Introduction
Mindfulness-based cognitive therapy (MBCT) (Segal et al., Reference Segal, Williams and Teasdale2013) is an approved therapy in all Improving Access to Psychological Therapy (IAPT) services in the National Health Service (NHS) in the UK. MBCT is an evidence-based group intervention recommended by the National Institute for Health and Clinical Excellence (NICE) since 2004 for relapse prevention for recurrent depression (NICE, 2022a) and more recently, as a treatment for mild to moderate depression (NICE, 2022a). The NICE guidelines for wellbeing at work (NICE, 2022b) also recommend that ‘all employees’ should be given access to mindfulness courses to support wellbeing.
The ‘Mindful Nation’ report produced by the Mindfulness All Party Parliamentary Group (MAPPG) (2015) recommended that 1,200 new MBCT teachers should be supplied to the UK National Health Service by 2020, equating to 300 new teachers per annum. It recommended using MBCT to treat 15% of those at risk of depressive relapse who met the NICE criteria for MBCT. The report suggested this would cost £10 million per annum leading to a saving of £15 for every £1 spent, with further savings in prescriptions for anti-depressant medication.
While MBCT has become a mainstream treatment for preventing recurrent depression in some parts of the UK National Health Service, it is absent in many others. The Mindful Nation report (MAPPG, 2015) described how 72% of General Practitioners (GPs) wanted to refer patients to NHS mindfulness courses but only one in five GPs had access to NHS mindfulness courses in their area. In an attempt to provide MBCT more readily and equitably in IAPT services, Health Education England (HEE) commissioned training for cognitive behavioural therapists to deliver MBCT in IAPT services in England. Although MBCT training programmes have been running in the UK for many years, this was the first time that training places have been commissioned and funded by a government body, with the explicit intention of meeting NICE guidelines for evidence-based practice.
A national training curriculum (HEE, 2017) was drafted by leading MBCT trainers at University and NHS centres of excellence, as well as researchers and NHS implementers in the UK, together with input from the developers of MBCT, the IAPT Education and Workforce Expert Reference Group and the IAPT Action for Choice Committee. The curriculum was designed to ensure graduates meet the UK Good Practice Guidelines (GPG) for teaching mindfulness-based courses developed by the British Association for Mindfulness-Based Approaches (BAMBA, 2019), the UK’s professional body for mindfulness teachers. Meeting the GPG is the key criterion for inclusion on the BAMBA Register of MBCT teachers, and in 2020, NHS England (2020) mandated that all MBCT teachers in IAPT should be BAMBA-registered.
Graduates from the training meet the stage 2 ‘Basic teacher training’ as identified by Crane et al. (Reference Crane, Kuyken, Hastings, Rothwell and Williams2010) in discussing the UK context, and would meet more requirements than those identified as Level 1 in the international training standards (Kenny et al., Reference Kenny, Luck and Koerbel2020) but would not have taught all of the eight courses or the further 120 hours of training expected from Level 2. This further work would be expected to be done in trainees’ services following the core training by meeting the annual requirements of the GPG (BAMBA, 2019) for supervised practice and continuing professional development (CPD).
The curriculum document (HEE, 2017) stated its expected learning outcomes on completion (HEE, 2017) were to:
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(1) Understand and critique the main MBCT theoretical underpinnings and evidence base.
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(2) Describe the MBCT curriculum and the rationale for different elements.
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(3) Articulate clear rationales for patient selection and undertake MBCT assessment/orientation sessions.
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(4) Have the requisite skills to lead mindfulness practices and support clients in learning and developing mindfulness practices.
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(5) Have the necessary skills to lead all aspects of the MBCT programme and support clients’ learning.
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(6) Choose appropriate methods to evaluate MBCT’s accessibility and effectiveness and interpret these evaluation data.
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(7) Judge when MBCT is appropriate for a particular population and context and maximise MBCT’s accessibility to people from diverse cultures and with different values.
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(8) Reflect on the ethical framework of MBCT teaching and apply this to complex issues arising in clinical practice.
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(9) Sustain a regular personal mindfulness practice, reflect on its relevance to MBCT teaching and embody this learning in MBCT teaching.
