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Psychotherapy Research
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Effects of pre-session centering for therapists on

session presence and effectiveness
a a b b
Rose Dunn , Jennifer L. Callahan , Joshua K. Swift & Mariana Ivanovic
a
Psychology, University of North Texas, Denton, TX, USA
b
Psychology, University of Alaska Anchorage, Anchorage, AK, USA
Published online: 15 Oct 2012.

To cite this article: Rose Dunn , Jennifer L. Callahan , Joshua K. Swift & Mariana Ivanovic (2013) Effects of pre-
session centering for therapists on session presence and effectiveness, Psychotherapy Research, 23:1, 78-85, DOI:
10.1080/10503307.2012.731713

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 Psychotherapy Research, 2013
Vol. 23, No. 1, 78
85, http://dx.doi.org/10.1080/10503307.2012.731713

Effects of pre-session centering for therapists on session presence and

effectiveness

ROSE DUNN1, JENNIFER L. CALLAHAN1*, JOSHUA K. SWIFT2, & MARIANA IVANOVIC2

1
Psychology, University of North Texas, Denton, TX, USA & 2Psychology, University of Alaska Anchorage, Anchorage, AK,
USA
(Received 4 June 2012; revised 13 September 2012; accepted 14 September 2012)

Abstract
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The present study tested whether engaging in a mindfulness centering exercise 5 minutes before a session could have a
positive impact on therapy, in particular on the therapists’ ability to remain present in session and on session outcomes.
Results indicated that therapists perceived themselves as being more present in session when they prepared for their sessions
by engaging in a mindfulness centering exercises (d.45), while clients perceived their therapists as being highly present
regardless of whether their therapist completed the mindfulness centering exercise. Clients did, however, perceive the
sessions as being more effective when their therapists engaged in the mindfulness centering exercise prior to the start of the
session (d .52).

Keywords: therapist training; psychotherapy outcomes; mindfulness; therapeutic presence; randomized controlled
adjunctive-instruction design

In recent years a burgeoning amount of empirical Cashwell, 2009). A major focus of mindfulness is
research has focused on the use of mindfulness in the developing moment-to-moment awareness and the
field of psychology. In particular, research on mind- ability to direct attention to the present moment.
fulness has demonstrated the positive effects of using McCollum and Gehart (2010) found that therapists
mindfulness as an intervention for clients experien- believed they were more present during sessions,
cing a variety of clinical conditions (Cullen, 2011). were more comfortable with silences, and were more
Furthermore, recent research has suggested that attentive and responsive to clients after participating
therapists’ practice of mindfulness may be beneficial in mindfulness training. Others have similarly found
to therapists’ personal well-being, while also helping positive results associated with mindfulness training
them develop important therapeutic skills and attri- for therapists (Greason & Cashwell, 2009; Moore,
butes, such as empathy and compassion (Aggs & 2008; Schure, Christopher, & Christopher, 2008;
Bambling, 2010; Bruce, Shapiro, Constantino, &
Shapiro, Astin, Bishop, & Cordova, 2005).
Manber, 2010; Davis & Hayes, 2011). For example,
Although research has demonstrated that thera-
Shapiro, Brown, and Biegel (2007) found that
pists who practice mindfulness report improvements
therapists who engaged in an 8-week mindfulness-
in their own well-being and therapeutic skills, few
based stress-reduction program showed significant
studies have examined whether these self-perceived
decreases in stress, negative affect, rumination, and
state and trait anxiety, and significant increases in benefits translate to actual improvements in ther-
positive affect and self-compassion. It is hypothe- apeutic outcomes. In particular, there is a lack of
sized that cultivating a non-judgmental, compassio- research investigating whether therapists’ use of
nate attitude for oneself through mindfulness will in mindfulness leads to improved therapy outcomes
turn promote a sense of acceptance and compassion from the clients’ perspective. This topic is of
for others (Kristeller & Johnson, 2005; Ryan, Safran, particular importance when considering attrition
Doran, & Muran, 2012). Therapists’ ability to rates in psychotherapy and the need to train begin-
remain attentive during sessions has been identified ning therapists in effective ways to establish strong
as another important factor in therapy (Greason & therapeutic relationships with their clients.

