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Mindfulness

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The Inside Out Group Model: Teaching Groups in Mindfulness-Based Programs

  • Gemma M. GriffithEmail author
  • Trish Bartley
  • Rebecca S. Crane
Open Access
ORIGINAL PAPER

Abstract

Objectives

Mindfulness-Based Programs (MBPs) were designed to be taught in groups, yet little attention has been paid to how MBP teachers can work with the potential of the group to enhance participant learning. Most extant literature about group processes relates to psychotherapeutic groups or work-based teams. A link is needed from the broader literature to the particular nature of the MBP teaching process.

Methods

The Inside Out Group (IOG) model arose through many years of engagement with MBP teaching and teacher training. The IOG model is a clarifying framework to support MBP teachers to understand and skillfully work with group processes.

Results

The inside out embodiment of the teacher is at the center of the IOG model, with three linked capacities that the teacher uses to support and guide the process: (a) reading the group, (b) holding the group, and (c) befriending the group.

Conclusions

Practice and research implications of the IOG model are discussed.

Keywords

Mindfulness-Based Programs Mindfulness-based teacher Group theory Inside out IOG model Embodiment 

Mindfulness-Based Programs (MBPs) were originally designed to be delivered in groups, and aim to help participants cultivate awareness through moment-to-moment attention, with the intention of reducing suffering and promoting well-being (Kabat-Zinn 2013; Segal et al. 2013). We use the term MBP as it is defined in Crane et al. (2017a, b)—i.e., with a particular focus on the key MBPs designed for delivery in mainstream, secular contexts: Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), and group programs which evolved from these. MBPs are mindfulness-based (i.e., the entire pedagogy is embedded within the practice and teachings of mindfulness), as opposed to being mindfulness-informed (i.e., influenced by the practice and teachings of mindfulness) (Germer et al. 2005). MBPs are educational, structured, time-limited, closed groups (Yalom and Leszcz 2005), with a unique program curriculum that involves mindfulness meditation practices, time for inquiry about those practices, and psycho-educational elements. Each MBP course is unique, with a co-creation between individual members in relation to each other, individuals in relation to the group, and the group and individuals in relation to the teacher (McCown et al. 2010; McCown 2016).

The literature on MBP pedagogy has not often foregrounded the role of group process, and there has been minimal research in this area. Indeed, McCown (2016) wrote that “the fact that we learn mindfulness together, that mindfulness is a relational achievement, has been obscured for decades in the scientific literature” (p. 11). This obscuration may be partly due to a research focus on the outcomes of mindfulness training for individuals, such as effects on depression and well-being (Dimidjian and Segal 2015). Furthermore, existing group process research is largely embedded within a psychotherapy context (Bonebright 2010), and thus does not directly relate to the skills-based, psycho-educational MBP context (Crane 2017). In this paper, we summarize the status of current practice-based and research literature on the role of group in MBPs, and then present the Inside Out Group (IOG) model which we have developed and implemented within our institution’s MBP teacher training programs. The model offers a framework to support MBP teachers to understand and skillfully work with the group processes. Our experience as MBP teachers and trainers has led us to the view that the way the MBP group process is managed has a profound influence on the quality of participants’ experience and learning. The practitioner literature concurs, with many practitioners emphasizing how knowledge and skills on group process can help MBP teachers enable participants to feel secure in the group setting; to co-create a culture of mindfulness practice among its members; to skillfully work with challenging participants and different experiences within the group; and to use the group to draw out processes such as general human vulnerability (Bartley 2012; Crane 2017; McCown 2016; Williams 2008).

Practitioner Literature

The practitioner literature on MBPs offers rich guidance on MBP pedagogy (e.g., Kabat-Zinn 2013; McCown 2016; Santorelli 1999; Segal et al. 2013). However, although the group context for the learning is inherent throughout the literature, it is often not explicitly highlighted (e.g., Segal et al. 2013). This may be due to Kabat-Zinn (2013) grounding MBSR within a culture of education rather than therapy—the sessions are termed “classes” and the facilitators are “teachers.”