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(10) Reflect on teacher learning and development, evaluate progress, engage actively with supervision and set goals for ongoing learning.
Pre-training pre-requisites were to have completed an MBCT course as a participant, to have an established formal, regular mindfulness practice and to be a CBT therapist who had worked in IAPT services for at least a year, or to be accredited by the British Association of Behavioural and Cognitive Psychotherapists (BABCP) as a CBT therapist and working in an IAPT service. Prospective trainees applied through an application form and individual online interview. In addition, the service director in which the individual applicant was working also submitted an application to make their strategic case for providing MBCT in their service, to demonstrate their commitment to supporting their applicant to complete all the requirements of the training and to enabling their staff to continue to meet the GPG in the future, for example through appropriate supervision and further training. Trainers were expected to meet the required standards for trainers set out by Kenny et al. (Reference Kenny, Luck and Koerbel2020) and by BAMBA (2013).
The components of the training included:
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(1) Ten training days over 3–4 months. The format of days 2–9 followed the eight sessions of MBCT programme with a mixture of theoretical explanation and then practising teaching delivery in small groups with feedback. Day 1 covered the research evidence regarding the effectiveness of MBCT in preventing depressive relapse, an exploration of the mechanisms involved in MBCT and the theoretical and empirical foundations of mindfulness practice. Day 10 covered assessing for depression, risk and for the appropriateness of MBCT for potential participants, including contribution from lived experience trainers and evaluating MBCT group outcomes.
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(2) Daily personal mindfulness practice and reflective writing was required for the entire year of the training. This was supported by the further requirement to attend a 5-day mindfulness practice retreat, funded personally, which enabled trainees to deepen their experience of their own practice and to teach from a more embodied place.
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(3) Supervised co-teaching of two consecutive 8-week MBCT groups in the trainees’ IAPT services, co-running the groups either with a fellow trainee or a more experienced teacher. Suitably qualified supervisors, who had completed both mindfulness-specific and IAPT-specific supervision training, were provided by the training programme. Supervisors used the Mindfulness-based Interventions-Treatment Assessment Criteria (MBI:TAC) (Crane et al., Reference Crane, Eames and Kuyken2013) to support focused reflection on trainees’ development. The MBI-TAC is being used by 45 mindfulness-based program (MBP) teacher training centres in 14 countries (Crane et al., Reference Crane, Hecht and Brewer2020).
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(4) Formal assessment of competence. This usually took place on the second MBCT group recorded in its entirety assessed independently using the MBI:TAC (Crane et al., Reference Crane, Eames and Kuyken2013). The MBI-TAC has six domains: Organisation of the Session/curriculum, Relational Stance, Embodiment, Guiding Practices, Inquiry (conveying course themes through interactive inquiry and didactic teaching) and Group Process. Trainees taught their MBCT groups either with another trainee or with an experienced MBCT teacher. They were required to teach the entire content of one or two whole group sessions. Assessors were able to rate competence looking at this session plus at least one other session and enough further material from the eight group sessions to ensure they had seen the assessed trainee lead a practice, an inquiry and a didactic exercise. In line with standard practice on mindfulness programmes nationally, trainees now need to achieve the level of ‘competence’ on five of the six domains and score no lower than ‘Advanced Beginner’ on the sixth domain. If they do not achieve this, they may make a second attempt on a subsequent MBCT group. After a second unsuccessful submission, they would be deemed to have failed the training.
The training was delivered by a national, multi-organisational collaboration with training sites in four centres spread across England. It drew from the extensive experience of the leading UK-based training centres. The training has also rested on a foundation of excellent collaboration with its commissioners, HEE, and with NHS England, who have backed minimum teaching and training standards for MBCT delivery.
Method
Participants
Thirty-seven out of 48 trainees from the first cohort successfully completed the training and answered an end of training evaluation questionnaire. All the trainees were cognitive behavioural therapists working at step 3 of an IAPT service. Seven trainees (15%) withdrew and four trainees (8%) took breaks for personal reasons and are still expecting to submit their assessments of competence.