Correspondence concerning this article should be addressed to Jennifer L. Callahan, University of North Texas, Psychology, 1155 Union
Circle #311280, Denton, 76203-5017 USA. Email: [email protected]

# 2013 Society for Psychotherapy Research

 Pre-session therapist centering 79

In the first contemporary study that examined the Ryan et al. (2012) investigated the association
relationship between therapist mindfulness and client between therapist pre-training, dispositional levels of
outcome, Stanley et al. (2006) measured levels of mindfulness and therapist self-affiliation (or friendli-
mindful awareness for 23 trainee therapists in a ness towards the self), the therapeutic alliance, and
psychology department training clinic. They con- treatment outcome. Results of the study indicated
ducted an archival review of the outcome data for all that therapists with higher levels of trait mindfulness
of the clients seen by those 23 therapists. While were found to report higher levels of positive self-
therapist mindfulness was not related to clients’ affiliation. Therapist mindfulness was also positively
ratings of their own improvement, it was negatively correlated with therapist ratings of the working
correlated with clients’ symptom reduction at termi- alliance. On patients’ ratings of working alliance,
nation. These results appear to indicate that therapist therapist mindfulness was associated only with
mindfulness might actually have a negative impact on the Act with Awareness subscale, suggesting that
treatment outcomes. One limitation of the study that therapists’ sustained attentiveness and focus may
should be considered is that they did not assess for positively impact patients’ perceptions of the work-
mindfulness levels while the therapists were seeing the ing alliance. There was no significant relationship
clients whose outcome data were used in the study. between therapist mindfulness and symptom im-
Thus, it cannot be assumed that therapists’ levels of provement; however, therapist mindfulness was as-
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mindfulness at the time of the assessment were the sociated with patient-rated improvements in
same as when the therapists were seeing the clients. interpersonal functioning. This study offers partial
Another limitation is that therapists were not trained support for the hypothesis that therapist mindfulness
in mindfulness during the study nor were they has a positive impact on therapeutic outcomes.
instructed to practice mindfulness exercises. The Due to the limited research and contradictory
researchers relied on a self-report measure of aware- findings, further research is needed to understand
ness and attention to assess for mindfulness, which whether therapists’ mindfulness actually influences
could be problematic since self-reports of mindful- therapeutic outcomes. Furthermore, no existing
ness may not reflect true levels of mindfulness research has examined whether completing a mind-
(Grossman, 2008). As Davis and Hayes (2011) point fulness exercise immediately preceding a session
out in their review of the mindfulness literature, would lead to improved client outcomes. While
mindfulness practice may be a better predictor of several studies have demonstrated the benefits of
treatment outcomes than self-reports of mindfulness. therapists completing a mindfulness training pro-
Grepmair et al. (2007) conducted a randomized, gram, it is unclear whether therapists continue to
double-blind, controlled study examining the influ- utilize mindfulness practice after the program ends.
ence of therapist mindfulness on client outcomes. For Training therapists to use a brief mindfulness ex-
this study trainee therapists were randomly assigned to ercise as a part of their preparation routine for
a 9-week daily Zen meditation group or a control upcoming sessions would provide them with an
group (no meditation). Compared to clients seen by accessible tool in order to maintain the benefits
the therapists in the control group, clients who were that were gained from the training program. Addi-
seen by the therapists who practiced daily Zen tionally, completing mindfulness practice immedi-
meditation reported a greater understanding of their ately before a session, as opposed to hours or days
problems, an increased problem-solving capacity, and before meeting with a client, may have a more potent
a greater reduction of symptoms by the end of their effect on therapeutic outcomes.
treatment. A strength of this study was the promotion The purpose of the current study was to test
of mindfulness in therapists through daily meditation whether engaging in a mindfulness centering exercise
practice rather than relying solely on self-report 5 minutes before a session could have a positive
measures. Additionally, the study’s randomized, dou- impact on therapy, in particular on the therapists’
ble-blind, controlled design adds to the strength of the ability to remain present in session and on session
findings. The use of randomization and control outcomes. We hypothesized that therapists who
conditions is significantly lacking in the existing completed the mindfulness centering exercise before
mindfulness literature. The results of this study a session would be rated (by self and client) as having
support the use of mindfulness practice to improve more presence in session and clients would rate
therapeutic outcomes; however, therapists in the study sessions as more effective, as compared to sessions
were asked to complete a relatively intense mind- when the therapist did not complete the mindfulness
fulness training program, which included 1 hour of centering exercise. The results of this study have
training each morning for 9 weeks. The applicability important implications regarding whether the prac-
of such time-consuming practice in the schedules of tice of mindfulness can be used as an effective
graduate students may be a limitation of the study. session preparation tool for therapists.
 80 R. Dunn et al.

