Teaching Integrity & Mindfulness Based Interventions:- The need for Contextual Integrity
An emerging concept associated with Mindfulness Based Interventions (MBIs) is ‘Intervention Integrity’. This concept in the mindfulness literature has been developed from the work of Weck et al., (2011) who in turn developed the work of Waltz et al. (1993).
Weck et al., (2011) differentiated 3 aspects of treatment integrity (by which they mean the treatment is carried out as intended):
- Adherence: the extent to which the therapist uses interventions and approaches as they are described in the treatment manual.
- Treatment differentiation: how the treatment differs from other forms of treatment (if different treatments were administered).
- Competence: how skilfully the therapist is able to carry out the interventions which, according to Weck et al (2011), includes taking the treatment context into account appropriately. Treatment context includes ‘client variables’ such as the client’s life situation, their specific problems, their degree of impairment and their ability to engage in the therapy.
In the development of instruments to measure intervention integrity in the context of MBIs, such as the Mindfulness Based Interventions Teaching Assessment Criteria (MBI-TAC) (Crane et al. 2012) and the MBCT Adherence Scale (MBCT-AS) (Segal et al., 2002) the competency aspect lost the association with treatment context. For example, Crane et al., (2013) in describing the development of the MBI-TAC state that:
Broadly, there are three dimensions to the concept of intervention integrity: adherence, differentiation, and competence (Weck et al., 2011). Adherence and differentiation may be considered the quantitative aspects of integrity: how frequently the teacher/therapist delivers prescribed intervention procedures and omits proscribed elements, and to what degree these procedures are employed to ensure intervention “purity.” Competence is the skill level of the therapist/teacher in delivering the intervention. While adherence, differentiation, and competence are closely related, they do not presuppose each other. In particular, delivering an intervention with adherence and differentiation does not necessarily mean the intervention has been delivered competently.
It is noticeable that discussions of ‘intervention integrity’ can start to directly equate this to ‘teaching integrity’. We would suggest that teaching integrity needs to encompass intervention integrity and what we term contextual integrity. The discussion below aims to briefly overview why we consider contextual integrity to be important and what we mean by that term.
While there could be significant concerns about inexperienced mindfulness teachers making changes to MBI curricula, it is a different situation entirely where an experienced teacher with a long track-record of working with a particular population adapts an MBI to meet the needs of a particular group. One result of this type of adaptation has been the proliferation of named adapted forms of MBSR and MBCT.
What is possibly more contentious is an experienced teacher delivering a named MBI and making significant adaptations to the curriculum within the sessions to meet emerging need. In doing so, is the teacher going against the ‘integrity’ of the curriculum? This is an important question.
Such ‘in session’ adaptations could be in terms of changes to content, sequencing or pacing. An example could be the decision to repeat a particular mindfulness practice in order to reinforce learning in response to what emerges in the inquiry process following that mindfulness practice. Repeating a practice may have a consequence that content planned for later in the session is abbreviated, missed out or postponed to a following session. Another common example would be the decision to give more time to a particularly rich inquiry process resulting in the need to abbreviate, miss out or postpone later content.
For the teacher to respond in this way by making adaptations to what emerges in the session would seem to be an embodiment of mindful awareness in action – responding to a situation as it is, this moment. This is in contrast to the teacher adhering rigidly to the intervention’s standard curriculum session plan and essentially ignoring contextual issues that might lead to changing the planned curriculum. While extreme adherence is unlikely to be found, we have had a surprising number of discussions with highly experienced professionals and established mindfulness teachers who feel, for whatever reason, unable to make adaptations to standard MBIs to meet the specific needs of the populations they work with and know well.
An example of such adaptations to a standard MBI occurred during the delivery of what was planned to be a standard MBSR course to participants with Parkinson ’s disease (PD) in a pilot research project overviewed here. Follow the body scan in the first session, the inquiry process (and observation of participants during practice) highlighted a common experience of a lack of awareness of sensations in the body and of struggling to stay awake after 5-10 minutes of the body scan. In response to this we could have continued with the standard MBSR curriculum but this would have risked the group struggling with learning experiences that were not accessible to them. While it could be argued that such struggle would be an opportunity to cultivate mindful acceptance of that experience of struggle, this would require the participants to be accessing the very capacities in week 1 that the 8 week course is designed to incrementally cultivate. Our decision was to shorten the body scan practice and to include invitations to move the body. The result of this was a reduction in the tendency to sleep and a gradually increasing capacity to attend to embodied experience.
In order to open up a discussion around the issue of adaptation of curricula we have been using the flowchart below to unpack the processes associated with participant learning experiences on mindfulness courses. It highlights the extremes between a ‘Closed Curriculum’ that is delivered with maximal adherence to a planned (or manualised) curriculum and an ‘Open Curriculum’ that is responsive to the emerging needs of the participants.
The word ‘integrity’ has a potency that can make discussions around these issues seem quite emotive. If ‘teaching integrity’ is primarily associated with ‘invention integrity’ then this can suggest that a mindfulness teacher who does not adhere to the curriculum might be lacking in this quality of ‘teaching integrity’. We have therefore termed the willingness to adapt to participant need ‘contextual integrity’ (highlighting the contextual aspect from Weck et al., (2011)).
In this way teaching integrity can be seen to be a dynamically changing state emerging from the interplay of intervention integrity and contextual integrity.
To complement the 3 aspects of intervention integrity (adherence, treatment differentiation and competence) we would suggest three key aspects of contextual integrity:
- Resonance: The empathic connection to the emerging group process.
- Wisdom: Insight into the underlying processes giving rise to human experience in general and the experience of the participants in the group in particular.
- Courage: It is challenging to let go of the apparent certainties of a session plan and be open to what emerges in response to adaptations made appropriate to participant need.
In due course we intend to publish an article developing these themes and will update this page.
You are welcome to post any comments on this article below. In particular it would be really helpful to have links to other authors addressing the issues associated with our term ‘contextual integrity’.
Also, there is a day symposium exploring issues related to this article being held in Manchester on July 1st – see the booking page here.
Note: The above discussion has focused primarily on adaptations to participant need but there is potentially an equally interesting discussion around adaptions to the teacher’s needs.
Crane, R. S., Eames, C., Kuyken, W., Hastings, R. P., Williams, J. M. G., Bartley, T., … & Surawy, C. (2013). Development and validation of the mindfulness-based interventions–teaching assessment criteria (MBI: TAC). Assessment, 20(6), 681-688.
Crane, R. S., Kuyken, W., Williams, J. M. G., Hastings, R. P., Cooper, L., & Fennell, M. J. (2012). Competence in teaching mindfulness-based courses: concepts, development and assessment. Mindfulness, 3(1), 76-84.
Segal, Z. V., Teasdale, J. D., Williams, J. M., & Gemar, M. C. (2002). The mindfulness‐based cognitive therapy adherence scale: inter‐rater reliability, adherence to protocol and treatment distinctiveness. Clinical Psychology & Psychotherapy, 9(2), 131-138.
Waltz, J., Addis, M. E., Koerner, K., & Jacobson, N. S. (1993). Testing the integrity of a psychotherapy protocol: assessment of adherence and competence. Journal of Consulting and Clinical Psychology, 61(4), 620.
Weck, F., Bohn, C., Ginzburg, D. M., & Stangier, U. (2011). Treatment integrity: implementation, assessment, evaluation, and correlations with outcome. Verhaltenstherapie, 21(2), 99-107.