Examining the Therapist Mindfulness in the Context of Therapeutic Alliance and Therapeutic Relationship: A Systematic Review

Headnote

The objective of this study is to conduct a comprehensive review literature researches examining the relationships between therapist mindfulness and the therapeutic alliance and therapeutic relationship. To this end, articles published on the subject between 2006 and 2024 were identified through a search databases PubMed, Web of Science, Medline, Taylor & Francis Online, Science Direct, Turkish Psychiatry Index, ULAKBIM and TR Index databases using the identified keywords. After rigorous evaluation process based on the inclusion and exclusion criteria, 25 quantitative, qualitative and mixed methods studies were included in this study. Mindfulness practices were mostly conducted under the guidance of the Mindfulness-Based Stress Reduction programme, which includes a variety of practices such as body scanning, hatha yoga, sitting meditation, daily mindfulness practices and conscious relaxation exercises. The results showed that mindfulness supports the therapeutic alliance in a very consistent way. It was found that therapists' acceptance of themselves and their clients increased with the practice of mindfulness, and that clinicians with high levels of mindfulness were able to maintain the therapeutic alliance more effectively. It was found that clinicians who practised mindfulness on a weekly basis were able to engage in a stronger therapeutic alliance than those who did not practise at all, and clinicians with a high frequency of weekly practice were able to engage in a stronger therapeutic alliance than those with alow frequency of practice. In addition, mindfulness practice was found to support the therapeutic alliance through several mechanisms, such as reducing countertransference, increasing empathy, and increasing tolerance of negative emotions. In conclusion, the findings of this review suggest that increasing therapists' levels of mindfulness would be a highly worthwhile endeavour in terms of developing a strong therapeutic alliance. Keywords: Therapist mindfulness, mindfulness, therapeutic alliance, therapeutic relationship

Bu çalışmanın amacı, terapistin bilinçli farkındalığı ile terapötik ittifak ve terapötik ilişki arasındaki ilişkileri inceleyen alanyazın çalışmalarını sistematik olarak gözden geçirmektir. Bu amaçla, 2006- 2024 yılları arasında konu ile ilgili yayınlanmış makaleler belirlenen anahtar kelimeler kullanılarak, PubMed, Web of Science, Medline, Taylor & Francis Online, Science Direct, Türk Psikiyatri Dizini, ULAKBİM ve TR Dizin veri tabanlarında taranmıştır. Dahil etme ve hariç tutma kriterlerine dayalı incelikli bir değerlendirme sürecinin ardından, nicel, nitel ve karma yöntemlerle yürütülmüş 25 araştırma bu çalışma kapsamında ele alınmıştır. Bilinçli farkındalık uygulamaları çoğunlukla beden tarama tekniği, hatha yoga, oturma meditasyonu, günlük farkındalık uygulamaları ve bilinçli gevşeme egzersizleri gibi farklı pratikleri içeren Farkındalık Temelli Stres Azaltma programı rehberliğinde gerçekleştirilmiştir. Elde edilen sonuçlar son derece tutarlı bir şekilde bilinçli farkındalığın terapötik ittifakı desteklediğini ortaya koymuştur. Bilinçli farkındalık uygulamaları ile terapistlerin kendilerine ve danışanlarına yönelik kabulünün arttığı, bilinçli farkındalık düzeyi yüksek olan klinisyenlerin ise terapötik ittifakı daha etkili biçimde sürdürebildikleri bulunmuştur. Haftalık olarak farkındalık egzersizi yapan klinisyenlerin hiç pratik yapmayanlara göre; haftalık egzersiz sıklığı yüksek olan klinisyenlerin ise uygulama sıklığı düşük olanlara kıyasla daha güçlü terapötik ittifak kurabildikleri saptanmıştır. Ayrıca, bilinçli farkındalık uygulamalarının karşı aktarımı azaltma, empatiyi ve olumsuz duygulara karşı tahammülü arttırma gibi farklı mekanizmalar aracılığıyla terapötik ittifakı desteklediği bulunmuştur. Sonuç olarak, bu derlemenin bulguları, terapistlerin bilinçli farkındalık düzeylerini artırmalarının, güçlü bir terapötik ittifak geliştirme açısından oldukça kaydadeğer bir çaba olacağını ortaya koymaktadır. Anahtar sözcükler: Terapistin bilinçli farkındalığı, mindfulness, terapötik ittifak, terapötik ilişki

Introduction

The therapeutic alliance, defined as the collaboration and strength of the bond between the therapist and client (Castonguay et al. 2010), is a crucial factor influencing treatment outcomes for various therapeutic interventions and psychological complaints. (Horvath and Luborsky 1993, Martin et al. 2000, Horvath and Bedi 2002, Marker et al. 2013). The abundance of empirical data on this subject has highlighted the therapeutic alliance as a common denominator across different psychotherapy schools (Catty 2004). The therapeutic alliance is also known by various terms such as therapeutic relationship, helping alliance, and working alliance, which are all used synonymously, conveying the same concept (Horvath and Luborsky 1993). Some authors propose the therapeutic alliance as the most significant determinant of the change achieved in therapy (Greenson 1967, Horvath and Greenberg 1989).

Freud was the first theorist to point out that the treatment process does not proceed independently of the therapist-client alliance, stating, "We make the patient collaborative" (Freud and Breuer 1893; cited in Kanzer 1981). Furthermore, Freud (1913) emphasized the critical role of the alliance in therapy, demonstrating that the undisturbed part of the self could take on the healing task by developing collaboration with the actual therapist (regardless of transference). Subsequent theorists put even more precise and direct emphasis on the therapeutic alliance's importance, carrying the relationship's strength in the therapeutic process to a more visible level (Greenson 1967, Safran and Muran 1998). Over time, the need for a conceptualization led Bordin (1979) to define the therapeutic alliance as a measurable structure for empirical research expressed through the goal, task, and bond components, including mutual trust between the therapist and client. According to this approach, while the goal and task components vary depending on the therapist's adopted school, the bond component has found a commonplace in all therapeutic approaches (Soygilt and Isikli 2008). Finally, Gelso (2014) extended the scope of the therapeutic alliance by including the concepts of authentic relationships and transference/countertransference in addition to it. However, since these added components are tightly interconnected with the concept of the therapeutic alliance and can be considered as almost the same concepts (Gelso 2011, Gelso 2014, Gelso and Kline 2019), therapeutic relationship has continued to be used widely synonymously with the therapeutic alliance in the following research.