Method include a wide age range (18
73 years; M 30.25,

SD 10.08). Clients seen in these clinics present
Participants
with a wide variety of clinical concerns and diag-
Participants were 25 trainee therapists who were noses; the most common diagnoses for both clinics
completing their in-house practicum at one of two fall among the mood and anxiety disorder categories.
psychology department training clinics. Nineteen of Both of the psychology department training clinics
the trainees were graduate students enrolled in one for this study are similar in that they serve students
of three APA-accredited, scientist-practitioner doc- from their respective universities as well as indivi-
toral programs in psychology (Clinical Psychology, duals from their larger communities and both
Clinical Health Psychology and Behavioral Medicine operate on a low-cost sliding-scale fee system. All
(accredited as Clinical), and Counseling Psychology) participants in this study were treated in accordance
at a large university in the West South Central with the American Psychological Association’s
Division of the United States. The remaining six (APA) code of ethics (APA, 2002) and approval
trainees were graduates students enrolled in either a was obtained from each university’s Institutional
Clinical Psychology master’s program or an APA- Review Board (IRB) and training clinic prior to
accredited doctoral program in Clinical-Community collecting any data.
Psychology at a large University in the Pacific
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Northwest Division of the United States. All of the

training programs espouse a scientist-practitioner Procedures
model of training and neither training clinic requires Early in the fall 2011 semester, graduate students
their students to adhere rigidly to one specific who were completing their practicum in either of the
theoretical orientation. Students from each program training clinics were recruited for study participa-
normally begin their practicum at the end of their tion. Those students who agreed to participate
first year or beginning of their second year in engaged in a brief 5-week manualized mindfulness
training, following successful completion of pre- training program (a copy of the training manual can
practicum training and competency attainment (to be obtained by contacting the authors). The goal of
include instruction and supervision in the areas of the program was to provide an introduction to some
basic clinical skills, ethics, and psychopathology). of the basic principles of mindfulness as well as
While the master’s students typically complete only provide guided practice of mindfulness exercises.
one semester of training in the department clinic, the The five training sessions were each 20 minutes long,
doctoral students see clients in the clinic over several beginning with didactic instruction of core mind-
consecutive semesters. fulness principles, including moment-to-moment
Trainees were primarily female (68%) and Cau- awareness, attention, acceptance, non-judging, pa-
casian (72%; Hispanic n 2; Asian-American n 1; tience, and non-striving. Participants then com-
Bi/multi-racial or other n 4). The average age was pleted a 5-minute guided mindfulness exercise.
26.28 (SD 2.75), ranging from 22 to 34 years old. Participating trainees were also instructed to com-
They reported an average of 2.75 (SD 0.85) years plete daily formal (home practice with the guided
of training in their respective programs and an exercises from the training sessions) and informal
average of 2.48 (SD 1.69) years of clinical experi- mindfulness practices (e.g., being present while
ence. Almost all of the trainees endorsed either a brushing teeth) on their own between the training
cognitive-behavioral (42.9%) or integrative (42.9%) sessions. During each session therapists were asked
theoretical orientation, with the remaining identify- to discuss the previous week’s homework along with
ing with a dynamic (4.8%), client-centered (4.8%), any positive or negative aspects they had experienced
or other (4.8%) orientation. with it. Results from a test of the effectiveness of this
Client participants (n 89) were those adults who program (Swift, Callahan, Dunn, & Ivanovic) are
were seen for at least one individual therapy session available from the corresponding author.
during the study time period. Given that the clients Data collection occurred over a period of 2 weeks
were secondary participants, and were unaware of in the larger clinic and 3 weeks in the smaller clinic.
the purposes or nature of the study, no demographic Immediately prior to every adult individual therapy
data were obtained from these specific clients. In session during the weeks of data collection, partici-
general, clients seen in the clinic are often female pating therapists drew a slip of paper that instructed
(63.5%), diverse (full clinic demographics reveal them to engage in either a mindfulness centering
77.2% are Caucasian, 7.9% Latino/Hispanic, 7.2% exercise (n 68) or a control activity (n 64). Per
biracial, 4.8% African-American, 1.4% Asian, and routine clinic procedures, therapists then gave their
less than 1% each Asian-American, Native-American, clients the Outcome Questionnaire 45.2 (OQ-45.2;
Pacific Islander, African, and ‘‘other’’ ethnicity) and Lambert et al., 1996). If the therapist had drawn a
 Pre-session therapist centering 81