Measure
Trainees were given forms evaluating all aspects of the training at the end of the training programme. This form asked five closed, Likert-scaled questions about the usefulness of the training for their development as a MBCT teacher; the relevance of the training for their development as a MBCT teacher; the quality of the training delivery; the quality of the training locations; and the extent the training pitched at the right level for their existing level of skills and knowledge.
Open-ended questions asked trainees to expand on their experiences of the teaching days, the supervision, their two taught groups, the retreat, the assessment of competence process, and the administration and organisation of the training. Trainees were asked about the degree to which they were supported by their work do the training and what support they needed post-training to support their continuing development as a mindfulness teacher.
Procedure
Trainees were emailed a questionnaire when they had completed all aspects of the training. Responses were compiled and analysed by an assistant psychologist. Descriptive statistics were used to present findings from the Likert-scaled questions. The data generated by the open-ended questions was analysed using thematic analysis (Braun and Clarke, Reference Braun and Clarke2006). Data were coded and categorised into themes and sub-themes.
Results
Quantitative
Ninety-five per cent of the trainees found the training ‘extremely’ or ‘very’ useful and 94% found it ‘extremely’ or ‘very’ relevant. One hundred per cent of the trainees found the quality of the training ‘excellent’ or ‘good’ and 93% found the quality of the training location to be ‘excellent’ or ‘good’. Ninety-seven per cent thought it was pitched at the right level and 3% thought it was too simplistic. See Table 1 for a summary of the results.
Results as percentages (number of trainees in parentheses) from Likert-scaled questions; n=37
Qualitative
The material generated by each open-ended question on the forms given to trainees at the end of the training, was analysed, coded and categorised into themes and sub-themes. Over-arching themes across all questions were then identified and are presented below.
Theme 1: Trainer and supervisor embodiment and knowledge
Trainees commented on the ‘embodiment’ of the trainers and supervisors Trainers were reported to take a ‘compassionate approach’ with a ‘calm, kind and generous presence’.
‘The modelling of kindness and of “being” whilst teaching was very useful.’
Supervisors were described as having a ‘depth of knowledge’ and ‘embodiment of the practices’, adapting what they did to individual needs and work demands. Trainees commented that supervisors were ‘very supportive’ with ‘genuine warmth’. Trainees reported particularly appreciating ‘concrete feedback’.
‘The genuine warmth of the spirit in which feedback was offered.’
Theme 2: Structure of the training
The training days were described as ‘extremely helpful and supportive’, ‘well structured’ and ‘the group dynamic was really engaging and supportive’. There was an appreciation of starting the training with the attitudinal foundations and of ‘how experiential’ the training days were, with a focus on mindfulness practice.
‘Teaching by discussion, demonstration. It helped to get a grasp on what we were doing intellectually, see it demonstrated then get to practise it experientially. Overall, a very effective way of learning.’
‘The sequence of the eight sessions came together as an overall concept and flow.’
Some found the days ‘full’ with a suggestion to have a ‘longer course to look at sections in more detail’ so there was more time to ‘fully explore theory and develop … competency of doing the practices’ or ‘consolidate learning’. There were also challenges for some people who had to travel sometimes long distances to the training sites which was time they could not always claim back. Some people received no reply to their reflective writing which was de-motivating. Some would have liked ‘more direct communication between the training providers and managers of the services’.
‘As the course was condensed there was not enough time to fully explore theory and develop my competency of doing the practices.’
Theme 3: Retreat deepening and challenging
The value of taking five days out of everyday life to have the opportunity to deepen our practice, understanding and application of mindfulness was appreciated. The retreat was described as ‘amazing’, ‘enlightening’ and ‘powerful’ but also ‘hard’ and ‘frustrating’. Trainees reported the retreat as ‘an opportunity to build on my own practice’, ‘deepen my practice’ and ‘vital to the ongoing practice of mindfulness’. The silence was ‘golden’ and ‘refreshing’.
‘Hard, but so worth it. I loved it and found the experience to be life changing.’
Some trainees reported difficulty with the ‘dorm type sleeping arrangements’, the cost and the logistical challenges of managing child-care arrangements.
‘Some flexibility may be helpful – for myself with two small children it was difficult to find the time and put a lot of pressure on my partner.’
