I was pleased to be invited to review this book. As the editors note, it addresses a gap in the literature, an area of genuine interest that has not yet been investigated in any elaborated way. As an experienced cognitive behaviour therapist with a much more recent beginning as an instructor in mindfulness-based cognitive therapy (MBCT), I was intrigued to discover how practitioners from different orientations might view the implications for the therapeutic relationship of the recent marriage between mindfulness and clinical practice.

After a brief foreword by the aptly chosen Zindel Segal (one of the original brokers of this marriage), the book is divided into four logically sequenced parts, each prefaced by a brief overview and each containing a chapter by different authors. Part I addresses theory and practice, discussing the nature and role of the therapeutic alliance and its relationship to psychotherapy outcome. Part II considers congruencies between Buddhist and western psychologies in the context of psychotherapy. Part III allows practitioners from a range of orientations to reflect on how, within their particular contexts, mindfulness might enhance the quality of the therapeutic relationship. Part IV describes possible methods for teaching mindfulness and thus enhancing therapeutic presence, empathy and communication.

The essential message of the book can be simply conveyed:

1. 1. The therapeutic relationship is central to positive outcome in psychotherapy.

2. 2. A successful therapeutic relationship depends on the capacity to listen attentively, and to respond with authenticity, sensitivity, empathy and acceptance.

3. 3. Mindfulness practice could encourage the development of these capacities, with beneficial effects for therapist and client.

4. 4. As yet, empirical data are lacking to support these hypotheses.

Thus the book's interest lies not in the gradual unfolding of a complex line of argument but rather in an exploration of how these fairly straightforward propositions might play out in the hands of experienced and creative therapists, working in different contexts and with differing models of psychotherapy.

In Part I, mindfulness is defined by Steven Hick in Chapter 1 as “non-elaborative, non-judgmental, present-centred awareness in which each thought, feeling or sensation that arises in the attentional field is acknowledged and accepted as it is”, “a way of paying attention with empathy, presence and deep listening” (p. 5). He proposes that preliminary research on how this might enhance the therapeutic relationship, though limited, suggests that further investigation is warranted. In Chapter 2, Michael Lambert and Witold Simon note that across different theoretical orientations, the therapeutic relationship is viewed as an essential foundation for productive outcome in psychotherapy. They outline relevant research suggesting that the relationship, rather than being particular theoretically driven interventions, may be the essential prerequisite for change. Evidence supporting this proposition has indeed been provided by a range of studies. However, I suspect this review underestimates both variability in findings and methodological weaknesses in the field. For example, Safran and Muran (Reference Safran and Muran2006) noted that, although a positive correlation between relationship quality and outcome has been consistently shown, it accounts in fact for only about 6% of outcome variance. Equally, what you find may depend on what methods of analysis you use: for instance, Elkin and colleagues (Reference Elkin, Falconnier, Martinovich and Mahoney2006) and Kim and colleagues (Reference Kim, Wampold and Bolt2006) used different methods to analyze the same data set from the big 1980's NIMH trial of treatments for depression, with exactly contradictory results.

Part II includes three chapters exploring the Buddhist roots of mindfulness and relating them to concepts familiar to psychotherapists of many orientations, notably Carl Rogers's central facilitative factors: genuineness/authenticity, unconditional positive regard and accurate empathy. Potential links between these and the decentred, non-judgmental, kindly stance embodied in mindfulness swiftly come into focus but distinctions are also helpfully elaborated: we should not assume one-to-one correspondence. In Chapter 3, Thomas Bien discusses the “Four Immeasurable Minds”: love (the capacity to offer joy and happiness); compassion (the capacity to offer relief from suffering); joy (lightness in the therapeutic encounter, including the capacity to take pleasure in the client's company, laughter and humour); and equanimity (the capacity to experience even painful feelings without being engulfed). Bien suggests that mindfulness meditation might be an effective means of cultivating a helpful therapeutic stance, especially metta (loving kindness) meditation. This, as described, raises echoes of Paul Gilbert's work on compassionate mind and Deborah Lee's on developing a “perfect nurturer” (e.g. Gilbert, Reference Gilbert2005), though with the crucial added dimension that compassion and benevolence are extended step-by-step outward from the self, ultimately to all beings. Paul Fulton (Chapter 4) tackles the difficult concept of “non-self”. He points out that the concept of a self differentiated from others is universal, but nonetheless malleable and shaped by concept and culture. In the west, there is a particular emphasis on individuation – independence at the expense of interdependence and connectedness. Yet “self” can be viewed simply as a higher order concept, a means of organizing experience – an ongoing process rather than a “thing”, momentary and constantly changing: “something we do, not something we are” (p.61). Bien suggests that this becomes clear only through close observation, such as mindfulness practice. Finally, Russell Walsh (Chapter 5) explores how mindfulness practice might enhance empathy by helping therapists to cultivate continuous willingness to see experience afresh, rather than becoming bound by their own theoretical preconceptions, formulations and diagnoses.

