The Association of Medical Faculties of Canada has set a strategic direction to transform
medical education through the implementation of competency-based training programs
[1]. We propose an application of this paradigm to the training of Mindfulness-Based
Interventions (MBIs) in Canadian psychiatry postgraduate programs. We have developed
competency-based guidelines, informed by a survey of postgraduate directors on current
MBI training opportunities across Canada, as well as an examination of the unique
training requirements associated with MBIs.
MBIs such as Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive
Therapy (MBCT), and Mindfulness-integrated Cognitive Behaviour Therapy (MiCBT) are
manualized individual and/or group treatments that emphasize mindfulness practices,
along with psychoeducation and reflective discussions, termed inquiry [2–4]. MBIs
have proliferated and are now used to treat a broad range of psychiatric disorders,
including depressive and anxiety disorders, substance use disorders, eating disorders,
and insomnia [5–9]. MBCT is one of the most researched and applied MBI adaptations
within psychiatric practice. It has level 1 evidence as a first-line maintenance treatment
for major depressive disorder and is as effective as remaining on maintenance antidepressants,
with no significant difference in cost [10, 11].
The current Objectives in Training in psychiatry for the Royal College of Physicians
and Surgeons of Canada requires that graduates have “introductory knowledge in assessing
suitability for, prescribing, and delivering … mindfulness training” [12]. It is therefore
incumbent on residency programs to provide introductory MBI instruction so that all
residents are qualified to assess patient suitability for MBIs, as well as to prescribe
these treatments. We argue that “introductory knowledge in delivering” MBIs as described
in the Objectives of Training is not adequate for safe and competent MBI treatment
delivery. Furthermore, it should not be expected that all psychiatrists have competency
in MBI delivery. Rather, only those clinicians who elect to provide mindfulness-based
psychotherapies require advanced training.
Although general training standards, certification programs, and assessment criteria
for MBI clinicians have been proposed, we are unaware of training guidelines or defined
competencies for the training of psychiatrists and psychiatric residents in MBIs,
such as MBCT, directly serving psychiatric populations [13–17]. Standardized competencies
within psychiatry have the potential to promote targeted learning and clear assessment
standards, and complement the Competence by Design framework developed by the Royal
College of Physicians and Surgeons of Canada, which represents a transformational
change in postgraduate training and is scheduled for implementation between 2018 and
2022 [18].
The Competence by Design framework emphasizes outcomes-driven education and assessment
across the spectrum of medical training, in contrast to the current emphasis on defined
time periods within rotations [18]. Knowledge and abilities are specified for six
stages of practice, two of which are applicable to MBI training: Core of Discipline
(Core), which defines abilities integral to all psychiatric practice, and Advanced
Expertise (AE), which denotes development of specialized skill sets [18]. The Competence
by Design framework is structured around Entrustable Professional Activities (EPAs),
which refer to tasks in the clinical setting that a supervisor can delegate to a resident,
once sufficient competence has been demonstrated. Organized by CanMEDS roles, discrete
skills and attitudes required for competency with a specific EPA are termed “milestones”
and serve as observable markers of an individual’s ability at a specific stage of
expertise [18, 19]. EPAs can be used as assessment tools to ensure that relevant milestones
have been learned, and the milestones themselves can be used to design curricula and
implement targeted teaching.
We define the EPA of assessing patients for suitability and appropriately prescribing
MBIs as a Core of Discipline activity, for which all psychiatry trainees should be
equipped. Some clinicians will also develop specialization in delivering MBI treatments
and, for senior psychiatrists, in providing MBI training and quality improvement leadership.
To characterize these Advanced Expertise (AE)-stage skills, in the absence of a precedent
within the Competence by Design framework, we have created two sub-stages: AE-Therapist
and AE-Leader. Program directors can use the Core competencies to formalize program-wide
training, while a subset of residents and practicing psychiatrists can be guided by
the milestones associated with the AE-Therapist EPA to plan MBI electives and Continuing
Professional Development opportunities.
In addition to defining EPAs and milestones, we propose MBI training pathways with
examples of specific training experiences for each stage that can be integrated into
psychiatry postgraduate training and Continuing Professional Development programs.
Approaches to possible implementation challenges are also discussed.