In the last decade, some practitioners have explicitly highlighted group processes in MBPs: McCown et al. (2010) identified group processes as one of the four core skill sets of MBP teachers. They labeled this as “stewardship of the group,” whose role is to foster the following three “treasures”: (1) Freedom—permission for the participant to allow themselves to be who they are in their moment-to-moment experience, (2) Belonging—participants acknowledge their place in the group and the influence they have on others, and being accountable for that influence, and (3) Resonance—the felt inter-subjective experience of the group at any one time. McCown (2016) later wrote about stewardship in relation to co-creating an atmosphere, where the teacher can work with seven stewardship skills, which range from the practical (caring for place) to the subtle (sensing sublime moments), with the teacher keenly sensing and helping to shape the atmosphere.

The Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC: Crane et al. 2013; Crane et al., 2017a, b) is a widely used tool to assess mindfulness teaching competence, and one of the six core domains is “Holding the group learning environment.” This domain is further divided into four key features: (1) learning container—the teacher establishes a safe group environment in which participants feel able to voice their own experiences, even when it seems to differ from the rest of the group; (2) group development—the teacher purposely works with group development processes such as establishing ground rules and group norms at the start, and then allows space towards the end of the course for participants to explore their own relationship to the mindfulness practices, and acknowledging the ending of the group; (3) common humanity—the teacher purposely uses the group to normalize experience and to make links to the universality of the habitual processes of the mind; and (4) leadership style—the teacher demonstrates authority and potency, yet without imposing a particular view, and allows participants to take risks.

Other mindfulness practitioners also emphasize the importance of group process. Bartley (2012) dedicated a chapter to “facilitating the learning” (p. 340), with guidance for proactively working with forming and holding the circle of the group, where the MBP teacher is encouraged to be aware of and look after the internal and external boundaries of the group, both through an appropriate orientation process before the MBP, and through understanding the factors that influence participants behavior and experience of the group (e.g., early family relationships and other group experience). The value of small group work (dyads, triads, and larger numbers) is highlighted within the chapter, suggesting their importance in helping to build trust and reduce barriers among group members. By forming connections between participants and gathering key threads of their small group discussions back into the larger group, participants are enabled to learn from each other and encounter first hand a sense of shared vulnerability (Bartley 2012). Crane (2017) dedicates a chapter to the creation of a productive learning environment in MBCT, and includes the themes of the relationality of the learning process, intentionality, the emphasis on experiential learning, and the ways in which the group is used to enable the learning process. Brandsma (2017) has a chapter on “creating a fertile learning setting” with a section on “the power of the circle” (p. 57), which explores how, when a group of people come together, there is resonance between members, wisdom shared, insights gained, and a sense of togetherness that would not be possible if studying mindfulness alone.

Research Evidence

Research on MBPs most frequently report changes on an individual level, which perhaps creates a tendency to regard MBP teaching as an individualized learning experience that happens to take place in a group context. However, a group “is not just a collection of individuals, but a psychosocial environment which profoundly affects (and is affected by) the feelings, attitudes and behaviors of the individuals in that system” (Kepner 1980, p. 5). An MBP is a complex intervention, with many factors that interweave and change moment-by-moment; thus, it is challenging to tease out the relationships between these factors and participant outcomes (May et al. 2007). Factors such as group process (for example having a cohesive, safe, group experience or a discordant, edgy one) may influence outcomes in ways that are unrelated to mindfulness per se. There is a dearth of research about group processes in MBPs, and more is needed before any definitive conclusions can be drawn; however, extant research does point to the experience of being part of a group as a potentially critical ingredient in terms of influencing participant outcomes in MBPs (Cormack et al. 2017; Imel et al. 2008). Although the research of groups in MBPs is still very much in its infancy, there are two areas of research that are relevant to MBP groups: (i) qualitative and quantitative studies that investigate the role of the group in MBPs; (ii) trials that compare an individually delivered MBP to a group-delivered MBP.