Although therapeutic alliance develops and deepens over time within the therapeutic process (Horvath 2005), the dynamic nature of relationships means that, like all other interpersonal relationships, the therapeutic relationship also contains unpredictable fluctuations (Glosh 2019). The strain in the relationship between the therapist and the client, or a rupture in the therapeutic alliance, threatens both the trust-based relationship and therapeutic process. However, what is more critical here is not the rupture itself but the failure to repair the disruption within the relationship (Guliim and Soygilt-Pekak 2018, Horvath 2000). In this regard, the therapist needs to be attentive to all psychotherapy process dynamics, not only in constructing the therapeutic alliance but also in overcoming the processes that lead to ruptures within the alliance (Safran and Muran 2000). Freeman and McCloskey (2005) identified four main areas that could negatively affect the relationship established in therapy. These areas comprise client factors (failure to comply with psychotherapy requirements and tasks, etc.), environmental factors (including external or stress from the person's group), factors related to the client's problems and pathology, and therapist factors. When examining the therapist factors in more detail, it becomes clear that this aspect encompasses the therapist's personal values, therapeutic skills, and motivation.

The aforementioned attributes of a therapist are crucial in determining the course of the relationship and the treatment. Wampold (2001) concluded, based on the studies he reviewed, that the therapist's impact dominates the effect of the treatment. Accordingly, therapist attributes such as empathy, non-judgmental acceptance, and affirmation strongly correlate with the therapeutic alliance and treatment outcomes (Orlinsky 1994). Thus, the therapist's impact is evaluated more regarding interpersonal relationship characteristics than the techniques used or orientation adopted (Wampold 2015). Even in research results in which a particular disorder is monitored with a standardized treatment orientation, it has been found that the effect of the therapist on the outcome measurement may vary (Huppert et al. 2001). Nonetheless, another study (Dinger et al. 2008) reported that while the variance of therapists revealing the treatment outcome was 3%, the level of explaining the therapeutic alliance was 33%. Therefore, these results exhibit the critical importance of the therapist's characteristics in establishing the therapeutic alliance. Even though relevant studies have raised the issue of training therapists on how to form better alliances, it has been observed that these trainings are not always as successful as expected (Horvath 2000). The authors treated this as a "failure to learn" and suggested that therapists' unresolved relationship problems prevented them from responding appropriately to their clients. Thus, this has been associated with countertransference dynamics. The research results by Hayes etal. (1998) revealed that therapists could not be entirely separated from their pasts. In this study, 80% of the therapists, regardless of their experience, had a countertransference pattern in their sessions. Hence, the related research finding is striking evidence that the psychotherapy relationship, like any other relationship, is surrounded by social and cultural elements and that the therapist cannot be exempted from it.

Baker (1999) defined a series of factors directly related to the therapist that affect the psychotherapy process. These include the degree of self-awareness of the clinician, the clinician's openness to recognizing the client as they are by surpassing preconceived biases, the degree to which the clinician attempts to understand the client holistically concerning cultural values, and the familiarity between the clinician's and client's larger system affiliations. To manage these factors, the clinician must be able to observe their subjective experiences, including feelings, thoughts, and bodily sensations, and be aware of these positive or negative effects on the therapeutic relationship (Safran and Muran 2000). Moreover, therapists' ability to avoid using their cultural lenses in a way that will affect their opinions about their clients is also possible by increasing clinicians' awareness of the socio-cultural characteristics to which they belong (Baker 1999). For this reason, it is recommended that therapists first examine their past, socioeconomic class, race, and cultural characteristics to increase their awareness. On the other hand, Safran and Muran (2000) emphasized that development as a therapist cannot be considered separately from personal awareness and development. All these point to the significance of the therapist's mindfulness of the process and themselves.

In this regard, recent studies indicate that clinicians' therapeutic presence can be enhanced through mindfulness practices. Mindfulness is a type of awareness that requires a person to be completely aware of their experience within the moment and to accompany the emotions, thoughts, and body sensations they experience in composure without judging (Christopher and Maris, 2010). In other words, mindfulness means accepting the present experience as it is, far from judgment, and with kindness (Siegel et al. 2009). Including the therapist or therapist candidate in mindfulness practices can prevent negative burdens, such as burnout and self-judgment, which may arise during therapy (Dorian and Killebrew 2014, Martin-Cuellar et al. 2019In this regard, therapeutic presence can increase the therapist's listening and adaptation skills. Consequently, all these factors are anticipated to support the therapeutic relationship. Considering this anticipation, numerous studies have been conducted regarding therapeutic presence (Mearns 1997, Ryan et al. 2012, Greason and Welfare 2013) Hence, studies suggested that mindfulness-based practices support the personal growth of therapists/therapist candidates by preventing burnout and indirectly contributing to both therapeutic engagement and the therapeutic relationship. These benefits entailed increased positive emotions and reduced negative emotions (Shapiro et al. 2007, Moore 2008); enhanced positive physical, mental, and emotional experiences (Chrisman et al. 2009, Dorian and Killebrew 2014); greater self-compassion and compassion with a concurrent reduction in judgment (Shapiro et al. 2007, Moore 2008, Chrisman et al. 2009, Dorian and Killebrew 2014); and improvements in therapists' quality of life, subjective well-being, and vitality (Martin-Cuellar et al. 2019). Although, in these studies, the relevant themes were found to be effective in the personal growth of clinicians, the reflections of these practices on the therapy process were not addressed.