Theme 4: Technical challenges
A number of technical issues were reported. Most of the supervision was online and some would have preferred having it face-to-face. There were connectivity challenges and information governance issues. For example, some Trusts would not allow the use of certain platforms for video conferencing. There were also technical challenges in recording the groups which added a lot of stress and in the process of submitting the recordings for assessment. Administrators were experienced as ‘extremely supportive and understanding with all the ongoing IT/recording difficulties’ and to have ‘gone out of their way to help’.
‘Although technology could theoretically make things work smoothly, in practice there are so many technical and IT issues that it had the opposite effect.’
Discussion
The quantitative evaluation shows a high level of satisfaction with the usefulness, relevance and quality of the training which was considered to have been pitched at about the right level. There was slightly less satisfaction with the training locations which is picked up in the discussion of Theme 2 below.
The trainees’ experience of the trainers and supervisors as exhibiting some of the key qualities that might be expected from mindfulness practice described in Theme 1 – kindness, warmth and presence – suggests that the training staff attended not only to content and outcome but to process. ‘Embodiment’ (Crane and Reid, Reference Crane, Reid, McCown, Reibel and Micozzi2016, p. 122–123; Crane et al., Reference Crane, Kuyken, Hastings, Rothwell and Williams2010; Crane et al., Reference Crane, Eames and Kuyken2013) describes the principle that teachers embody mindfulness as they teach it. It is defined as ‘the quality of instantiating into one’s being, actions and phenomenological experience the skills that are cultivated through mindfulness practice’ (Dobkin et al., Reference Dobkin, Hickman and Monshat2014, p. 4). This develops organically as trainees learn and teach, and is not dependent on a purely intellectual or academic understanding, but it rests predominantly on a firm foundation of personal mindfulness practice (Kabat-Zinn, Reference Kabat-Zinn2011). Crane (Reference Crane2017) goes so far as to state in relation to mindfulness-based programmes that ‘the entire theoretical basis and pedagogy rests upon the experiential engagement in meditation practice by both teacher and participant’. Prior to the training, applicants were expected to have an established personal mindfulness practice, and during the training, trainees were required to maintain a daily mindfulness practice, and sit a 5-day retreat. Nobody could graduate from the training without having completed the 5-day retreat. Although the personal daily practice was not policed, four written reflections on personal practice were required throughout the taught part of the training and personal practice was explicitly stated as one focus of supervision when teaching the two MBCT groups. Post-training, they commit to ongoing regular practice and annual retreat as required by the GPG. This has enabled trainees to teach in an organic and authentic way and not as a technique to be bolted onto an idea about mindfulness. As Piet et al. (Reference Piet, Fjorback, Santorelli and Shonin2016) state: ‘we find it especially important that teaching mindfulness is not viewed as some professional endeavour separate from the foundational intention and practice of bringing awareness to all aspects of one’s life’.
Theme 2 on the structure of the training suggested that the principle embedded in the training of learning by doing was well received, with a demonstration of each session of MBCT followed by a theoretical explanation in the morning and an opportunity for trainees to practise it and get feedback in the afternoon. The actual engagement in all aspects of mindfulness teaching, both on the training programme and then in the MBCT training groups, with intense feedback first from peers and trainers and then from supervisors watching recorded live teaching, supported the development of teachers who would be able to teach from their own experience and not from a merely conceptual understanding of how to teach mindfulness.