In Part III, the argument that mindfulness has a potential role in enhancing the therapeutic relationship and thus therapy outcome is elaborated by clinicians of differing theoretical orientations. In Chapter 6, Kelly Wilson and Emily Sandoz discuss mindful awareness (both the therapist's and the client's) in the context of ACT, capturing ACT's creative capacity to translate knotty behavioural theory into emotionally charged, multi-sensory experiential exercises. They draw parallels between Buddhist psychology and ACT's interdependent principles of psychological health (e.g. present moment awareness, acceptance, cognitive defusion (decentering from concepts) and a transcendental sense of self (self as process, not thing). They suggest mindfulness is important in helping clients to acknowledge their current reality and adopt a commitment to living in accordance with their deepest values. While providing vivid clinical examples, they acknowledge the dearth of supporting research. Alan Marlatt's Chapter 7 is the only one to describe systematically training clients in mindfulness meditation, as opposed to more implicitly integrating mindfulness principles into therapy. Acknowledging a debt to Jon Kabat-Zinn's Mindfulness-Based Stress Reduction (MBSR) and to MBCT, he describes an 8-week programme of relapse prevention for substance abusers, which integrates meditation practices with cognitive-behavioural interventions, much as MBCT integrates meditation with ideas from cognitive therapy for depression. This chapter outlines intensive mindfulness training for therapists and (unusually in this section) describes a systematically developing empirical evidence base. Marlatt also discusses in some depth the benefits of therapists developing a personal mindfulness practice, noting that it enables them to embody the attentive, non-judgemental, compassionate stance they wish to teach participants and that it contributes within classes to a sense of common humanity and shared experience, rather than of an expert dispensing wisdom. As an MBCT instructor, I would fully endorse this recommendation. Jeremy Safran and Romy Reading (Chapter 8) explore the cross-fertilization between Buddhism and contemporary psychoanalysis, in which the therapist is seen as co-creator of a therapeutic alliance, in an encounter shaped by the relational schemas of both parties. Readers of Safran and Segal's Interpersonal Schemas in Cognitive Psychotherapy (Reference Safran and Segal1990), probably the first book to consider relational processes in CBT in depth, will recognize many of the ideas expressed here. Finally, Mishka Lysack (Chapter 9) presents an approach to family therapy influenced by social constructionism, in which dialogue is seen as the prime vehicle for transformation. Within this context, therapy “may be considered a form of co-meditation practice” (p.144) through which the possibility of accepting multiple perspectives (rather than identifying with one as members of distressed families often do) emerges, and dialogue, awareness and compassion can grow.

Part IV turns to how clinicians might best be taught to listen deeply and attend closely to their experience in the therapeutic encounter. In Chapter 10, Shauna Shapiro and Christin Izett note that the cultivation of empathy in therapist training programmes remains relatively unexplored, despite its widely acknowledged importance. They provide an overview of research supporting the use of mindfulness practices (particularly MBSR) to enhance three key processes that they view as central to empathy: reducing stress, fostering self-compassion, and learning to disidentify from one's own perspectives in the interests of seeing through another's eyes (reperceiving). They propose practices that might help in this endeavour: metta meditation, compassion meditation, and informal practice in everyday life (e.g. practising listening attentively in an open and non-judgemental way). Diane Gerhart and Eric McCollum (Chapter 11) explore the role of “therapeutic presence”, acknowledging the difficulty of defining this “ineffable quality”, a “quality of self or way of being” (p. 178), meaning not so much a set of skills or behaviours, but rather a stance in relation to present moment experience in the therapeutic encounter characterized by openness to the client's experience and one's own, the capacity to see these clearly and a deep understanding of common humanity. They outline a highly experiential curriculum designed to encourage this. Verbal feedback supports its usefulness; it would have been useful to see data showing that it results in actual changes in what therapists do, in therapist and patient evaluation of their relationship, and in outcome. Gregory Kramer, Florence Meleo-Meyer and Martha Lee Turner (Chapter 12) recognize that most meditation practices are not relational in nature and describe in some detail “Insight Dialogue” and the “Interpersonal Mindfulness Program” (a short, structured course loosely based on MBSR), which they have evolved and successfully taught over some years. These trainings, rooted in Buddhist teachings, focus on a form of meditation practice involving exploring moment-by-moment experience with another person, with honesty, kindness, respect and curiosity. The authors note that this training, relational in nature, may be more readily transferable to other contexts (including therapy) than personal practice engaged in alone. In Chapter 13, Rebecca Shafir, writing as a speech-language pathologist and neurotherapist, recognizes that therapists' capacity to listen attentively and wholeheartedly is potentially compromised by pressurised working environments that demand multi-tasking and are full of distractions. She draws on mindfulness meditation practices in offering pragmatic guidelines to help therapists to become “mindful listeners”, with the assumption that this is a foundation stone for a successful therapeutic relationship and thus a positive outcome.

In closing, Steven Hick and Thomas Bien draw out unifying themes, identify disagreements and varying shades of emphasis (e.g. the relative importance of technique and therapy process) and highlight the need for further investigation of the book's main propositions.