Proposed Canadian Psychiatry MBI Competencies
Core Stage of Competency
Psychiatric populations are at increased risk for experiencing symptom exacerbation
during MBIs, for example, the triggering of severe anxiety by maintaining attentional
focus on the breath or body in the context of trauma history, or aggravating rumination
during thought-focused practices [20]. Although most patients with anxiety and depressive
disorders benefit from acquiring mindfulness skills, all psychiatrists must be equipped
to assess suitability in the context of a patient’s unique illness, rendering this
a Core stage EPA (Table 1a).
Table 1
Mindfulness training competency milestones by stage of training and by CanMEDS role
(a) Core of discipline stage (all residents and psychiatrists)
Entrustable Professional Activity (EPA): assess for suitability and prescribe an appropriate
Mindfulness-Based Intervention (MBI)
Medical expert
• Describe the basic psychological framework underlying MBIs and how mechanisms developed
through mindfulness practice result in symptom reduction
• Be aware of the evidence base regarding efficacy of MBIs in various clinical populations
• Exercise appropriate patient selection for specific MBIs based on indications,
contraindications, and alternate treatment options
• Inform patients about expected risks and benefits in the context of best evidence
and guidelines
• Address common misconceptions about MBIs and possible barriers to participation
• Recognize when personal values, biases, or perspectives may have an impact on assessment
and influence either under- or over-prescription of MBIs
Health advocate
• Promote role of MBIs in self-management, relapse prevention, and maintaining wellness
within and beyond the clinical environment
(b) Advanced expertise–therapist stage (self-chosen residents and psychiatrists)
Entrustable Professional Activity (EPA): deliver a manualized MBI to individuals or
groups for whom it is indicated, with fidelity to core aspects of mindfulness-based
teaching (assumes core milestones are met)
Medical expert: Perform a patient-centred clinical assessment and establish a management
plan
• Devise an individualized formulation for each patient, establishing a rationale
for selection of an MBI as a treatment of choice
• Demonstrate an awareness of psychological frameworks underlying MBIs
• Identify specific target symptoms for each patient and outline the rationale for
addressing individuals’ target symptoms using theorized MBI mechanisms of action
• Obtain and document informed consent, including the rationale for, and mechanisms
of, MBIs, and describe possible adverse effects
• Address common misconceptions about mindfulness that can become barriers to practice,
such as expectation of specific outcomes (e.g., relaxation)
Medical expert: Plan and perform therapies for the purpose of management
• Guide MBI-specific mindfulness practices, languaging the instructions to integrate
essential elements of practice, such as attentional placement, noting of specific
characteristics of objects of attention, and attitudinal underpinnings
• Draw on personal mindfulness practice to exemplify present moment focus and attitudinal
underpinnings of mindfulness practice (e.g., receptivity, equanimity, metacognitive
awareness) through behavior and verbal and non-verbal communication, utilizing these
processes to inform management of the needs of individuals and of the group
• Inquire on MBI-specific mindfulness practices, using an experiential focus to explore
the direct experience of practice, reflect on this experience and apply learnings
to daily life (i.e., the three layers of inquiry)
• Utilize participants’ descriptions of mindfulness practice during inquiry to inform
pacing and presentation of session content in guided practices and discussion
• Understand the integration of mindfulness techniques with cognitive-behavioral
techniques, including psychoeducation and behavioral activation
• Foster the recognition and development of metacognitive awareness, guiding participants
to practice meta-awareness, disidentification from internal experience, and reduced
reactivity to thought content
• Discern between psychiatric symptoms and the arising of mental phenomena associated
with meditation “side effects”
• Recognize when to seek supervision from a senior MBI teacher regarding occurrences
beyond the limits of one’s expertise, such as management of specific MBI “side effects”
• Contribute to continuous quality improvement of MBIs and attention to patient safety
• Engage in learning and improvement through regular supervision and other means
of reflecting on and assessing MBI facilitation skills
Communicator
• While embodying mindfulness skills, demonstrate ability to establish, repair when
necessary, and maintain therapeutic alliance
Collaborator
• Recognize that MBIs are brief treatments in the context of chronic illnesses and
negotiate overlapping and shared care responsibilities with clinical colleagues
Health advocate
• Facilitate MBIs with awareness of their role for self-management, relapse prevention,
and maintaining wellness within and beyond the clinical environment
Scholar
• Maintain and expand knowledge and skill base through academic and clinically oriented
training materials and regular supervision
• Use assessment and feedback, including from peers and mentors, to inform a professional
enhancement plan for ongoing MBI learning
(c) Advanced expertise–leader stage (self-chosen senior psychiatrists)