Theme 2 also highlighted the recognition of how much ground there was to cover in what felt like a tight schedule with perhaps limited time for reflection and consolidation. The demands of this training programme were significant. Trainees were on a steep learning curve to reach a formal assessment of ‘competence’ on at least five MBI-TAC domains within a year and during the delivery of what for many will be their second taught MBCT group. They needed to do this while working within services that were themselves very often stretched and pressurised places to work in. We are not aware of any other UK mindfulness teacher training that makes such demands in such a short timescale. Commissioners of this training had to strike a balance between ‘high quality training, by drawing on best practice’ and the ‘pragmatic realities of resource constraints, such as funding and release of staff for additional training’ (HEE, 2017). There has been a debate in the mindfulness literature about how the balance between pragmatism and integrity is struck. As Rujgrok-Lupton et al. (Reference Rujgrok-Lupton, Crane and Dorjee2018) state, ‘the pressing demand for more Mindfulness-Based Programme (MBP) teachers can conflict with the requirement for in-depth teacher training and meditation experience, widely accepted within the MBP training community as fundamental to ensuring MBPs are conveyed correctly and efficaciously’. Although more resources would have made it possible to increase the training input, there is no evidence that there has been a threat to the integrity of the mindfulness approach through the current required time frame. The achievement of steep learning goals was helped by a selection process that identified motivated people with a good idea of the commitments required by the training, with an established personal mindfulness practice, and with experience in most cases of both group work and therapy with people with recurrent depression.
Theme 3 illustrated the value trainees described gaining from the 5-day silent retreat. There were frequent comments on how it had helped deepen their practice, sometimes in life-changing ways. At the same time, there were no comments on its utility for them as MBCT teachers. There is widespread agreement in the mindfulness teacher training community about the need to support the deepening of practice in those teaching mindfulness to others and it remains a key component of the national GPG for mindfulness teachers. However, we cannot yet point in the literature to an empirically established correlation between deeper personal practice and depth of teaching. There is a debate in the mindfulness teacher training community about whether deepening practice could be achieved in a wider variety of ways (see Oxford Mindfulness Foundation blog, 2016), not least because of the risk of limiting the diversity of those who may become MBCT teachers if this remains an annual requirement in the GPG post-training. This was flagged in Theme 3 in which comments were made about the time and financial challenges of doing retreat, especially for those with caregiving responsibilities.
Although we cannot be sure no adverse experiences occurred on retreat, it is worth noting that none was reported. There has been more interest in the last few years, both in the popular media and in academic circles about the possible harm that could be caused by meditation. Various authors (e.g. Aizik-Reebs et al., Reference Aizik-Reebs, Shoham and Bernstein2021; Baer et al., Reference Baer, Crane and Montero-Marin2021; Hirshberg et al., Reference Hirshberg, Goldberg, Rosenkranz and Davidson2022; Lomas et al., Reference Lomas, Cartwright, Edgington and Ridge2015) have stated that we should not be complacent about harm and that further research is needed but that any harm from mindfulness meditation tends to occur infrequently, transiently and manageably. Goldberg et al. (Reference Goldberg, Sin, Britton and Davidson2021) reported some slightly more frequently occurring and longer-lasting trauma reactions and generally these have tended to have been reported more frequently in retreat situations than in less intensive mindfulness programmes. Set against this, Khoury et al. (Reference Khoury, Knäuper, Schlosser, Carrière and Chiesa2017), reviewing 21 studies, found positive effects from retreats on measures of anxiety, depression and stress, emotional regulation and quality of life.
As reflected in Theme 4, there were frequent difficulties with technical issues either in connecting with supervisors on Zoom and sharing recordings from their teachings remotely and also in the assessment of competence submission process. Sometimes these were purely technical issues, such as poor internet connections or lack of familiarity with the platform’s functionality, and sometimes they were more information governance issues such as NHS Trusts not approving the use of certain online platforms or clouds. Most supervisors used Zoom but some Trusts did not allow Zoom and required MS Teams. Those who could use Zoom were not initially all familiar with the technicalities of sharing recorded teaching and making it fully audible to supervisors. In the period following this evaluation, we have all been given a great deal more experience of working online due to COVID, and the familiarity of trainees, trainers and supervisors with platforms like Zoom and MS Teams has increased massively. Organisations have also had to become more flexible in terms of how they allow information to be shared electronically and as a result, the picture has now changed from that described here.
Strengths and limitations
This study offers multiple indicators of the ways in which this training worked and also needed revision. Its mixed quantitative and qualitative data allows for triangulation in methods (Noble and Heale, Reference Noble and Heale2019) and the richness of its open-ended questions is a strength, particularly when exploring the effects of experiences like a retreat which may serve a variety of different purposes and have widely varying outcomes.