paper slip that instructed him or her to engage in the Session Rating Scale. Session effectiveness was
mindfulness centering exercise, he or she went assessed following each session with the four-item,
directly to the therapy room and listened to a 5- visual analogue Session Rating Scale (SRS; Johnson,
minute centering audio recording while the client Miller, & Duncan, 2000). The SRS is used to
completed the OQ-45.2. The centering exercise can measure session-specific therapeutic alliance and
be found in Eifert and Forsyth’s (2005) Acceptance & effectiveness. The four items include a rating of the
commitment therapy for anxiety disorders. If the thera- relationship (‘‘I felt heard, understood, and re-
pist had drawn a paper slip that instructed her or him spected’’), goals and topics (‘‘we worked on and
to engage in the distraction activity, she or he was talked about what I wanted to work on and talk
instructed to chat with other therapists, check email, about’’), approach or method (‘‘the therapist’s ap-
or use the restroom while the client completed the proach is a good fit for me’’), and the overall session
OQ-45.2. Prior to the start of the study, participat- (‘‘overall, today’s session was right for me’’). To
ing therapists were asked what activities they usually indicate their response, clients are instructed to place
engage in while their clients complete the OQ-45.2; a hash mark on a 10-cm line with bi-polar anchor
these were the three most common responses. descriptions to indicate how well their experience in
Therapists were also given a log to record what the preceding session fits with the anchored descrip-
activities they had engaged in prior to sessions as a tors. Using a millimeter for scale measurement,
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means to check whether any therapists were com- scores on each item range from 0 to 100. A total
pleting mindfulness exercises as preparation for their score is computed by simply summing the item scores.
sessions that had been assigned to the control group. Internal consistency of .88 has been previously
No therapists reported that they had completed reported (Duncan et al.; 2003). Duncan and collea-
mindfulness exercises before sessions that were gues reported initial test-retests reliability to be .70,
assigned to the control group. Sessions then pro- with lower test-retest reliability (.64) found over the
ceeded as usual. At the end of these sessions, clients course of multiple administrations, demonstrating
completed a measure of therapist presence and the measure’s sensitivity to measure change. Duncan
session effectiveness. At the same time, therapists et al. also reported that the SRS adequately pre-
also completed a self-report measure rating their dicted treatment outcomes. The SRS and the Help-
own presence during the preceding session. Thera- ing Alliance Questionnaire-II (HAQ-II; Luborsky
pists were instructed to complete measures and have et al., 1996) have been found to be moderately
their clients complete measures after every session correlated (.48). With our sample an internal
during the 2-week period of data collection. consistency of .83 was found for the four items.

Measures Data Analysis

Therapist Presence Inventory
Therapist
and Client Forms. The Therapist Presence Inven-
We were interested in examining whether our thera-
pists were more present (as rated by themselves and
tory (Geller, Greenberg, & Watson, 2010) includes their clients) and more effective (as rated by the
two forms, the therapist (TPI-T) and the client clients) in sessions that were preceded by the mind-
(TPI-C), both of which were administered immedi- fulness centering exercise compared to those pre-
ately following sessions. Both forms are self-report ceded by the control activities. Since we were
questionnaires with 7-point Likert-style scaled re- interested specifically in session-level impacts, ran-
sponses. The TPI-T consists of 21 items on which domization occurred at the session, not therapist or
the therapist rates his or her own level of presence in client, level. Randomization at the session level
the preceding session. The TPI-C contains three allowed for a comparison of conditions for the
items in which the client rates his or her therapist’s same clients and therapists, thus reducing the
level of presence in the preceding session. Reliability potential issues with internal validity that might
and validity for both versions of the measure have have occurred if clients or therapists actually differed
previously been reported to be adequate (Geller between conditions (e.g., clients with most severe
et al., 2010), with internal consistencies ranging symptoms seen by therapists assigned to one condi-
from .82 (TPI-C) to.94 (TPI-T). The TPI-C has tion). Because the sessions were nested within clients
been found to predict client scores on the client (some clients were seen for multiple sessions during
version of the Working Alliance Inventory (Horvath & the study) and the clients were nested within
Greenberg, 1989) and a rating of session effectiveness therapists (some therapists conducted multiple ses-
(CTSC-R; Watson, Schein, & McMullen, 2010). sions with multiple clients during the study), the data
Within the current sample, internal consistency was obtained from the sessions were not independent.
found to be .94 for the TPI-T and .72 for the TPI-C. Given the non-independence of the data, hierarchical
 82 R. Dunn et al.