Nevertheless, studies examining the effectiveness of mindfulness-based practices and the therapist in the therapy process have similarly shown that mindfulness interventions increase therapeutic skills (Christopher and Maris 2010). These studies are primarily qualitative, exploring an area that had previously been unknown. Based on the findings of qualitative research, review studies have collectively shown that mindfulness-based practices support both the personal lives and professional development of therapists or therapist candidates and contribute to an increase in their therapeutic skills (Guliim 2016, Guliim 2017, Fletcher et al. 2021). Even though the qualitative findings do not reflect the therapists' personal experiences in numerical data (Dunn et al. 2013), these findings indicate that quantitative testing of these relationships would be meaningful.

As a result, this study aims to systematically review both qualitative and quantitative research that examines therapists' mindfulness and the therapeutic process in the context of therapeutic relationship and therapeutic alliance. The prevalence of mindfulness practices and their inclusion in research has accelerated since 2006 (Baminiwatta and Solangaarachchi 2021). The increasing popularity of mindfulness-based practices (Baer 2003) and the growing demand for scientific evidence regarding clinical interventions played a vital role in shaping developments in this field (Ferreira and Demarzo 2024). In light of these developments, this study considers 2006 as a starting point, reviewing published studies from 2006 to September 2024 that explore therapists' mindfulness in relation to the therapeutic alliance and therapeutic relationship. The goal is to provide practitioners with a comprehensive perspective on the subject.

Method

In the current review study, published articles related to the subject of the study were scanned in PubMed, Web of Science, Medline, Taylor & Francis Online, Science Direct, ULAKBIM, Turkish Psychiatry Index, and TR Index databases with the determined keywords and 2006-2024 (September) year limit. The writing language of the articles to be included in the review study is Turkish and English. In the screening process, Turkish keywords and their English equivalents "therapist mindfulness and therapeutic relationship (terapistin bilincli farkindaligi ve terapotik iliski)", " herapist mindfulness and therapeutic alliance (terapistin bilincli farkindaligi ve terapotik ittifak)", "clinician mindfulness and therapeutic relationship (klinisyenin bilincli farkindaligi ve terapotik iliski)", "clinician mindfulness and therapeutic alliance (klinisyenin bilincli farkindaligi ve terapotik ittifak)", "mental health worker's mindfulness and therapeutic relationship (ruh sagligi calisanmm bilincli farkindaligi ve terapotik iliski)", "mental health worker mindfulness and therapeutic alliance (ruh sagligi calisanmm bilincli farkindaligi ve terapotik ittifak)" were used. The scientific publications reached were reviewed considering the inclusion and the exclusion criteria below.

The inclusion criteria;

1. Examination of the relationship between the therapist's mindfulness and the therapeutic relationship/alliance based on qualitative or quantitative data,

a. In qualitative studies, when therapeutic skills, tolerance for silence, increased level of empathy, reduced emotional reactivity toward the client, and the ability to be present with the client, which indicate the strength of the therapeutic alliance and the depth of the therapeutic relationship were incorporated, they should be considered within the context of the therapy process

2. If the study included participants with titles: therapist, psychologist, psychological counselor, and psychiatrist,

3. If multiple articles were based on the same dataset, only the one with a more comprehensive and detailed analysis was included in the study,

The exclusion criteria:

1. The therapist's mindfulness and the concepts of therapeutic relationship/alliance were not addressed together,

a. For qualitative studies, therapeutic skills related to the strength of the therapeutic alliance and depth of the therapeutic relationship were included but not in the context of the therapy process.

2. If the study did not include participants with titles: therapist, psychologist, psychological counselor, and psychiatrist,

3. If mindfulness was considered as a quality of the client/patient, not the therapist's,

4. Articles that are review, literature review, or theoretical text,

5. If multiple articles were based on the same dataset, the one with a more comprehensive and detailed analysis was not included.

Screening the aforementioned databases excluded some studies from the review due to the specified exclusion criteria. While the scanning revealed an extensive number of studies focusing on mindfulness, many were outside the scope of the current review by the first exclusion criterion (Moore 2008, Stafford-Brown and Pakenham 2012, Dorian and Killebrew 2014), the third exclusion criterion (Kalmar et al. 2022), the fourth exclusion criterion (Bruce et al. 2010, Campbell and Christopher 2012, Brito 2014, Fletcher et al. 2021), and the fifth exclusion criterion (Christopher et al. 2006, Schure et al. 2008). Additionally, four studies were not included in the current study due to the second exclusion criterion. Although these studies examined mindfulness and the therapeutic relationship, they were excluded since their participant groups consisted of pediatric occupational therapists (Smith et al. 2024), healthcare professionals (Leger et al. 2023), nurses (Aldridge 2015), and first-year medical students (Saunders et al. 2007), which fell outside the scope of this study. As a result, 25 studies that met the inclusion criteria were examined in this review study.

Methodological Characteristics of the Studies

Sample

The participants included in the studies within the scope of this review were therapists aged between 22 and 78 years. In 19 of the studies, only therapists participated as subjects (Newsome et al. 2006, Aggs and Bambling 2010, Hemanth and Fisher 2015, Johnson 2018, Johnson and Walsh 2021). However, in the remaining six studies, participant pairs were involved, with therapists as the primary participants and clients as the secondary participants (Grepmair et al. 2007, Ryan et al. 2012, Dunn et al. 2013, Greason and Welfare 2013, Horst et al. 2013, Ivanovic et al. 2015). Among the examined studies, therapists consisted of clinical psychologists in three (Boellinghaus et al. 2013, Hopkins and Proeve 2013, Hemanth and Fisher 2015), psychologists in four (Grepmair et al. 2007, Baker 2015, Ivanovic et al. 2015, Leonard et al. 2018), and psychological counselors in five (Greason and Welfare 2013, Schomaker and Ricard 2015, Duffy et al. 2017, Johnson 2018, Johnson et al. 2019). Additionally, seven studies comprise groups of mental health professionals, that were psychologists, psychological counselors, and psychiatrists (Aggs and Bambling 2010,

Cigolla and Brown 2011, Ryan et al. 2012, Keane 2014, Millon and Holewood 2015, Razzaque et al. 2015, Johnson and Walsh 2021). However, in six studies, the therapists featured graduate students (Newsome et al. 2006, McCollum and Gehart 2010, Christopher et al. 2011, Dunn et al. 2013, Horst et al. 2013, Felton et al. 2015). The number of participating therapists in the studies ranged from a minimum of 5 (Millon and Halewood 2015) to a maximum of 206 (Johnson and Walsh 2021).

