Mindfulness Training for Psychotherapeutic Care

Study Overview
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Brief Summary
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It has been shown that mindfulness-based interventions (MBI) applied to psychotherapists improve their empathy and increase the therapeutic alliance. It is expected that these improvements may beneficially affect the results of psychotherapy. However, new studies are needed to examine whether an MBI can have an effect on the healthy evolution of these professionals' patients. The objective of this project is to analyze the influence of a mindfulness and compassion based intervention (MCBI) applied to psychotherapists, on the empathy perceived by their patients, the therapeutic alliance and their symptomatology. This study is a randomized clinical trial of an intervention based on MBSR and adapted to the population of psychotherapists, including in the last two sessions the practice of compassion, called Mindfulness and Compassion Based Intervention (MCBI). The subjects (n = 63) were randomly assigned to MCBI (n = 33) or to a Waiting List group in which they fill in a self-record of their own feelings, thoughts, etc. in therapy for 8 weeks (n = 30). Participants in the MCBI intervention condition were asked to meet weekly during a two-hour session for two months. Pre / post-intervention and five-month evaluations were performed as a follow-up. Mindfulness measures (FFMQ) will be taken for the evaluation of psychotherapists, Self-compassion (SCS-SF), negative symptomatology (DASS-21), empathy (EUS-T, TECA), personal therapist style (EPT-C) and mindfulness instructional style (MIQ). For the evaluation of patients, measures of mindfulness (FFMQ), self-compassion (SCS-SF) will be taken - to try to control without these skills they can be vicariously modified without being directly trained-, subjective well-being (PHI), psychological well-being (BSI), therapeutic alliance (WATOCI, ENAT) and perceived empathy (EUS-P).

Detailed Description
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The practice of psychotherapy involves the formation and development of a series of skills by the professional. These skills encourage the establishment of a quality therapeutic link, which helps to improve the effectiveness of therapy sessions. In this sense, current research indicates that the link established between the psychotherapist and his patients has a high effect on the evolution and results of psychotherapy. This improvement is to a greater extent attributed to the establishment of the link than to the specific techniques that are applied in therapy. Among the variables that favor the link, the empathy of the psychotherapist has been widely studied, and has proven to be highly related to the benefits of psychological interventions. Therefore, the development of healthy empathy is one of the most important variables on which the benefits of psychotherapy are based. It facilitates a true understanding of the vital situations of the patients and is essential in establishing the therapeutic link. The influence of the latter on the results of psychological interventions has meant that empathy training is one of the basic objectives to follow in the training of clinical and health psychologists, increasing research on effective strategies for this, among which mindfulness and compassion based interventions (MCBI) stand out. In recent years, the MCBI have established themselves as a very useful intervention in the healthcare field, and several authors suggest the advantages of their application in psychotherapists, pointing out their beneficial influence on the therapeutic relationship and the psychotherapeutic process. The MCBI are structured interventions in which a series of attitudes and mental states associated with mindfulness and compassion are trained through different meditation techniques. You also learn to generalize these states in the way we relate to the experiences we live. Based on this, the MCBI can be an especially useful strategy to train a series of skills that beneficially influence the therapeutic link and the results of psychotherapy. In relation to the above, it has been seen that MCBI have a beneficial effect on the levels of self-reported empathy of clinical and health psychologists. In addition, an interesting association has been observed between the levels of mindfulness and self-reported empathy in psychotherapists, and between these variables and the therapeutic alliance established with their patients. An association has also been found between the results of the therapeutic alliance measures between therapists and patients after a Mindfulness-based Intervention (MBI). Finally, it has been seen that the application of an MCBI in psychotherapists indirectly influences the evolution of their patients, helping to reduce their symptoms and increase their levels of well-being. These results imply important support for the advantages of including the MCBI in the training of clinical and health psychologists, in order to increase their levels of empathy and the effectiveness of their interventions. However, there are many limitations we find in these results. First, the studies that have analyzed the influence of MCBI on empathy only include a self-reported evaluation of psychotherapists on this variable. In addition, this evaluation does not give us information about whether the MCBI affects the empathy that patients perceive in their therapists, which prevents us from assessing whether these benefits exert a real influence on the therapeutic relationship and the psychotherapeutic process. On the other hand, studies that have established a relationship between levels of mindfulness and direct results in therapeutic alliance include only mindfulness-based interventions (MBI), not including compassion training in a manner explicit. We are interested in observing whether a MCBI significantly influences the perception of the therapeutic alliance by patients. Finally, in Grepmair's study in which the benefits of applying an MCBI in psychotherapists on the evolution of their patients have been observed, the mediating variables that could explain these results were not evaluated. The objective of this project is to identify the mechanisms of action of the MCBI and its effect on the different variables that could be influencing the results of psychotherapy, such as the empathy of the psychotherapist and the therapeutic alliance established with their patients.