Qualitative and Quantitative Studies That Investigate the Role of the Group in MBPs

Imel et al. (2008) analyzed 59 MBP groups and reported that group membership accounted for 7% of the variance in change in psychological symptoms but did not account for variability in change in medical symptoms. They could not pinpoint why group membership affected change in psychological symptoms and not medical symptoms (but did test for and rule out teacher differences), although they suggested that psychological symptoms may be more amenable to being influenced by social factors such as group cohesion. They proposed that group membership effect was likely to be a result of the culture of a particular group having an impact on learning and practicing MBPs, with the psychological outcomes influenced by non-mindfulness pathways such as group cohesion, perceived support, and expectation of change. This is the only study of its kind, therefore cautious interpretation is needed, and it remains unknown which aspects of teacher or group behavior may influence these differences in group process.

Cormack et al. (2017) conducted a grounded theory analysis from which they developed a core theme of the “group as a vessel on a shared journey.” They concluded that the MBP group had a profound and powerful effect on the participants’ learning experience (in positive and negative directions depending on the skill of the teacher); and that there are some aspects to the MBP group experience that are unique—in particular that the characteristic phase of group storming (Tuckman 1965) tends to arise within the MBP process as participants’ resistance to turning towards their own psychological processes.

There are three meta-syntheses of qualitative research on participant experience of MBPs, which together incorporate 24 original qualitative studies (Cairns and Murray 2015; Malpass et al. 2012; Wyatt et al. 2014). Group processes emerged as a core theme across all three synthesis papers, although none of the original 24 qualitative studies stated that exploration of group process was a core aim. Participants’ experiences of group broadly fell into two categories. The first described how being in a group was a normalizing experience for participants; typical statements included “I’m not a nut” (Wyatt et al. 2017, p. 220), and “I’m not the only one, there are other people with the problem” (Malpass et al. 2012, p. 71). The second category was about how the group helped participants persevere with the meditation practices, for example, one participant stated, “If you were on your own you would quite easily walk away and give up” (Cairns and Murray 2015, p. 352). Additionally, some individuals spoke of how they did not experience the group as safe at first (Malpass et al. 2012), and others said that due to the accepting culture of the MBP group, they felt a deep empathy for others in the group, which led to greater emotional closeness with their friends and family (Cairns and Murray 2015).

Van Aalderen et al. (2014) conducted qualitative research on the role of the teacher in MBPs, triangulating interview results from participant and teacher interviews, and observations of MBCT sessions. They identified four overarching themes characterizing the teacher-participant relationship in MBCT: embodiment, empowerment, non-reactivity, and peer support. Critically in relation to this current exploration of group process, the teacher’s skill in embodying mindfulness and in managing group process was identified as key factors by participants, and yet the importance of peer support and skillful group holding was generally underestimated by the teachers themselves. In summary, qualitative research shows that many participants of MBPs regard other members of the group, and the group itself, as a vehicle that helped (or hindered depending on teacher skill) both their understanding of, and commitment to mindfulness practice.

Trials That Compare an Individually Delivered MBP to a Group-Delivered MBP

In the broader psychotherapy literature, there is no clear consensus on the relative efficacy of group-versus individually delivered psychotherapy (e.g., Burlingame et al. 2016). There are a small number of MBP trial designs that explicitly set out to compare an individual- to a group-delivered MBP, with similarly mixed results. For example, Schroevers et al. (2016) found that individual- and group-delivered MBCT are equally effective for people with depression and somatic disease. In contrast, Mantzios and Giannou (2014) compared an individual- vs. group-delivered MBP for weight reduction and found that weight loss benefits were significantly better for participants who received the group-delivered format. Interestingly, this trial also indicated that practicing meditation in a group context led to higher reductions in avoidance which was correlated with successful weight reduction. The social connectedness of the group process therefore seemed to be significant in encouraging participants to stay with the challenge of meeting uncomfortable experience. The research on MBP groups is in its infancy, but tentatively points to the importance of proactively harnessing the positive potential of group during MBP teaching, and suggests that exploring group factors in MBPs in future research may help to further elucidate the mechanisms behind participant outcomes.