The participants were observed to be either therapists practicing mindfulness regularly (Cigolla and Brown 2011, Keane 2014, Millon and Halewood 2015), those who are inexperienced in mindfulness practice (McCollum and Gehart 2010, Horst et al. 2013, Baker 2015) or mixed groups including both experienced and inexperienced therapists (Aggs and Bambling 2010, Christopher et al. 2011, Greason and Welfare 2013, Hopkins and Proeve 2013, Felton et al. 2015, Hemanth and Fisher 2015, Leonard et al. 2018, Johnson et al. 2019). In contrast, some studies did not provide information on participants' level of mindfulness experience (Newsome et al. 2006, Grepmair et al. 2007, Ryan et al. 2012, Dunn et al. 2013, Ivanovic et al. 2015, Razzaque et al. 2015, Schomaker and Ricard 2015, Duffy et al. 2017, Johnson 2018, Johnson and Walsh 2021).

Research Design

Evaluation of the studies included in this review revealed that only two employed an experimental design with a control group (Grepmair et al. 2007, Schomaker and Ricard 2015), four used a quasi-experimental design (Dunn et al. 2013, Hopkins and Proeve 2013, Felton et al. 2015, Ivanovic et al. 2015) and the remaining 19 adopted a cross-sectional research design. In addition, 12 studies collected quantitative data using measurement tools (Grepmair et al. 2007, Aggs and Bambling 2010, Dunn et al. 2013, Greason and Welfare 2013, Ivanovic et al. 2015, Razzaque et al. 2015, Schomaker and Ricard 2015, Johnson 2018, Leonard et al. 2018, Johnson et al. 2019), whereas 10 gathered qualitative data (McCollum and Gehart 2010, Christopher et al. 2011, Cigolla and Brown 2011, Boellinghaus et al. 2013, Horst et al. 2013, Baker 2015, Felton et al. 2015, Hemanth and Fisher 2015, Millon and Halewood 2015, Duffy et al. 2017). Moreover, three studies evaluated the relevant variables using qualitative and quantitative data (Newsome et al. 2006, Hopkins and Proeve 2013, Keane 2014).

Measurement Tools and Interviews

In studies examining the effect of mindfulness on the relationship between therapeutic alliance and therapy, mindfulness has been approached in various ways. In some studies, intervention programs were implemented to enhance participants' mindfulness (Grepmair et al. 2007, Aggs and Bambling 2010, Hopkins and Proeve 2013, Baker 2015, Hemanth and Fisher 2015, Ivanovic et al. 2015, Newsome et al. 2015), while in others, it was presented as a course within graduate training programs for clinician candidates (Felton et al. 2015, Duffy et al. 2016). As part of these studies, participants were later asked to assess their own therapeutic relationships. Furthermore, some studies examined the status of the therapeutic alliance through individuals' current frequency of mindfulness practice (Greason and Welfare 2013, Johnson et al. 2019), those who engage in mindfulness meditation (McCollum and Gehart 2010, Cigolla and Brown 2011, Keane 2014, Millon and Halewood 2015), and the implementation of a five-minute centering exercise by the clinician before the session (Dunn et al. 2013). On the other hand, Horst et al. (2013) provided participants with mindfulness-based training to explore therapist and client experiences when mindfulness-based interventions were introduced for the first time during a therapy session. However, in the study, control groups were not included to see the effect of the training since the study focused solely on examining the initial use of a mindfulness intervention within a session.

Some other studies used self-report measurement tools to assess the therapist's mindfulness. The first was the Mindful Attention Awareness Scale-State (MAAS; Brown and Ryan 2003), a measurement tool to evaluate momentary mindfulness levels (Johnson 2018). Other measurement tools were the Five Facet Mindfulness Questionnaire (FFMOj Baer et al. 2006) and the Five Facet Mindfulness Questionnaire - Short Form (FFMQ-SF; Bohlmeijer et al. 2011). These measurement tools, which have the subdimensions of observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity of inner experience, examine mindfulness capacity (Greason and Welfare 2013, Hopkins and Proeve 2013, Keane 2014, Johnson 2018, Leonard et al. 2018, Johnson et al. 2019). The Mindful Therapy Questionnaire (MTQ) and the Five-Minute Mindfulness Scale (FMMS) were designed by Aggs and Bambling (2010). The MTQ assesses the impact of mindfulness in a therapeutic context, while the FMMS measures the capacity to experience and sustain mindfulness. Both scales were explicitly developed for the study. Additionally, the Mindful Therapy Scale (MTS; Baer et al. 2006) was adapted from the FFMQ to evaluate the use and experience of mindfulness in therapy. In comparison with other measurement tools, the Freiburg Mindfulness Inventory - Short Form (FMI; Walach et al. 2006), which assesses overall mindfulness levels, was preferred less frequently (Razzaqueet al. 2015). Another identified measurement tool was the Kentucky Inventory of Mindfulness Skills (KIMS; Baer et al. 2004), designed to evaluate an individual's mindfulness capacity through the subdimensions of observing, describing, acting with awareness, and accepting without judgment (Ryan et al. 2012). Finally, the Therapist Presence Inventory-Client Form (TPI-C; Geller et al. 2010), which comprises the subdimensions of presence, emotional awareness, and relational awareness, was another measurement tool employed to evaluate the therapist's capacity for presence during sessions from the client's perspective (Dunn et al. 2013, Ivanovic et al. 2015).

Multiple approaches have examined the therapeutic alliance. While some studies evaluated it based on client assessments (Ryan et al. 2012, Greason and Welfare 2013, Horst et al. 2013, Ivanovic et al. 2015), others relied on therapist evaluations (Hemanth and Fisher 2015, Duffy et al. 2017, Johnson 2018, Johnson et al. 2019, Johnson and Walsh 2021). Moreover, certain studies incorporated client and therapist assessments (Dunn et al. 2013).