Official Title
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Influence of a Mindfulness and Compassion-Based Intervention in Psychotherapists: Analysis of Its Effects on Empathy, the Therapeutic Alliance and the Symptomatic Evolution of Their Patients

Conditions
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Mindfulness, Compassion, Empathy, Working Alliance, Patients' Symptomatology, Psychotherapeutic Process, Psychotherapist

Intervention / Treatment
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* Behavioral: MCBI
* Behavioral: Active Comparator


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Therapists inclusion criteria: Have a psychology degree. Be able to read and write using the Spanish language. Be doing therapy with at least one patient. Eligible participants were contacted through the main psychotherapeutic schools and university centers to invite them to an explanatory meeting of the study. Patient inclusion criteria: Be between 18 and 75 years old. Be able to read and write using the Spanish language. Eligible participants were contacted by their personal psychotherapist, either by a phone call or regular therapy appointment to invite them to participate in the study. Exclusion Criteria: Therapists exclusion criteria: Have extensive experience in mindfulness practice Use mindfulness in therapy with your patients. Do not engage in clinical psychology or psychotherapy Patient exclusion criteria: Serious active mental disorders (schizophrenia, bipolar disorder, psychotic disorders) • Disorders due to active substance use (if consumed in the last year) Cognitive impairment Take more than 2 and a half years in therapy with the same therapist

