expectations was employed along with continuous reflexivity (Willig 2008) on the part of the researchers. Nevertheless, IPA accepts that any understanding of the 'life world' of participants will always be subject to a degree of mediation according to the researcher's own conditioning and epistemological stance. An additional limitation was the fact the final one-to-one support session took place in the seventh week of the course. Whilst this reduced the risk of any recall bias which has been cited as a methodological limitation of other qualitative investigations of MM techniques (e.g. Williams et al. 2011), it meant that analysis of participant experiences did not factor in changes that may have occurred during the final week of the programme. Future studies could address this issue by including a follow-up interview. J Relig Health 123 Author's personal copy Analysis of participant experiences suggests that MAT could potentially be an effective means for improving psychological well-being. Findings also confirm the acceptability within the current sample in respect of the more traditionally congruent (yet still secular) programme design. The inclusion within MAT of various support practices and its emphasis on the development of solid meditative foundations appeared to give rise to a richness of experience which for some participants, included a degree of meditative insight into impermanence and emptiness. Various (and highly laudable) initiatives are presently underway by bodies such as the MHF to raise awareness and improve service-user access to techniques utilizing MM (MHF 2009). However, whilst they are constructed upon an infrastructure and theoretical framework that is seemingly incongruent with traditional (and tried and tested) theory, it is very possible that treatment efficacy yield may not have been maximized in such techniques. Future research should seek to investigate whether there are additional benefits to be gained from following a more traditionally congruent approach to meditation and mindfulness. Similarly, efforts should also focus upon the development and accreditation of a programme of training and regulation for facilitators of MM courses. Finally, professionals and researchers using MM should consider whether there is a need (or duty) to provide greater clarification to patients or participants on exactly what is inferred by the term MM. Whilst such programmes adopt a secular standpoint, they nevertheless appear to attribute a great deal of the authenticity of MM to the assertion that it is grounded in Buddhist practice. This could potentially be misleading because mindfulness, as it is practiced in MM techniques, has been isolated from its original context and 'watered down' to such an extent that it is questionable whether it continues to resemble the faculty of 'right mindfulness' as it is construed by the Buddhist teachings. Acknowledgments We would like to thank Dr Eva Sundin for her feedback on earlier versions of this manuscript. References Allen, M., Bromley, A., Kuyken, W., & Sonnenberg, S. (2009). Participants experiences of mindfulnessbased cognitive therapy: ''It changed me in just about every possible way''. Behavioural and Cognitive Psychotherapy, 37, 413–430. Arias, A. J., Steinberg, K., Banga, A., & Trestman, R. L. (2006). Systematic review of the efficacy of meditation techniques as treatments for medical illness. Journal of Alternative and Complementary Medicine, 12, 817–832. Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143. Bien, T. (2006). Mindful therapy: A guide for therapists and helping professionals. Massachusetts: Wisdom Publications. Bowen, S., Chawla, N., Collins, S., Witkiewitz, K., Hsu, S., Grow, J., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30, 295–305. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848. Centre for Mindfulness in Medicine, Health Care and Society (CFM) (University of Massachusetts Medical School). (2009). Stress reduction program. Retrieved February 24, 2012, from http://www.umassmed. edu/cfm/home/index.aspx. Cohen-Katz, J., Wiley, S., Capuano, T., Baker, D. M., Deitrick, L., & Shapiro, S. (2005). The effects of mindfulness-based stress reduction on nurse stress and burnout: A qualitative and quantitative study, part III. Holistic Nursing Practice, 19(2), 78–86. J Relig Health 123 Author's personal copy Crane, R. S., Kuyken, W., Williams, J. M. G., Hastings, R. P., Cooper, L., & Fennell, M. J. V. (2012). Competence in teaching mindfulness-based courses: Concepts, development and assessment. Mindfulness, 3, 76–84. Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). London: Sage. Dalai Lama. (2001). Stages of meditation: Training the mind for wisdom. London: Rider. Eatough, V., & Smith, J. A. (2006). I feel like a scrambled egg in my head: An idiographic case study of meaning making and anger using interpretive phenomenological analysis. Psychology and Psychotherapy: Theory, Research and Practice, 79, 115–135. Eatough, V., & Smith, J. A. (2008). Interpretative phenomenological analysis. In C. Willig & W. StaintonRogers (Eds.), The Sage handbook of qualitative research in psychology (pp. 179–194). London: Sage Publications Ltd. Fitzpatrick, L., Simpson, J., & Smith, A. (2010). A qualitative analysis of mindfulness-based cognitive therapy (MBCT) in Parkinson's disease. Psychology and Psychotherapy: Theory, Research and Practice, 83, 179–192. Griffiths, K., Camic, P. M., & Hutton, J. M. (2009). Participant experiences of a mindfulness-based cognitive therapy group for cardiac rehabilitation. Journal of Health Psychology, 14, 675–681. Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57, 35–43. Hayes, S., Strosahl, K., & Wilson, K. (1999). Acceptance and commitment therapy. New York: Guildford Press. Howells, K., Tennant, A., Day, A., & Elmer, R. (2010). Mindfulness in forensic mental health: Does it have a role? Mindfulness, 1, 4–9. Husserl, E. (1999). Ideas I. In D. Welton (Ed.), The essential Husserl: Basic writings in transcendental phenomenology (pp. 60–79). Bloomington and Indianapolis: Indiana University Press. Imel, Z., Baldwin, S., Bonus, K., & MacCoon, D. (2008). Beyond the individual: Group effects in mindfulness-based stress reduction. Psychotherapy Research, 18, 735–742. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York: Delacorte. Kang, C., & Whittingham, K. (2010). Mindfulness: A dialogue between Buddhism and clinical psychology. Mindfulness, 1, 161–173. Linehan, M. (1993). Cognitive behavioural treatment of borderline personality disorder. New York: Guildford Press. Mackenzie, M. J., Carlson, L. E., Munoz, M., & Speca, M. (2007). A qualitative study of self-perceived effects of mindfulness-based stress reduction (MBSR) in a psychosocial oncology setting. Stress and Health, 23, 59–69. McWilliams, S. A. (2011). Contemplating a contemporary constructivist Buddhist psychology. Journal of Constructivist Psychology, 24, 268–276. Mental Health Foundation. (2009). Mindfulness report. London: Mental Health Foundation. Morone, N. E., Lynch, C. S., Greco, C. M., Tindle, H. A., & Weiner, D. K. (2008). ''I felt like a new person.'' The effects of mindfulness meditation on older adults with chronic pain: Qualitative narrative analysis of diary entries. Journal of Pain, 9, 841–848. Naht Hanh, T. (1999). The heart of the Buddha's teaching: Transforming suffering into peace, joy and liberation. New York: Broadway Books. National Institute for Health and Clinical Excellence (NICE). (2009). Depression: management of depression in primary and secondary care. London: NICE. Neff, K. D., Kirkpatrick, K. L., & Rude, S. S. (2007). Self-compassion and adaptive psychological functioning. Journal of Research in Personality, 41, 139–154. Pace, W. W., Negi, L. T., Adame, D. D., Cole, S. P., Sivilli, T. I., Brown, T. D., et al. (2009). Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology, 34, 87–98. Parke, A., & Griffiths, M. D. (2012). Beyond illusion of control: An interpretative phenomenological analysis of gambling in the context of information technology. Addiction Research and Theory, 20, 250–260. Roth, B., & Stanley, T. W. (2002). Mindfulness-based stress reduction and healthcare utilization in the inner city: Preliminary findings. Alternative Therapies in Health and Medicine, 8, 60–66. Segal, Z. V., Williams, J. M., & Teesdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guildford Press. Singh, N. N., Lancioni, G. E., Wahler, R. G., Winton, A. S., & Singh, J. (2008). Mindfulness approaches in cognitive behaviour therapy. Behavioural and Cognitive Psychotherapy, 36, 1–8. J Relig Health 123 Author's personal copy Smith, J. A. (1996). Beyond the divide between cognition and discourse: Using interpretative phenomenological analysis in health psychology. Psychology and Health, 11, 261–271. Smith, J. A. (2004). Reflecting on the development of interpretative phenomenological analysis and its contribution to qualitative research in psychology. Qualitative Research in Psychology, 1, 39–54. Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis. Theory, method and research. London: Sage Publications Ltd. Smith, J. A., Jarman, M., & Osborn, M. (1999). Doing interpretative phenomenological analysis. In M. Murray & K. Chamberlain (Eds.), Qualitative health psychology: Theories and methods (pp. 218–240). London: Sage. Smith, J. A., & Osborn, M. (2003). Interpretative phenomenological analysis. In J. A. Smith (Ed.), Qualitative psychology: A practical guide to research methods (pp. 51–80). London: Sage. Tellegen, A., Watson, D., & Clark, L. A. (1999). On the dimensional and hierarchical structure of affect. Psychological Science, 10, 297–303. Tsong-kha-pa. (2000). In: J. Cutler, G. Newland (Eds.), & T. L. Committee, Trans. The great treatise on the stages of the path to enlightenment, volume I. Canada: Snow Lion. Walshe, M. (1995). Mahasatipatthana Sutra. In The. Long (Ed.), Discourses of the Buddha: A translation of the Digha Nikaya (pp. 335–350). Somerville, Boston: Wisdom Publications. Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester: Wiley. Williams, M. J., McManus, F., Muse, K., & Williams, J. M. (2011). Mindfulness-based cognitive therapy for severe health anxiety (hypochondriasis): An interpretative phenomenological analysis of patients' experiences. British Journal of Clinical Psychology, 50, 379–397. Willig, C. (2008). Introducing qualitative research in psychology (2nd ed.). Maidenhead: Open University Press. Yardley, L. (2000). Dilemmas in qualitative health research. Psychology and Health, 15, 215–228. Yardley, L. (2008). Demonstrating validity in qualitative psychology. In J. A. Smith (Ed.), Qualitative psychology: A practical guide to research methods (pp. 235–251). London: Sage. J Relig Health 123 Author's personal copy