Entrustable Professional Activity (EPA): support effective MBI delivery and integration
into healthcare systems, with attention to continuous quality improvement and scholarship
(assumes core and AE-therapist milestones are met)
Medical expert
• Consult on challenging or unusual clinical situations
• Teach MBI fundamental principles related to the Core and AE-Therapist EPAs
• Supervise AE-Therapists, with fidelity to MBI principles
• Develop modified mindfulness interventions for special patient populations
Leader
• Lead quality improvement initiatives related to MBI provision
• Develop and implement MBI delivery models that improve care, value, and efficiency
Health advocate
• Respond to the health needs of the population by supporting, planning, and leading
program development for MBIs, given their role in self-management, relapse prevention,
and maintaining wellness
Scholar
• Participate in research efforts, discussing and disseminating research findings,
with an understanding of the scientific principles related to MBI theory and practice
• Advance knowledge and skill base through academic and clinical teaching and scholarship,
including interdisciplinary collaboration
• Use assessment and feedback to reflect on fulfillment of CanMEDS roles and inform
a professional enhancement plan for ongoing MBI learning
Professional
• Contribute to the development of standards of competency and ethical codes governing
MBI provision
• Provide mentorship to colleagues, exploring challenges and opportunities in MBI
provision and inquiring on the mentee’s personal mindfulness practice
Specifically, clinicians need to be aware of potential contraindications to intense
practices in MBCT, such as the intolerance of affect associated with borderline personality
disorder. These patients are better served by interventions such as Dialectical Behaviour
Therapy, in which mindfulness practices are intentionally brief and carefully designed
to gradually progress exposure to bodily sensations [21]. In addition, clinicians
must consider the suitability of MBI providers, recognizing the lack of standardization
among non-certified MBI clinicians and the implications for MBI delivery, safety,
and efficacy.
To appropriately inform patients when prescribing MBIs, psychiatrists need to master
several knowledge-based milestones: familiarity with a clinically applicable definition
of mindfulness, such as the alert, receptive, and equanimous observation of moment-to-moment
experience [22], as well as awareness of the mechanisms by which mindfulness leads
to symptom improvement, including increased interoceptive awareness, affect tolerance,
attention regulation, and the development of metacognitive awareness [23]. They must
be able to address common misconceptions that can be barriers to participation, such
as mindfulness misconstrued as religious practice, or as detachment from emotions
or emptying the mind of thoughts. They may need to clarify the common misunderstanding
that mindfulness favors acceptance over taking action. In actuality, mindfulness is
a platform for change: some mindfulness-based treatments, such as MiCBT, require patients
to identify specific maladaptive behaviors (e.g., those that stem from avoidance)
and to define measurable outcomes that indicate their successful resolution (e.g.,
socializing three times a week in previously avoided situations), thus targeting specific
symptoms and functioning [4].
Advanced Expertise-Therapist Stage of Competency
We propose an AE-Therapist EPA of delivering MBIs with fidelity to key aspects of
mindfulness-based teaching. Foremost among the milestones (Table 1b) is an experiential
understanding of mindfulness, as it is the clinician’s own experiences with meditation,
combined with an understanding of the psychological framework underlying MBIs, that
allows for optimal structuring and languaging of practice instructions and inquiry
[24]. For example, the development of equanimity, defined as bringing an equal interest
to each moment of subjective experience, irrespective of its implicit affective valence
(pleasant, unpleasant, or neutral), plays a key role in symptom reduction [25, 26].
Given that developing equanimity includes repeatedly returning attention to unpleasant,
unwanted sensations, or pleasant, highly desirable sensations, without enacting even
subtle forms of avoidance or attachment, it is nearly impossible for a clinician to
guide participants through these practices without having repeatedly worked equanimously
with a variety of sensory experiences and emotional states in their own mindfulness
practice.
One of the more challenging AE-Therapist milestones is acquiring the skill of inquiry,
the interactive investigation of mindfulness practice. During inquiry, the clinician
begins by supporting an observational stance through exploration of the patient’s
direct experience of meditation, with emphasis on bodily sensations. Attention is
drawn to present-moment experience, rather than narratives of the past or forecasts
of the future. In the second stage of inquiry, the clinician investigates mental processes
that follow from direct experience, such as habitual reactions of attachment or aversion
to pleasant and unpleasant sensations. Finally, in the third stage, the clinician
assists patients in linking the recognition of these habitual reactions to their role
in propagating symptoms, such as panic or avoidance of intimacy. AE-Therapists avoid
being formulaic with inquiry but rather conduct it as a relational mindfulness practice
[27].