The Working Alliance Inventory (WAI; Horvath and Greenberg 1989) was frequently used to evaluate the therapeutic alliance (Ryan et al. 2012, Greason and Welfare 2013, Razzaque et al. 2015, Johnson 2018, Leonard et al. 2018, Johnson et al. 2019, Johnson and Walsh 2021). The WAI measures the strength of the alliance between the client and the therapist and consists of three subdimensions: goal, task, and bond. Similarly, in related studies, the Session Rating Scale (SRS; Johnson et al. 2000, as cited in Dunn et al. 2013, Duncan et al. 2003) was adopted to examine session-specific therapeutic alliance and effectiveness (Dunn et al. 2013, Ivanovic et al. 2015, Schomaker and Ricard 2015). In two studies included in this review (Hopkins and Proeve 2013, Keane 2014), empathy, recognized as a fundamental principle of the therapeutic relationship (Cozolino 2014), was considered in assessing the therapeutic alliance. These studies utilized the Interpersonal Reactivity Index (IRI; Davis 1983), which measures empathic engagement through the subdimensions of perspective-taking, empathic concern, fantasy, and personal distress. In another study (Grepmair et al. 2007) employedcthe Session Questionnaire for General and Differential Individual Psychotherapy (STEP; Krampen 2002, as cited in Grepmair et al. 2007) to measure factors influencing the psychotherapeutic process, incorporating the subdimensions of openness, problem-solving, and relational perspectives. Moreover, as mentioned above, 12 studies adopted semi-structured interviews and weekly journal records to evaluate the relevant variables (Newsome et al. 2006, Grepmair et al. 2007, McCollum and Gehart 2010, Christopher et al. 2011, Cigolla and Brown 2011, Hopkins and Proeve 2013, Horst et al. 2013, Keane 2014, Baker 2015, Felton et al. 2015, Hemanth and Fisher 2015, Millon and Halewood 2015, Duffy et al. 2017). For information regarding the Turkish adaptations of the relevant scales, view Table 1.

Content of Mindfulness Practices in Studies

Some mindfulness groups in the studies were integrated into the educational curriculum, where participants received course credits (Newsome et al. 2006, Christopher et al. 2011, Felton et al. 2015, Duffy et al. 2017). In three studies (Newsome et al. 2006, Christopher et al. 2011, Felton et al. 2015), the 15-week course titled 'Mind/Body Medicine and the Art of Self-Care' aimed to teach self-care practices through mindfulness training. The foundations of this course were based on the Mindfulness-Based Stress Reduction (MBSR) program. Twice a week, the course requirements included 75-minute in-class mindfulness practices such as hatha yoga, sitting meditation, mindful relaxation exercises, and qigong (a meditation and movement practice aimed at harmonizing the body, mind, and breath). In addition, participants were expected to complete four 45-minute out-of-class mindfulness practices per week. Alternatively, in another study (Duffy et al. 2017), the 15-week course titled 'Counseling Theory and Practice' was designed by integrating mindfulness-based activities into counseling theory education. Accordingly, each class session began with a 10-minute mindfulness meditation. In their study, McCollum and Gehart (2010) provided mindfulness training to therapists in a clinical rotation, incorporating mindfulness exercises and theoretical readings during which participants were assigned to maintain daily records while engaging in 5- to 10-minute mindfulness exercises.

Alongside course implementations, MBSR interventions were frequently planned for eight weeks (Aggs and Bambling 2010, Hopkins and Proeve 2013, Horst et al. 2013, Baker 2015). However, studies also examined the effects of shorter interventions, including six weeks (Schomaker and Ricard 2015) and five weeks (Dunn et al. 2013, Ivanovic et al. 2015). The duration of sessions varied, ranging from 20 minutes (Dunn et al. 2013, Ivanovic et al. 2015) to 1.5 hours (Aggs and Bambling 2010). Nevertheless, certain approaches encouraged practice between sessions (Dunn et al. 2013, Ivanovic et al. 2015, Schomaker and Ricard 2015). MBSR interventions encompassed body scan techniques, hatha yoga, sitting meditation and daily mindfulness exercises, aiming to cultivate mindfulness through theoretical knowledge and practical application. On theother hand, some studies integrated more specialized modules. For instance, Schomaker and Ricard (2015) adopted a modular approach that emphasized interpersonal practice and relational skills. Moreover, in some cases, mindfulness training was complemented by additional exercises, containing a five-minute centering practice before sessions (Dunn et al. 2013), a 30-minute loving-kindness meditation (Boellinghaus et al. 2013), or a one-hour meditation session (Grepmair et al. 2007).

Findings

Experimental Studies

In the present study, only two reviewed research studies (Grepmair et al. 2007, Schomaker and Ricard 2015) included clinicians in the experimental and no-intervention comparison groups. Schomaker and Ricard (2015) pointed out that clinicians who received training in mindfulness-based practices developed a stronger therapeutic relationship and demonstrated better adaptability skills than those in the comparison group. Another study with an experimental design was conducted by Grepmair et al. (2007). Clinicians who practiced Zen meditation received higher evaluations in openness and problem-solving perspectives than those who did not engage in Zen meditation. However, no significant difference was observed in the relationship perspectives subdimension, which includes trust, bond, and collaboration with the therapist.

Other Quantitative Studies

The findings indicated a statistically significant relationship between therapists' mindfulness scores, obtained from various mindfulness scales, and the therapeutic alliance. Clinicians with higher levels of mindfulness maintained the therapeutic alliance more effectively (Leonard et al. 2018). In other words, mindfulness played a key role in developing a strong working alliance in counseling. One study analyzed the relationship between the therapeutic alliance and the subdimensions of mindfulness, revealing that openness to experience had the highest correlation, while insight had the lowest (Razzaque et al. 2015). Furthermore, it was reported that mindful presence and insight, components of mindfulness, did not have a predictor role. In contrast, nonjudgmental acceptance and openness to experience were predictors of the therapeutic relationship (Razzaque et al. 2015). Another study compared different types of mindfulness, including therapists' state and trait mindfulness. Considering trait mindfulness and the effect of dispositional empathy, in-session state mindfulness accounted for 40% of the variance in the therapeutic alliance (Johnson, 2018).