The IOG model builds on existing research and practitioner literature by distilling key MBP group processes into a single model. It offers a concise framework with which to structure training on group process for MBP teacher trainees; it offers to mindfulness supervisors a framework within which to engage in reflective conversation with supervisees; and it offers to trainees a digestible summary of the key issues which can help frame learning and provide a map of the territory of group process in the MBP context. Maps are useful, but are not the actual territory, and so do not replace the practice of embodied teaching (see Kabat-Zinn’s 2011 paper on this theme). The IOG model is fairly straightforward in structure, with just five sections, but each of these sections addresses complex and nuanced inter-related processes. The IOG model arose through many years of engagement with MBP teaching and teacher training, and dialogue with colleagues. It is offered with the aspiration that it may be of practical use to support future MBP teaching and training practice.

The Inside Out Group Model

In the IOG model (Fig. 1), the inner triangle represents the teacher teaching from “inside out” embodiment at the center of the MBP group process. Simultaneously, she is also engaging with the other three capacities of the group process: (1) “reading,” (2) “holding,” and (3) “befriending.” At the heart of the learning context lies the MBP teacher’s inside out embodiment and her congruence with her values, intention, and teaching practice, and the way she commits herself to bringing this out within the reading, holding, and befriending of the group. Clearly seeing group development processes for what they are is part of reading; enabling learning to take place in a safe space is part of holding; and relating to themselves and participants with compassionate awareness is part of befriending.
Fig. 1

The Inside Out Group model for Mindfulness-Based Programs

Circling all of this is the learning context: this is seen in the widest of terms, as a combination of conditions that include the quality of the teacher’s training and supervision; their ethical and personal mindfulness practice; the integrity of the MBP being taught; effective orientation, preparation, recruitment, and assessment of group participants; the social context within which the group is situated; the suitability and type of venue; the reason the group has been brought together (i.e., is it a MBP for people with cancer, for those in a business context, or a general public group?); and the learning materials of the program.

The Teacher: Inside Out Embodiment

The inside out embodiment of mindfulness practice (in the person of the teacher) is at the center of the IOG model. Similar to the term mindfulness, embodiment is challenging to define, because it is a subjective, felt experience. It is not striving for a particular state, nor does it suggest a persona evoked for the purposes of teaching MBPs (Bartley 2012; Crane et al., 2017a, b; Grossman and Van Dam 2011; McCown 2016). We propose that inside out embodiment is the arising of non-judgmental present moment awareness within the teacher. The “inside” encompasses phenomena arising within the boundary of the body of the teacher, such as thoughts, the felt sense of the body, and emotions, and “out” referring to phenomena arising outside the body of the teacher, such as what is seen and heard in the group while teaching. In a sense, these boundaries are arbitrary and in constant flux, but the main point is that the teacher is able to be aware of and purposefully direct attention to the range of phenomena that arises while teaching. Inside out embodiment involves attentional expertise—the capacity to direct the attentional system in purposeful ways, along with attitudinal qualities of acceptance, non-striving, trust, and non-fixing. Embodiment is a congruence arising from mindful connection to both these inside and out experiences—which in turn guides actions and behavior.

Within the literature on psychotherapeutic practice, therapeutic presence—which overlaps with the concept of embodiment of mindfulness—is defined as having three components: “an availability and openness to all aspects of the client’s experience, openness to one’s experience in being with the client, and the capacity to respond to the client from this experience” (Geller and Greenberg 2002, p. 72). Like embodiment, therapeutic presence is not a skill set—it is a quality of being which can be deliberately cultivated through mindfulness practice (McCollum and Gehart 2010). We propose that if embodied practice includes an awareness of the MBP group itself, this enhances the quality of participants’ learning experience.

The theme of imitative behavior is also particularly relevant to inside out embodiment (Yalom and Leszcz 2005). How do teachers influence the group by embodying certain ways of being? If they are strongly embodied in the practice of mindfulness, this is likely to encourage participants to try on mindfulness by modeling the behavior of the teacher, and thus acquire for themselves a chance to develop (and embody) similar qualities of balance and stability. Using the principles behind Yalom and Leszcz’s (2005) work, the MBP teacher can be aware of the impact of their therapeutic presence on participants. This process relies strongly on the depth of personal mindfulness practice and integrity of the teacher. The participants may try on mindful behavior through being inspired by their teacher’s behavior, and this may indeed be a bridge for them to absorb these qualities.