Its limitations include the lack of demographic data of the trainees which means that trends based on demographics cannot be identified. The fact that trainees completed the questionnaire on completion of the training meant that the data from those who did not complete the training are not available. Reporting on the reasons why some trainees dropped out would help inform strategies for future retention. It would also be useful to have data on how many MBCT courses were taught after graduating and to what extent those graduate teachers continued with their own regular mindfulness practice. These issues should be addressed in future evaluations.
Implications for trainers
Various revisions to subsequent cohorts have already been made to this training based on this evaluation:
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(1) More supervision and tutor time has been made available to allow for deeper consolidation of learning.
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(2) An additional training day was provided after trainees taught their first MBCT group, allowing trainees to return to the material learnt on the training days but with the hindsight of a real world application. Particular emphasis was given on that day to ‘inquiry’ (the process of engaging in dialogue with course participants in the form of an interpersonal mindfulness practice) as this was the aspect of teaching MBCT that trainees tended to struggle with most at first.
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(3) Better communication with IAPT services has enabled the training programme to provide guidance in recruiting patients for trainee MBCT groups, support to increase understanding of the various pressures on trainees (for example for preparation time for groups) and advice on the suitable pre-requisites for starting this training and ongoing governance requirements for continuing to teach MBCT in IAPT.
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(4) More advice has been provided on recording, working online and submitting online so it is a smoother and less stressful experience.
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(5) Greater flexibility has been provided to those who are unable to sit a 5-day residential retreat by allowing online options or by splitting this requirement into two long weekend retreats where caregiving or financial constraints make the full 5-day residential option untenable. Although trainees need to be able to pay this themselves, in practice, many services are also now paying for it, making it less of a bar for those with less means.
Conclusion
This is the first training of its kind and the results demonstrate the feasibility of operating a national, multi-site, multi-training centres’ collaboration operating in partnership with government bodies such as HEE and NHS England. It points to the value of delivering a mindfulness training in a way that is mindful, modelling for trainee teachers the central importance of their own mindfulness practice and embodiment for their potency as MBCT teachers. It shows that, despite some challenges, the inclusion of a 5-day silent retreat as a core part of the training was possible, and likely to have been safe and effective in deepening practice, and was in some cases transformative. It highlights some challenges around technical delivery which have been addressed.
Key practice points
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(1) Multi-site and multi-agency collaboration can work very effectively in the delivery of a national training programme.
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(2) Collaboration between training programmes and IAPT services supports the delivery of training that occurs within those services.
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(3) Mindfulness ‘embodiment’, as described in the MBI-TAC (Crane et al., Reference Crane, Eames and Kuyken2013) is key to engagement in training and to authenticity in the mindfulness approach to working.
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(4) Attending a 5-day silent mindfulness retreat present challenges but deepens the practice of many and is transformative for a few.
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(5) Providing advice and solutions on technical challenges of operating online is required for the smooth operation of training and to reduce stress.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Acknowledgements
We would like to thank Professor Willem Kuyken at Oxford University for drafting the curriculum, Dr Adrian Whittington at NHS England and Neil Carleton at HEE for commissioning the training, Dr Paul Bernard, Dr Tim Sweeney and Kay Octigan, Dr Rachel Handley, and then Dr Nicole Jamani, the training site leads for this training cohort for steering and delivering the training at their sites, Professor Clara Strauss for leading the evaluation of the MBCT groups, Alison Yiangou for leading the assessment of competence process and for all the supervisors, assessors, trainees and patients who together made the training possible.
Author contributions
Robert Marx: Conceptualization (equal), Project administration (equal), Supervision (equal), Writing – original draft (equal), Writing – review & editing (equal); Pippa Menzies: Investigation (lead), Methodology (lead); Richard Symon: Methodology (supporting), Writing – review & editing (supporting); Sally Turner: Methodology (supporting); Amy Pound: Methodology (supporting).
Financial support
The training that this paper reports on was funded by HEE. However, the evaluation received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
The lead author was the national lead for delivering the training. There were no other conflicts of interest.
Ethical standards
The authors confirm that they have abided by the ethical principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. Specific ethical approval for this study was not required as it formed part of routine audit that was an agreed part of the training programme tender approved by HEE.
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