Through mindfulness practice and inquiry, patients develop metacognitive awareness,
the interrelated processes of meta-awareness, disidentification from internal experience,
and reduced reactivity to thought content [28]. Metacognitive awareness has been shown
to contribute to positive outcomes by mediating reduction in anxiety and depressive
symptoms [29]. MBI clinicians support participants in relating to thinking as a process
(e.g., “I am having thoughts about tomorrow”) instead of identifying with the content
of thoughts (e.g., “Tomorrow is going to be a busy day”). Meta-awareness promotes
disidentification, allowing patients to relate to experience as transient and arising
independently of self-narrative (e.g., “A feeling of happiness is present” rather
than “I am happy”). In turn, meta-awareness and disidentification aid the ability
to notice thoughts without reacting in habitual ways that perpetuate depressive or
anxious states. Participants are then better able to disengage from mental proliferations
typical of psychiatric syndromes and to recognize capacity for choice in response
to internal and external experiences, particularly those that could precipitate relapse.
Despite the popular view that MBIs are solely benign or beneficial, challenging “side
effects” can be encountered [30]. These can be divided into two broad categories [31].
The first includes states that can usually be addressed with guidance by skilled teachers,
such as transient dissociative states and increased anxiety. The second, while less
common, are effects that may persist during daily life, outside of formal meditation
practices. These can include destabilizing symptoms consistent with psychiatric syndromes
such as depression, mania, prolonged derealization, psychosis, and suicidality, several
of which require swift clinical management. In the traditions from which MBIs are
derived, the occurrence of these latter effects is anticipated and proactively managed
[24]. The recognition of their potential occurrence has led to the development of
training modules for MBSR and MBCT clinicians to include in formal training programs
(Britton, 2016 August 30, personal communication) covering adverse effects, multiple
interpretive frameworks, and empirically based management strategies. A questionnaire
is also under development to aid clinicians in the early detection, corrective instruction,
and clinical management of these adverse effects (Britton, 2016 August 30, personal
communication). Therefore, clinicians at the AE-Therapist stage must be able to recognize
both categories of side effects and provide appropriate psychological and pharmacotherapeutic
treatment. Competency includes recognition of the need to consult with AE-Leader clinicians,
who can assist with contextualization of experiences for participants and advise on
modifying MBI practice instructions.
Advanced Expertise-Leader Stage of Competency
The AE-Leader EPA involves providing mentorship, supervision and teaching to MBI therapists,
and leading integration of MBIs within healthcare systems (Table 1c). These clinicians
draw on well-established personal mindfulness practices and in-depth knowledge of
meditation phenomena to provide clinical consultation for exigent cases. AE-Leaders
also direct systemic quality improvement initiatives, trialling, and assessing optimal
means for supporting MBIs as integrated components in stepped-care models for chronic
and recurrent mental illness. This involves advocating for the role of MBIs as self-management
strategies in systems that have traditionally focused on acute care. AE-Leaders may
have the opportunity to support and implement novel MBI delivery models, such as online
platforms, in order to improve care and efficiency. AE-Leaders contribute to refining
standards of competency, in collaboration with others in the international MBI community,
as clinical applications of mindfulness and understanding of underlying mechanisms
evolve.
Implementation of MBI Training
The processes that specialty postgraduate programs will utilize to implement the Competence
by Design framework of the Royal College of Physicians and Surgeons of Canada are
under development. We describe possible training pathways for successful performance
of the three MBI EPAs, providing examples of the breadth of teaching formats, as well
as possible challenges in implementation.
Training Experiences for Core Stage
There is a requisite amount of both didactic and experiential information for clinicians
to assimilate to support successful execution of the Core EPA. Additional learning
will occur under supervision as residents incorporate MBIs into treatment plans. The
milestones (Table 1a) outline required curricular content, such as knowledge of the
psychological framework underlying MBIs, and associated mechanisms of symptom reduction.
This content could be taught by means of online case-based modules, accessed in a
manner synchronized with the learner’s needs. Ideally, comprehensive content could
be developed by MBI experts and distributed online nationally. Such non-traditional
approaches could assist psychotherapy curriculum coordinators in ensuring high quality
and standardized competency for psychiatrists prescribing MBIs.