As with any emerging awareness and developing skill, learning how to work with group process is at first, likely to be held deliberatively in attention, as the teacher learns to incorporate group in their field of awareness, build understanding of theories, and learn to use their own inner visceral awareness to gain clues about what the group needs. However, given time and experience, these new ways of being become an integrated part of the personhood of the MBP teacher.

Inside

The teacher monitors the immediacy of their felt experience within the boundaries of their body—with a particular emphasis on raw sensory data arising through interoceptive (awareness of visceral stimuli originating inside of one’s body) and proprioceptive capacities (awareness of the position of the body). This will include the feeling of contact of body with ground, sensing the feeling tone of sensory experience, and attuning to subtle shifts in emotional valence in response to contact with individuals and the group as a whole. Thoughts are also part of immediate experience, and a key part of monitoring the inside processes is to recognize thoughts as thoughts, to choose which thoughts to engage with, and to repeatedly reconnect to and sustain connection with the sensed physicality of bodily experience. In this way, the teacher is less prone to having their attention hijacked by thoughts that trigger constriction or identification around a particular theme—such as a sense of “I’m not good enough” or “that participant is annoying,” etc. Inside, for the purposes of this paper, thus refers to the teacher’s conscious connectivity to the immediacy of their inner experience (somatic, cognitive, and affective) with a focus on their inside responses to themselves, individuals, and the group while teaching.

Out

In parallel with this inside connectivity, the teacher connects to the moment-by-moment arising of what is seen, heard, and sensed with individuals, the group, and in the surrounding space. Out involves awareness of the processes and activity arising in the space, outside the boundaries of the teacher’s body. The boundary between inside and outside to some extent is arbitrary and dissolves with mindfulness practice. However, the key point here is that the teacher has an integrated and inclusive awareness of processes emerging within and without the boundary of their body and is attuned to the interplay between them. The teacher also responds to all inside and out phenomena that arises within the teaching context through an embodied understanding of its nature, i.e., recognition of it as arising and passing process, rather than as narrative to engage or identify with (Shapiro et al. 2018).

Inside Out Embodiment

The teacher can shift their attention between an orientation towards inside experiencing, and an orientation towards out experiencing according to what is needed at a given moment (Young 2016). This comes together to “achieve the co-created flowing disposition” which gives rise to the capacity to respond to the moment-to-moment unfolding of the MBP group (McCown 2016, p. 21). The manifestation of this practice of inside and out mindful connection is seen and felt by participants through the teacher’s bodily expression, speech, attitudes, and behaviors—and is a way of expressing embodied practice.

An example of inside out embodiment at work can come from the act of seeing. When an MBP teacher scans round the circle of participants (out), they may see signs of engagement and interest, and/or distractedness and boredom. This may be quickly followed by a movement into the conceptual mind (inside) and an interpretation of “they are bored because…” which trigger a negative judgment about their teaching. This movement from what is actually seen to interpreting and judging can distance the one who sees, thinks, and judges from the ones who are seen, and whose actions are interpreted. MBP teachers cultivate the capacity within these challenging moments to turn towards inside sensations and recognize the internal felt sense within the body, as a means of interrupting potential reactivity and personal identification, and instead reconnecting to the wider sense of emerging experience in the “body” of the group. As Ray (2016) wrote “‘Knowing from the inside’ involves setting aside the bright daylight world of the thinking mind and learning to view—to viscerally sense—our life from within the half-light of our body” (p. 2).