A particular study expanded the scope by including the therapeutic alliance subdimensions in the analyses. The results indicated that participants who practiced mindfulness exercises at least four times weekly reported a higher level of consensus on the goal and task components of the working alliance compared to those who practiced less than four times per week (Johnson et al. 2019). Similarly, a study (Johnson and Walsh 2021) examined the relationship between various mindfulness practices (focused attention, open monitoring, progressive body scan, open body scan, walking meditation, and yoga) and specific aspects of the therapeutic relationship, namely cognitive therapeutic alliance (goal, task, and perspective-taking) and emotional therapeutic alliance (bond, situational empathic concern, and situational personal distress). The results demonstrated that a progressive body scan practiced once a week had a significant relationship with the task dimension of the alliance, whereas practicing it four times weekly established a stronger connection with the task and goal dimensions. The relationship with the task dimension accounted for 3% of the shared variance, while that with the goal dimension accounted for 9%. Likewise, when the open body scan was performed four times a week, it showed significant relationships, accounting for 2% of the shared variance in the goal dimension and 3% in the task dimension. On the other hand, loving-kindness meditation formed a strong relationship with perspective-taking, accounting for 6% of the shared variance, and with the task dimension, accounting for 5%. Additionally, situational empathic concern demonstrated a significant relationship with loving-kindness meditation, accounting for 2% and 3% of the shared variance. In another study (Greason and Welfare 2013), therapists who participated in weekly meditation practices (such as yoga and sitting meditation for 1 to 10 hours) exhibited greater effectiveness in the bond dimension of the therapeutic alliance compared to those who did not engage in weekly meditation. Following research on the relationship between mindfulness and the therapeutic alliance, a study investigating the mediating role of empathy (Leonard et al. 2018) concluded that not all aspects of empathy mediated this relationship; however, personal distress empathy (the feeling of distress upon observing another's suffering) partially mediated the effect. In other words, therapists who reported higher mindfulness were less likely to feel personal distress empathy, which helped strengthen the therapeutic alliance.

Dunn et al. (2013) investigated the effects of five-minute centering exercises therapists performed before sessions. The findings indicated that while therapists engaged in these exercises before psychotherapy sessions reported feeling more present during the session, their evaluations by clients did not significantly differ from those of therapists who did not engage in the exercises. However, clients rated therapists who performed centering exercises as more effective in treatment and alliance. In comparison, a study on therapists' in-session presence (Ivanovic et al. 2015) found that after a five-week mindfulness training, although clients acknowledged their therapists as more effective, they did not report significant changes in their therapists' level of presence. Another study examining pre- and post-training changes in mindfulness (Aggs and Bambling 2010) revealed significant improvements in clinical mindfulness behaviors during sessions, particularly in nonjudging/acceptance and nonreactivity/calmness following mindfulness practice.

Qualitative Studies

Various themes regarding therapists' mindfulness emerged within the reviewed qualitative studies, including common positive concepts such as compassion and way of being. These themes were observing and not identifying, developing a compassionately curious attitude, being aware in the present moment, deepening the therapeutic relationship (Millon and Halewood 2015), mindfulness as a therapist's resource, opening up another way of being, enhancing relational depth, integrating mindfulness (Baker 2015), being present, the effects of meditation, shift in modes, and compassion and acceptance (McCollum and Gehart 2010). The themes in qualitative studies highlighted the connection between the therapist's mindfulness and the depth of the therapeutic relationship (McCollum and Gehart 2010, Cigolla and Brown 2011, Christopher et al. 2011, Horst et al. 2013). Cigolla and Brown's study (2011) defined "way of being" as the primary theme and considered it a way of existing in one's personal life and the therapeutic process. Therefore, this finding suggested that the positive changes by mindfulness in clinicians' personal lives were also reflected in their professional practice. The study further demonstrated that mindfulness facilitated the therapist's ability to regulate impulsive reactions that could have led to therapeutic ruptures. Similarly, Christopher et al. (2011) identified two themes: the impact on personal and professional life. However, the analysis discovered that the impact on professional life consisted of three subthemes: the therapist's self-experience during counseling, the therapeutic relationship, and clinical practice. Mindfulness practice enhances therapists' self-awareness, aids in grounding, and strengthens acceptance toward themselves and their clients. Moreover, interviews in another study (Duffy et al. 2017) revealed that mindfulness-based activities reduced factors that could negatively impact the counseling process and improved in-session presence skills.

A therapist's mindfulness contributes to their presence during sessions (McCollum and Gehart 2010). In other words, state mindfulness facilitates attunement in therapeutic encounters (McCollum and Gehart 2010). Additionally, understanding one's own experience and that of the client increases therapeutic attunement, strengthening the working alliance (Newsome et al. 2006). The therapist's mindful engagement with their own and the client's experiences enables them to act therapeutically (McCollum and Gehart 2010). Furthermore, in another study, participants stated that mindfulness helped them relax, functioned as a form of self-care, and improved their therapeutic presence with clients (Hemanth and Fisher 2015). Finally, in a separate study, therapists who practiced loving-kindness and compassion meditation exhibited greater compassion toward their clients. As a result, their awareness of relationships with themselves and others increased, leading to a more accepting and compassionate attitude (Boellinghaus et al. 2013).