linear modeling, compared to an independent sam- session, regardless of whether their therapists en-
ples t-test or an ANOVA, provides a more appro- gaged in pre-session centering or another activity.
priate method for data analysis (Adelson & Owen, Last, we were interested in examining whether
2012; Kenny & Hoyt, 2009). In this study we were clients rated the sessions as more effective using the
not interested in examining whether a set of client SRS in sessions that followed the therapist centering
and/or therapist variables were able to predict exercise. Clients failed to complete the SRS for four
therapist presence or session effectiveness. Instead sessions that were preceded by centering and 11
we were only interested in testing whether differences sessions that were preceded by another activity. On
in session presence and effectiveness existed between average, clients rated the quality of the session as
the sessions that were preceded by therapist center- M 381.66 (SD 26.01) for sessions that were
ing and those preceded by some other activity. Thus, preceded by the centering exercise (n 64). In
clients and therapists were included at Levels 2 and 3 contrast, clients rated the quality of the session as
and condition (centering or control) was entered at M 363.64 (SD 40.87) for sessions that were
Level 1 in order to account for the nested nature of preceded by a control activity (n 53). Using
the data, but no client or therapist predictors were HLM, the adjusted difference between groups,
included in any of the models. 13.48, 95% CI [3.46, 23.50], was found to be
significant, t(260.43) 2.65, p B.01, d.52, thus
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indicating that clients perceived the sessions as being

Results more effective when their therapists engaged in the
We were first interested in examining whether centering exercise prior to the start of the session.
therapists perceived themselves as being more pre-
sent using the 21-item TPI-T in sessions that were
Discussion
preceded by the centering exercise. Therapists failed
to complete the TPI-T for six sessions that were The purpose of this study was to test whether
preceded by centering and three sessions that were engaging in a mindfulness centering exercise
preceded by another activity. On average, therapists 5 minutes before a session could have a positive
rated their level of presence as M120.63 (SD  impact on therapy, in particular on therapists’ ability
19.05) for sessions that were preceded by the to remain present in session and on session out-
centering exercise (n 62). In contrast, therapists comes. Although clients perceived their therapists as
rated their level of presence as M111.93 (SD  being highly present regardless of whether their
19.48) for sessions that were preceded by a control therapists completed the mindfulness centering ex-
activity (n 61). Using HLM, the adjusted differ- ercise, therapists perceived themselves as being more
ence between groups, 9.96, 95% CI [.04, 19.88], present in session when they prepared for their
was found to be significant, t(22.40) 2.08, pB.05, sessions by engaging in a mindfulness centering
d .45. These results indicate that therapists per- exercise. In addition, clients did perceive the sessions
ceived themselves as being more present in session as being more effective when their therapists engaged
when they prepared for their sessions by engaging in in the centering exercise prior to the start of the
a mindfulness centering exercise. session.
We were next interested in testing whether clients Mindfulness training has been found to impact
rated their therapists as being more present using the therapeutic skills and attributes, and some existing
three-item TPI-C in sessions that were preceded by evidence had demonstrated that it also has an
the centering exercise. Although all clients were influence on therapy outcomes (Aggs & Bambling,
asked to complete the TPI-C following sessions, a 2010; Bruce et al., 2010; Ryan et al., 2012). This
few indicated that they were pressed for time due to study offers support for the idea that mindfulness
other obligations (n 4 for centering condition, practice is a positive predictor of session outcomes.
n 9 for control condition; see Figure 1). On Furthermore, in this study we show that mindfulness
average, clients rated their therapists’ level of pre- can also be used as a convenient, in-the-moment tool
sence as M19.78 (SD 1.74) for sessions that for therapists to utilize when preparing for an
were preceded by the centering exercise (n 64). In upcoming session.
contrast, clients rated their therapists’ level of pre- Similar to the findings of McCollum and Gehart
sence as M19.44 (SD 1.66) for sessions that (2010), our results indicated a positive relationship
were preceded by a control activity (n 55). Using between therapist mindfulness and therapists’ self-
HLM, the adjusted difference between groups, 0.30, perceptions of their therapeutic presence during
95% CI [ .77, 1.38], was not significant, t(14.47)  sessions. Our findings combined with previous re-
.60, p .56, d.20, thus indicating that clients search offer support for the use of training in mind-
perceived their therapists as being highly present in fulness as a means to increase therapists’ feelings of
 Pre-session therapist centering 83