We posit that online learning alone, however, will not be adequate for acquiring those
Core milestones that require an experiential aspect. Seminars led by teachers with
AE-leader qualifications are recommended, and these could be video-conferenced from
other sites for postgraduate programs without qualified faculty. We strongly recommend
that the experiential component link theoretical teaching of the psychological frameworks
underlying MBIs with mindfulness practice itself. This can be achieved, for example,
by seminars where residents are guided in mindful observation of pleasant and unpleasant
sensations and the associated experiences of attachment and aversion. Experiential
exposure through seminars supports other medical expert milestones, such as awareness
of when personal values or biases may be influencing under- or over-prescription of
MBIs. In addition, some programs may consider more extensive mindfulness training
for residents by means of a longitudinal course or supported meditation opportunities
as part of addressing the well-being component of the CanMEDS professional role.
Training Experiences for Advanced Expertise-Therapist Stage
We propose that the following training experiences will promote the acquisition of
competencies for delivering MBIs:
Develop and sustain a personal mindfulness practice that includes formal sitting meditation.
Participate in an MBI clinical group for the duration of the group (e.g., 8 sessions).
This allows trainees to appreciate the interplay of personal practice, CBT concepts,
and group phenomena on an experiential level.
Complete a training program that includes theory, experiential practice, and training
in inquiry. Formal training should optimally include simulated clinical situations
that allow for immediate supervision (e.g., teach-backs or role plays), as well as
case conceptualization informed by theoretical frameworks.
Co-facilitate three or more manualized MBI groups and/or provide one-on-one manualized
MBI to six or more individual patients, with weekly supervision.
These recommendations are consistent with the minimum training guidelines outlined
in MBI certification programs and will equip psychiatrists with an MBI skillset that
ensures integrity of therapy delivery and promotes shared understanding with certified
MBI allied health professionals [13–15]. Where participation in a clinical MBI group
is not available (item 2, above), online MBI programs, such as Mindful Noggin (MBCT)
or Sounds True (MBSR), offer initial exposure to MBI content and support the development
of personal practice.
For residents, training to facilitate MBCT (item 3, above) could be integrated by
means of electives, distance-learning training programs, or educational leaves to
attend residential components of MBI certification programs (e.g., MBSR, MBCT, MiCBT).
For example, the University of California San Diego Mindfulness-Based Professional
Training Institute offers 5-day residential trainings that can be completed individually
or as part of certification programs [32]. Comprehensive MiCBT training can be obtained
through an online certification program, removing geographical limitations; trainees
can also access ongoing online MiCBT group supervision after completion of the 3-month
online course [33]. With regards to clinical supervision (item 4, above) where local
AE-Leader supervisors are not available, trainees can access regular supervision through
external MBI training programs that include online mentorship with advanced teachers
or through supervision with AE-Leaders at other psychiatry programs [32].
Training Experiences for Advanced Expertise-Leader Stage
AE-Leader competency is developed through focused work with MBI delivery, supervision,
academic writing and teaching, and collaboration with peers. While these pursuits
are largely self-directed, they can be supported by establishing mentorship relationships,
both with clinical and contemplative practice mentors. Ongoing personal practice continues
to form the foundation for development of milestones, and extended practice, such
as annual 5–7-day silent meditation retreats, is recommended. A cadre of Canadian
leaders needs to be developed to assist with educational product development and to
establish accessible, psychiatric-specific supervision, and Continuing Professional
Development resources.
In summary, in the context of the upcoming transformational redesign of Canadian postgraduate
training to a Competence by Design framework, we propose competency-based guidelines
for training in mindfulness-based interventions. MBIs are an emerging mental health
treatment, and thus invite explication of competencies and incorporation of novel
training methods into psychiatry postgraduate training programs. Ideally, feedback
mechanisms will be built into the new assessment framework, allowing effectiveness
of competency guidelines, such as those presented, to be iteratively assessed and
improved.
We have structured the guidelines around three specific EPAs and recommend that all
psychiatry trainees develop competency for the Core of Discipline EPA of assessing
suitability for, and prescribing, MBIs. A subset of residents and psychiatrists in
the Advanced Expertise stage of the competency continuum may elect to develop proficiency
with the EPA of MBI delivery, and we have defined detailed milestones that can be
utilized to develop a precise and comprehensive skillset that has personal meditation
practice as its core. The advanced training encourages innovative formats that may
include brief residential training and online group and individual supervision. Thus,
even clinicians in under-resourced areas can access MBI leaders, who have a vital
role in training, mentoring, and assuring quality and scholarship. As learning methods
evolve, Canada-wide MBI competencies have the potential to standardize training and
ensure a baseline of MBI knowledge within the Canadian psychiatric community.