Discussion

The therapeutic alliance is a crucial factor in developing the therapeutic process and is one of the fundamental determinants of therapeutic outcomes (Shedler 2010). Thus, establishing a strong therapeutic alliance is essential for achieving psychotherapy progress (Leonard et al. 2018). Although the relationship is indicated as facilitative and constructive in treatment, ruptures within it are also considered potential threats to the therapy process (Safran et al. 2015). Managing such a therapy process requires the therapist to remain fully attentive to ongoing developments and maintain a therapeutic attitude without being influenced by triggering events during the session. These skills align closely with mindfulness, which has garnered significant interest recently. Germer (2005) defined mindfulness in its simplest form as moment-to-moment awareness. A more comprehensive definition would be that mindfulness is a skill that involves accompanying thoughts, emotions, and bodily sensations, which arise when a person is fully aware of their present experience, without judgment and with composure (Christopher and Maris 2010). These definitions and skills suggest that the therapist's mindfulness may be crucial in managing the therapeutic process. Therefore, this study aimed to explore the impact of a therapist's mindfulness on the therapeutic alliance and therapeutic relationship by reviewing therelevant literature. A total of 25 studies published between 2006 and 2024 that met the inclusion criteria were analyzed. While 23 studies were conducted in 2010 and beyond, the relevant variables were most frequently examined in 2015.

Studies investigating the effects of mindfulness on the therapeutic alliance and therapeutic relationship showed that various methods were used to approach mindfulness. Some studies introduced intervention programs to promote the mindfulness of clinician candidates; however, apart from two studies (Grepmair et al. 2007, Schomaker and Ricard 2015), the effectiveness of these interventions was not assessed by comparing them with a control group that did not receive the intervention. An experimental study comparing a mindfulness intervention to a control group (Schomaker and Ricard 2015) concluded that the mindfulness intervention increased therapists' engagement in the therapeutic process and treatment success. The findings demonstrated that mindfulness interventions can effectively support the development of therapists' therapeutic skills. However, Grepmair et al. (2007) found no significant treatment-time interaction effect between Zen meditation and relationship perspectives, trust, bond, and collaboration, established with the therapist. Therefore, more studies meeting the experimental research standards are needed to generalize the causal effects of mindfulness interventions. In certain studies, therapists received mindfulness intervention training, yet its impact on the therapeutic alliance was assessed through semi-structured interviews. According to these studies, therapists reported improvements in the efficiency of their relational processes, including therapeutic presence and collaboration with mindfulness training (Christopher et al. 2011, Cigolla and Brown 2011, Hopkins and Proeve 2013, Newsome et al. 2015, Felton et al. 2015, Hemanth and Fisher 2015, Baker 2015, Duffy et al. 2017). Moreover, therapists stated that mindfulness increased their capacity to attune to clients or establish a mutual connection and deepen the therapeutic relationship (Baker 2015). In other studies, mindfulness was examined in relation to therapists' existing frequency of mindfulness practice (Greason and Welfare 2013, Johnson et al. 2019). As therapists' frequency of mindfulness practice increased, the strength of the therapeutic alliance also improved. However, inconsistent findings emerged when the presence and frequency of mindfulness practice were evaluated with different components of the therapeutic alliance. Johnson et al. (2019) explored that therapists who practiced mindfulness four or more times weekly demonstrated higher efficacy in the working alliance's goal and task dimensions than other groups. Yet, no significant effects were noted in the bond dimension.

In contrast, Greason and Welfare (2013) showed that therapists who practiced meditation on a weekly basis were more effective in the bond component. The difference was believed to be caused by whether the therapeutic alliance was assessed primarily by the client or the therapist. Greason and Welfare (2013) relied on client assessments of the therapeutic alliance, whereas Johnson et al. (2019) used therapists' self-reports. These findings show that therapists and clients may perceive the impact of increased therapist mindfulness on the therapeutic process differently. While therapists gain greater clarity regarding their objectives and tasks within the therapeutic process through mindfulness practices, clients experience a sense of competence and trust, viewing their therapists as planning a treatment process that prioritizes their clients' benefits. From this perspective, the findings of relevant studies revealed a fundamentally consistent pattern. In one study examining the impact of meditation on the therapeutic alliance, therapists recognized their countertransference processes and observed them within the relational context, which deepened the therapeutic relationship. These findings highlighted various sources of influence on mindfulness (Millon and Halewood 2015). As a result, meditation, a fundamental exercise in mindfulness interventions, broadens people's awareness and thus shows a powerful influence that operates through various channels. Additionally, meditation exercises strengthen therapists' ability to attune to clients' inner experiences, accompany their distress, and experience it themselves, reinforcing the notion that mindfulness has multiple mechanisms of influence (David and Hayes 2011). On the other hand, mindfulness practices effectively increase self-compassion (Moore 2008) and develop empathy (Greason and Cashwell 2009). Mindfulness studies enhance the flexibility to be empathetic, decrease responsiveness, and increase the possibility of promoting therapeutic presence (Campbell and Christopher 2012).

Qualitative analyses identified themes indicating that mindfulness can be challenging for therapists. These themes included mindfulness being emotionally challenging (Christopher et al. 2011, Keane 2014), a certain level of discomfort in mindfulness group participation (Cigolla and Brown 2015), difficulties such as implementation challenges, self-criticism, guilt, and low motivation, as well as struggles with adapting to meditation (Hopkins and Proeve 2013). Some therapists also hesitated about mindfulness practices (Duffy et al. 2017). By the end of the process, all participants reported feeling significantly more comfortable and competent, moving away from their initial hesitation (Duffy et al. 2017). The common emphasis across studiessuggests that experiencing some discomfort when joining a mindfulness group is natural, yet this challenge tends to diminish as the process progresses.