Eligible clinicians (n = 44)

Clinicians recruited to participate

(n = 31)

Dropped out of
5-week mindfulness training training (n = 1)

Dropped out of study

(n = 2)

Did not see any clients

during randomization
phase (n = 3)

Clinicians participating in centering

randomization phase of the study (n
= 25)
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132 sessions for participating clinicians (n = 25) during

randomization phase—represents sessions for 89 clients

68 sessions preceded by centering 64 sessions preceded by control

exercise activity

Post session data Post session data

TPI-T for 62 sessions TPI-T for 61 sessions
TPI-C for 64 sessions TPI-C for 55 sessions
SRS for 64 sessions SRS for 53 sessions

Figure 1. Flow chart of study procedures and data capturing.

presence with clients. The use of mindfulness may be to the session rated their session as significantly more
particularly beneficial for beginning therapists who effective than clients seen by therapists in the control
may experience ‘‘inner chatter’’ and a reduced ability group. Our results suggest that even a brief mind-
to remain attentive and present in the room when fulness centering exercise can have a positive impact
they first embark on seeing clients. Future research on clients’ perceptions of treatment. The brief
may wish to focus specifically on this possibility. mindfulness training program and the 5-minute
Unexpectedly, our results indicated that therapists’ mindfulness exercises used in this study suggest
completion of the mindfulness centering exercise that therapists can conveniently integrate mindful-
before a session did not significantly predict clients’ ness practice into their training in order to improve
perceptions of therapeutic presence during sessions. therapeutic outcomes.
The null finding could potentially be attributed A second unique strength of this study can be
to the ceiling effect associated with the measure found in the study design. In this study we chose to
that was used to assess clients’ perceptions of randomize sessions rather than clients or therapists
therapeutic presence. The average rating of clients to conditions. Previous studies of mindfulness have
was 19.78 out of 21. randomized therapists to either engage or not engage
A unique strength of the present study was that we in mindfulness practices throughout the duration of
examined the effect of a brief mindfulness centering the study (e.g., Grepmair et al., 2007). These
exercise immediately prior to a session, while in previous studies have thus demonstrated that a
other studies therapists were only asked to engage in client’s outcomes can be improved if he or she is
mindfulness practice during the training period. Our assigned to a therapist who practices mindfulness.
results indicated that clients seen by therapists who With our design we demonstrate that even a single
completed the mindfulness centering exercise prior therapist can see session improvements (client rat-
 84 R. Dunn et al.

ings of effectiveness and therapist presence) for the lyses of recordings, or measuring immediate effects
sessions that she or he precedes with a mindful on the therapist and/or client.
centering exercise compared to the sessions that she Existing research has established that therapists’
or he does not precede with mindful centering. In use of mindfulness can positively impact their
turn, with our design, we demonstrate the same personal well-being as well as their perceptions of
client will experience a more positive session if his or their own therapeutic skills and attributes. The
her therapist prepares for it by practicing centering present study offers preliminary evidence that practi-
compared to some other pre-session activity cing a brief mindfulness exercise immediately before
Although our design allowed us to make between- a session can also improve session outcomes from the
condition comparisons within the same therapists clients’ perspective. It is recommended that graduate
rather than between therapist conditions, because programs in psychology offer training in mindfulness
randomization occurred at the session level rather to students and encourage students to engage in
than the therapist level we cannot be sure that mindfulness exercises as a means to prepare for their
therapists had an even distribution of sessions across
upcoming sessions.
conditions. In other words, it could be possible that a
particular therapist ended up having more sessions
randomized to one of the conditions over the other. References
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