Ages Eligible for Study
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Minimum Age: 25 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: MCBI Group<br>Training in mindfulness and compassion (MCBI) is facilitated in eight weekly sessions of 2 hours. With a didactic format, through theory, class discussions, and guided meditation practices. | Behavioral: MCBI<br>* The topics covered in the sessions are: Week 1: Introduction to mindfulness and attention to breathing. Week 2. Open awareness of bodily sensations. Week 3: Work with thoughts, introductory theory and practice in attention to sounds. Week 4: Working with thoughts, advanced theory and practice in mental landscape. Week 5: Introductory theory and practice in labeling emotions. Session 6: Advanced theory in working with emotions and practice in difficult emotions. Week 7: Introductory theory on self-compassion and compassion. Practice in self-compassion. Week 8: Practice in compassion and active compassion (acts of kindness and shared humanity).<br>|
| Active Comparator: Active-Wait List Group<br>Completion of a record during these 8 weeks. Active work of introspection about one's own sensations, thoughts, distractions, judgments, etc. in therapy sessions. Registered after each session. | Behavioral: Active Comparator<br>* Free observation of the psychotherapist's own feelings, thoughts, distractions, biases and behavior in general for 8 weeks. Observations of these variables are recorded during psychotherapy sessions with patients participating in the research.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in Empathic Understanding Scale Therapist's Version (EUS-TV) | Designed to assess self-perceived empathy by the therapist himself during therapy sessions. It consists of 16 items and respondents are asked to indicate on a scale of 1 (no, I strongly believe that it is not true) to 6 (yes, I strongly believe that it is true). From this questionnaire a total empathy score is obtained. Higher scores indicate improvements in empathy. Used to measure empathy in therapists. EUS has proven effective (Andrade-González, 2009; Barrett-Lennard, 1978) | 8 weeks, 6 months | 
| Empathic Understanding Scale Patient's Version (EUS-PV) | Designed to assess the empathy of therapists perceived by their patients during therapy sessions. It consists of 16 items and respondents are asked to indicate on a scale of 1 (no, I strongly believe that it is not true) to 6 (yes, I strongly believe that it is true). From this questionnaire a total empathy score is obtained. Higher scores indicate improvements in empathy. Used to measure empathy in therapists. EUS has proven effective (Andrade-González, 2009; Barrett-Lennard, 1978) | 8 weeks, 6 months | 
| Changes in Cognitive and Affective Empathy Test (TECA) | Designed to evaluate self-reported empathy by the therapists themselves. It is made up of 33 items and respondents are asked to indicate on a scale of 1 (totally disagree) to 5 (totally agree). Four subscales are obtained from this questionnaire: perspective adoption, which refers to taking the patient's point of view; emotional understanding; empathic stress, referred to the contagion of the patient's negative emotions; and empathic joy, referring to the ability to feel joy for the positive emotions of others. You also get a total empathy score. Used to measure empathy in therapists. TECA has proven effective (López-Pérez, Fernández-Pinto & Abad, 2008) | 8 weeks, 6 months | 
| Changes in Working Alliance Theory of Change Inventory (WATOCI): reduced version of the Therapeutic Alliance Inventory (WAI-S) | Designed to evaluate the therapeutic alliance, measured by the patient. It is divided into the subscales of tasks, link and joint goals in therapy and Theory of therapist change, with a general measure of therapeutic Alliance. Composed of 17 items with a Likert scale from 1 (Never) to 7 (Always). Used to measure therapeutic alliance in patients. WATOCI has proven effective (Corbella & Botella, 2004; Duncan & Miller, 1999). | 8 weeks, 6 months | 
| Changes in Alliance Negotiation Scale (ANS) | Designed to evaluate the flexibility, negotiation and expression of the therapist measured by the patient. Composed of 12 items with a Likert scale from 1 (Never) to 5 (Often). Used to measure therapeutic alliance in patients. ANS has proven effective (Díaz-Oropeza & Peña-Leyva, 2016; Doran, Safran, Waizmann, Bolger & Muran, 2012) | 8 weeks, 6 months | 
| Changes in Brief Sympton Inventory (BSI-18) | Designed to evaluate somatization, depression and anxiety. Composed of 18 items with a Likert scale from 0 (Nothing) to 4 (A lot). Used to measure psychological well-being in patients. BSI-18 has proven effective (Derogatis & Melisaratos, 1983; Ruipérez, Ibáñez, Lorente, Moro & Ortet, 2001) | 8 weeks, 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in Five Facet Mindfulness Questionnaire (FFMQ) | Designed to evaluate mindfulness capabilities, through the sub-scales of observation, description, acting consciously, not judging one's own experience and not reacting to one's own experience. This short version is composed of 20 items, with a scale ranging from 1 (never or very rarely true) to 5 (very often or always true). Used to measure mindfulness in therapists and patients. FFMQ has proven effective (Baer, Smith, Hopkins, Krietemeyer & Toney, 2006; Tran et al., 2014) | 8 weeks, 6 months | 
| Changes in the short scale of self-compassion (SCS-SF) | Designed to assess common humanity, mindfulness, self-judgment, excessive identification, isolation, personal goodness and general self-compassion. Composed of 12 items in its short version classified on a Likert scale from 1 (almost never) to 5 (almost always) with the total score obtained by adding the averages of each subscale. Used to measure self-compassion in therapists and patients. SCS-SF has proven effective (García-Campayo et al., 2014; Raes, Pommier, Neff & Van Gucht, 2011) | 8 weeks, 6 months | 
| Changes in the Mindfulness Instruction Questionnaire (MIQ; adapted from the Mindfulness In Parenting Questionnaire MIPQ) | Designed to evaluate mindfulness styles in the instruction of therapists and their ability to be present in session. (Obtained from: Mindfulness in Parenting Questionnaire). Composed of 28 items, with a Likert scale from 1 (never) to 5 (almost always). Used to measure mindfulness instructional style in therapists. MIPQ has proven effective (McCaffrey, Reitman & Black, 2017) | 8 weeks, 6 months | 
| Changes in Personal Style of the Therapist (PST-Q) | Designed to evaluate the instructional function, the expressive function, the involvement function, the attentional function and the operative function of the therapist. Composed of 36 items with a Likert scale from 1 (Total disagreement) to 7 (Total agreement). Used to measure the therapist's personal style in therapists PST-Q has proven effective (Fernández-Álvarez, García, LoBianco & Corbella, 2003) | 8 weeks, 6 months | 
| Changes in Depression Anxiety Stress Scale (DASS-21) | Designed to assess levels of depression, anxiety and stress. Composed of 21 items with a Likert scale from 0 (It didn't happen to me) to 3 (It happened a lot, or most of the time) with an overall score obtained from the sum of all the items. Used to measure negative symptomatology in therapists. DASS-21 has proven effective (Lovibond & Lovibond, 1993). | 8 weeks, 6 months | 
| Changes in the Pemberton Happiness Index (PHI) | Designed to assess remembered well-being (divided into the subscales of hedonic well-being, eudaimonic well-being, social well-being and a total score) and experienced well-being (divided into the subscales of positive experiences and experiences negative) Composed of a scale of 12 items that score from 0 to 10 the degree of agreement with each item. Used to measure subjective well-being in patients. PHI has proven effective (Hervás & Vázquez, 2013). | 8 weeks, 6 months | 
| Changes in Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) | Designed to measure the psychotherapeutic process, it evaluates the state of the client or patient from a series of dimensions (subjective well-being, problems / symptoms and general functioning). It is a is a self-report questionnaire composed of 34 items. It also has short forms of 18 (forms A and B), 10 and 5 items to use in each session as a form of continuous monitoring of the therapeutic process. The short form with 5 items was used in this study. It consists of a Likert-type scale that goes from 0 (never) to 4 (always or almost always). Used to measure the therapeutic process in patients. CORE-OM has been shown to be effective (Evans et al., 2000; Feixas et al., 2012). | 8 weeks, 6 months | 
| Changes in State Emotion Regulation Inventory (SERI) | Designed to assess distraction, reassessment, self-criticism and acceptance. Composed of 16 items with a Likert scale from 1 (Strongly disagree) to 7 (Strongly agree). Used to measure emotional regulation in therapists. SERI has proven effective (Katz, Lustig, Assis & Yovel, 2017). | 8 weeks | 
| Changes in the State-Trait Anxiety Inventory (STAI) | Designed to assess the subject's state anxiety, understood as the subjective feelings of tension and apprehension and the hyperactivity of the Autonomous Nervous System. Composed of 20 items on a Likert scale from 0 (Nothing) to 3 (Very good). Used to measure anxiety in therapists. STAI has proven effective (Spielberger, Gorsuch & Lushene, 1970). | 8 weeks | 
| Changes in Positive and Negative Affect Schedule (PANAS) | Designed to assess negative affect and positive affect. Composed of 20 items with a Likert scale from 1 (Very little or nothing) to 5 (Extremely). Used to measure affections in therapists. PANAS has proven effective (Sandín et al., 1999; Watson, Clark & Tellegen, 1988). | 8 weeks |