Teaching from inside out embodiment is a dynamic process, with the teachers’ attention shifting from internal phenomena (inside) to external phenomena (out), and from embodied connectivity to moments of conceptualizing, akin to what may arise during a formal mindfulness practice. Inside out embodiment while teaching involves recognizing moments of getting caught in thinking, and repeatedly returning to a live connection to the present moment experience of self, the participants, and the group. Speeth (1982) describes a similar process during her psychotherapeutic practice: “There is meta-information that tells me how my attention is fluctuating from inside to outside and back again, and how the beam of my awareness is focusing narrowly or opening panoramically” (p. 99). Surrounding all this is the capacity to recognize in a kindly way what is here, giving specific attention to elements of what is arising when needed, and cultivating a meta-perspective on the overall flux of experience. This latter skill is similar to the practice of choiceless awareness in mindfulness meditation practice, in which one does not purposely direct the attention towards a chosen object, but cultivates an openness to whatever moves into the field of awareness moment-by-moment, either inside or out (Young 2016). This capacity to shift the attentional system is systematically trained during the practice of mindfulness meditation, and intentionally brought as embodied practice to the MBP teaching process.

Reading the Group

To understand and interpret what is happening in the group as it unfolds, there is a need to read the group process. The definition of reading the group is the teacher’s capacity to be aware of and make sense of the processes that are happening in the group any one moment, thus enabling skillful responsiveness. Understanding theoretical frameworks is a key way to resource this capacity. Here we summarize two theoretical frameworks that we recommend MBP teachers become familiar with.

Two Key Theoretical Frameworks on Group Process

The first model of group theory described comes from Tuckman’s (1965) four stages of group development, which are as follows: (a) forming, (b) storming, (c) norming, and (d) performing, which can be used as a map of how the MBP group may develop. When a group first comes together (forming), participants characteristically experience anxiety, and show a level of reserved-ness and dependence on the teacher. This is a time when teachers need to offer clear and firm boundaries to build a sense of containment and safety—and to facilitate connections with their fellow group members. This phase can then evolve into storming when participants develop a sense of their place in the group, and start to test their interactions with the teacher, and her capacity to hold the group safely, and with fellow participants. Each group is different and may storm in the first week, some groups—especially those outside of therapeutic work and in experiential education such as some MBPs—may not storm in a clearly defined way or indeed, storming could serve as a performing function in some groups (Bonebright 2010). There is some research suggesting that group storming can arise within the MBP process as participants’ resistance to turning towards their own psychological processes (Cormack 2017), which, in the authors experience, most often arises during the first two sessions, or at the half-way point (Week 4 or 5) in an MBP course.

The third stage is norming, when participants become used to their roles and established group norms. Within an MBP, norming might be seen when participants learn what to expect during practice and inquiry. Performing follows when participants have formed bonds within the group and can work collaboratively. The group needs less teacher input, and participants support each other more independently in their discoveries about mindfulness practice, and show a deepening capacity for reflection. Tuckman added a fifth and final stage at a later date, called adjourning (Tuckman and Jensen 1977), which describes the ending of a group. In MBPs, this takes place as the program finishes, the group dissolves, and participants separate to take what they have learned into everyday life practice (often with an internalized sense of their group).

When the MBP teacher is aware that these developmental stages are at work within the group, and welcomes them as normal, healthy aspects of group development, she is able to respond skillfully to the needs of the participants and better support the ongoing development of the group. There is broad agreement that groups do develop and grow in relatively predictable and consistent ways (Bonebright 2010; Heinen and Jacobson 1976). However, as Miller (2003) pointed out, it is important to recognize that group development is more complex then linear models such as Tuckman’s (1965) might imply—the priority for the teacher is to respond to what is actually arising rather than ideas about what could be happening. Furthermore, group process theories such as Tuckman’s (1965), although very useful, do not always consider the context of the particular MBP group, such as the location (clinical, educational, yoga studio), and the cultural or contextual issues within the group.