This review examined qualitative research findings suggesting mindfulness strengthens the therapeutic alliance by enhancing the capacity for self- and other-understanding and empathy skills (Newsome et al. 2006). Additionally, studies exploring the alliance's strength while accounting for empathic disposition and different types of empathy were featured (Johnson 2018, Leonard et al. 2018). Leonard et al. (2018) determined that the capacity to tolerate others' stress improved as mindfulness levels increased. In other words, negative empathy levels decreased. This, in turn, played a partial mediating role in explaining the therapeutic alliance. Among these studies, Johnson's (2018) highlighted a key theoretical distinction between state mindfulness and mindful disposition (general mindfulness). This study uncovered a significant relationship between state mindfulness and the working alliance, even after checking for clinicians' awareness disposition and empathic dispositions. The study reported that a clinician's awareness state during a counseling session explained approximately 40% of the variance in the working alliance when all other variables were fixed. Accordingly, a high awareness disposition and state mindfulness are not identical, and state mindfulness supports the therapeutic alliance regardless of awareness disposition and empathy disposition. These results also support the thematic analysis conducted in the studies. Thematic analyses revealed that the therapist's mindfulness contributes to their presence during the session, indicating that state mindfulness helps attunement in therapeutic encounters. It was also reported that a therapist's mindful engagement with both their own experiences and those of the client enables them to act therapeutically (McCollum and Gehart 2010). Furthermore, therapists' constant attention and focusing skills positively affect clients' perceptions of the working alliance. This finding suggests that awareness of oneself and the other's experience enhances therapeutic attunement, thereby strengthening the working alliance (Newsome et al. 2006, Siegel 2007). Additionally, with less reactive orientation, it is observed that mindfulness practices develop critical clinical skills, such as greater acceptance and state-based attention regulation (Aggs and Bambling 2010). Mindfulness enables therapists to recognize and accept themselves as they are, helping them recognize and accept their clients, which results in the development of an effective therapeutic relationship (Bruce et al. 2010).

Studies that quantitatively measure therapists' mindfulness with self-report tools consider it a way of disposition (Ryan et al. 2012, Johnson 2018, Leonard et al. 2018). For this reason, the positive correlation between relevant measurements and therapeutic alliance assessments associated an increased level of mindfulness with alliance strength. Since the evaluations of the therapist's mindfulness were not conducted as a result of any intervention, this study's findings can be considered to reflect a personal trait. This suggests that therapists with higher mindfulness are also more effective in developing therapeutic relationships. However, as mentioned above, state mindfulness and mindful disposition are distinct concepts (Johnson 2018). Therefore, it is crucial to emphasize that both mindfulness types are significant in deepening the therapeutic alliance. On the other hand, one reviewed study obtained findings on which dimension of mindfulness predicts the therapeutic alliance (Razzaque et al. 2015). Accordingly, openness to experience and nonjudgmental acceptance, as subdimensions of mindfulness, were found to predict the therapeutic alliance, a significant variable. A therapist who is open to experience may strengthen the therapeutic alliance by being transparent with the client, ready to feel their sharing, and able to share without being judgmental. Nevertheless, the therapist's nonjudgmental acceptance shows an empathetic, accepting, deeper, and nonjudgmental attitude toward the client's experiences. It has also been observed that therapists' mindfulness enhances respect and acceptance toward others. In response to the therapist's positive attitude, the client's sense of trust is reinforced, initiating a healthy relational cycle (Razzaque et al. 2015). Moreover, all these qualities contribute to a strong therapeutic relationship, and mindfulness provides a suitable foundation for demonstrating these skills. The positive effect of the therapist's mindfulness may also be present indirectly through the reduction of negative effects. In fact, it has been stated that therapists' nonjudgmental self-acceptance reduces the criticism regarding their ability to build an alliance (Ryan et al. 2012). Furthermore, the finding that therapists' mindfulness decreases the possibility of responding to the client's problems with personal distress in a way that threatens the alliance can also be considered an example of this indirect effect (Leonard et al. 2018).

In conclusion, research demonstrates that the therapist's mindfulness positively impacts the therapeutic alliance-an integral part of psychotherapy- and strengthens it. Additionally, a therapist's mindfulness can improve the therapeutic alliance and the quality of the overall therapy process. On the other hand, while most studies investigating the therapeutic alliance were based on therapists' self-reports (Aggs and Bambling 2010, Cigolla and Brown 2011, Millon and Halewood 2015, Schomaker and Ricard 2015, Duffy et al. 2017); some studies assess the therapeutic alliance from the client's perspective (Ryan et al. 2012, Greason and Welfare2013, Horst et al. 2013, Ivanovic et al. 2015). Across both evaluation methods, studies have consistently concluded that higher levels of therapist mindfulness positively impact the therapeutic alliance and treatment outcomes. However, findings also suggest that the relationship between mindfulness and the therapeutic alliance varies depending on who evaluates the therapeutic alliance (Ryan et al. 2012). Consequently, the therapist's mindfulness exhibits a strong correlation with the alliance when evaluated by the therapist. In contrast, clients' evaluations of the alliance show a significant relationship only with a specific dimension of mindfulness (therapist's mindful acting with). Considering these findings, as emphasized by researchers in the literature, it should be acknowledged that the therapist's evaluation of the process they manage may entail certain limitations (Johnson 2018).

Although Turkish keywords were included in this study, no research on this topic conducted in our country was identified. While this study is not an original research project, it is expected to capture the attention of researchers in our country, encouraging further studies and facilitating a more in-depth investigation of the subject. The reviewed research findings underline the benefits of mindfulness practices for therapists from multiple perspectives. In this regard, integrating these techniques into psychotherapy processes is considered essential. Furthermore, mindfulness-enhancing practices should be incorporated into therapist training programs and clinical practice frameworks.

Conclusion

This study assessed the effects of therapists' mindfulness practices on the therapeutic alliance. The reviewed studies suggest that mindfulness practices strengthen the therapeutic alliance and contribute to improved client outcomes in the therapeutic process. However, significant methodological limitations in the existing literature stand out. These limitations consist of inadequate sample sizes, the lack of follow-up measurements to track long-term effects, susceptibility to social desirability bias due to reliance on self-report data, and the limited number of randomized controlled trials. Longitudinally designed randomized controlled trials are needed to elucidate the effects of therapists' mindfulness better. Such research would provide stronger empirical evidence regarding the role of therapist mindfulness in the therapeutic process.

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Authors Contributions: The author(s) have declared that they have made a significant scientific contribution to the study and have assisted in the preparation or revision of the manuscript Peer-review: Externally peer-reviewed. Conflict of Interest: No conflict of interest was declared. Financial Disclosure: No financial support was declared for this study.