Second, Berne’s group Imago theory (1963) highlights the importance for the group leader to acknowledge the conditioning and resultant unconscious projections that each participant (and the teacher) brings with him or her into the group. These are influenced by early family experiences and other personal group histories. The unconscious dynamics that influence roles and interpersonal behaviors get played out in the group, as well as how the teacher engages with the group (Amaro 2015). This is a complex area that highlights the hidden influences teeming under the surface of group process. Berne’s group imago is a way of acknowledging and concretizing this and describes the ways the group leader can support and make sense of the development of the group, without needing to know the detail of the group members’ backgrounds. Clarkson (1991) usefully links the stages of development of a healthy group imago with Tuckman’s group development theory. In the context of MBPs, the group imago model underlines the importance of the teacher cultivating awareness and compassion for group and individual behaviors that arise, as well as their own, knowing that their influence is often historical and unconscious.

The work of behavioral psychologists is also of relevance here, in relation to how the teacher may shape the behavior of the group by reinforcing particular contributions from group members which align with the group norms which are being encouraged (Crane et al. 2014), and which support the cohesiveness of the group, and inter-member solidarity (see Liberman 1970).

What is it that enables MBP teachers to read the group? The theoretical understandings summarized above (and others) are part of the answer—which allow the teacher to place the processes that are arising within the group into the context of wider understanding. Significantly though, the teacher needs to digest these theories in a way that releases them from consciously holding concepts as they teach. Once they are integrated as a coherent aspect of embodied practice—reading the group can then emerge and be recognized in relevant moments. Externally, there are visual, non-verbal body language clues from individual participants—e.g., folded arms, voice tone, leaning back or forward, avoiding eye contact (out). Internal sensory responses within the teacher can alert them to shifts within the group—perhaps through noticing slight butterflies in the belly, or maybe a sense of holding the breath (inside). All these belong to the experience of the teacher—but they may well be triggered by a resonance with feelings within the group. Just as an emotion has an inevitable expression in sensations in the body, so different reactivity arising in individuals in the group creates a resonance in the teacher (and probably in the group as a whole: McCown et al. 2010). By noticing and deliberately attending to this resonance, the whole group, including the teacher, is enabled to settle and hold whatever is arising.

Case Example: Reading the Group

The following description illustrates the process of reading the group. It shows the way in which reading can inform decisions made by the teacher, and how this in turn can impact on group process.

At a pre-course orientation session for an MBP group, a student (we will call him Mark) was absent. Then in week one, Mark arrived thirty minutes late, so at the end of the class, the teacher engaged with Mark to offer orientation information, and to emphasize the importance of arriving on time. In week two, Mark arrived on time but seemed disengaged; his small group was slow in returning to the large group, he whispered to his neighbor a couple of times, and it was difficult to engage him in eye contact. The teacher felt some internal discomfort at this, although also recognized that this was likely to be storming, a usual part of group development. He intentionally monitored the impact of Mark’s actions on the wider group. He could not discern anything obvious, but knew from his knowledge of forming that having a disengaged group member would likely affect the wider group. Mark was absent for week three, and the teacher noticed that the group was more open, responsive, engaged, and relaxed during this session. The teacher’s impression was that without Mark, the group was forming nicely and even beginning to move into a norming development phase.

In week four, Mark was present and the teacher noticed a subtle but definite shift in the engagement of the group from the previous week. In general, they seemed less confident with Mark in the room, and the teacher observed some participants looking towards Mark while they were speaking, as if to gauge his reaction. The teacher sensed that the group was looking to find ways of re-forming, and that it was important to help Mark settle into the group. To help facilitate this he emailed Mark and asked if there was anything he could do that might help him engage with the course and gain benefit from it. They had a productive exchange. In week five, the teacher read the body language of group as being more relaxed, and his internal experience resonated with that. Mark appeared to fit in better and his responses in the group were more in line with the others. An important topic opened up following one of his contributions within an inquiry that engaged many group members. The teacher surmised that the performing stage was happening. The rest of the course continued with the group appearing engaged, steady, open, authentic, and inclusive. Mark’s joining of the group was on one level an individual process, but it proved to be instrumental for the group as a whole. This was facilitated by the teacher reading the development of the group, assisted by his own internal sense of what was happening at the time, and what he needed to do to support Mark, himself, and the group as a whole.

Holding the Group

Holding is defined for the purposes of this article as: (i) establishing a sense of safety in the group, which then (ii) enables encounters with new learning (Thornton 2016). The holding process is how the teacher includes awareness of the whole group as an entity in its own right that needs attending to, in addition to each individual participant. As part of this, the MBP teacher has a wide awareness and pays attention to what they experience from the group. Thus, the teacher can hold the group by helping to maintain its safety (i.e., participants are able to be present and feel secure), and to facilitate connections between group members. This holding also requires the MBP teacher to attend to her own self-regulation, and through this embody a capacity to hold herself as well as the group in present and kindly awareness.

The term holding can be linked to the work of Winnicott (1971) on parent-infant relationships, in which the infant needs to feel safely held and provided for in its environment to enable risk-taking (Thornton 2016). This concept has been developed into a process-orientated theory describing how psychotherapy clients may experience anxiety when in a group—particularly in the early stages when they are uncertain of others in the group, and their own place within it. The task of the therapist is to hold the group in order that its members are able to gain a sense of safety, belonging, and identity within the group (Nitsun 1989). Similarly, in an MBP group, participants need to feel safe enough to risk starting to learn and change. Palmer (1998) also wrote of creating a learning environment that is safe enough to feel challenged within. Although the MBP teaching process itself is invitational, and some responsibility lies with each participant to engage in the way that is appropriate for them, the teacher has a responsibility to create and maintain the conditions within which learning can take place, and to offer inside out embodied presence (Geller and Greenburg 2002).

Establishing Safety

It is through skillful holding that safety builds, MBP teachers need to help the group to form—and be aware of how holding develops as the group matures. Holding is most tangible at the start of the course when the group is forming (Tuckman 1965) at which stage the teacher helps build trust through a warm welcome, well held boundaries, and safe connections.

To facilitate the group during the forming stage, teachers can help build the group community and ethos by ensuring practical arrangements are clearly in place. They take responsibility for the smooth running of the class by establishing external boundaries such as the layout of the venue, toilet locations, dates, arrangements, and that cost and time structures are clearly communicated. Internal boundaries play their part in how group members relate to each other, and this starts before the group has even met, with teachers ensuring appropriate group membership through orientation sessions and written contact.

At the beginning, participants are dependent on the teacher for direction about norms and expectations of behavior. The inside out embodied mindful practice of the teacher is vital in holding the group throughout the MBP, and this is especially important in the forming stages when establishing safety. As well as holding the group, the teacher must also hold herself, and be attuned to and tolerate feelings that may arise during teaching (inside). Speeth (1982, p. 158) wrote of the capacity of the therapist to “feel deeply and give those feelings no expression at all, as well as the ability to feel deeply and express it genuinely and spontaneously.” It is embodied awareness that enables the MBP teacher to discern what will serve in any given moment. Teachers may feel anxious about their teaching, feel deep compassion, concern, or frustration towards a participant, while at the same time holding the intention that all feelings and responses can be skillfully held in awareness in order to offer continuity of embodied presence, and to help establish a sense of safety within the group. Every encounter with individual group members, especially at the forming stage, will be evaluated consciously or unconsciously by each person in the group. Participants are alert to authenticity, respect, compassion, and safety from the teacher, particularly in the first few MBP classes. The teacher therefore has a responsibility to manage their own process (inside), and know when it is skillful to self-regulate by pulling attention back into themselves to regather and reconnect. This example of embodied holding may enable group members to develop this as a personal skill for themselves, which has parallels with the imitative behavior theme from Yalom and Leszcz (2005).

Enabling Encounters with New Learning

As the MBP group becomes established with the forming of safe connections within the group, the priority shifts to holding a process which enables participants to wholeheartedly engage with the work they have come to do. If participants feel safe in the group, they will be more likely to take risks alongside others and learn new ways of relating to themselves and others through mindfulness. Taking risks may include encountering challenging experiences, and this requires the teacher to continue to embody steady confidence in the process of MBP learning. Holding has a physical component that requires the teacher to regularly visually scan around the group in order to stay in contact with the whole circle (out)—not just to those who are talking, or those the teacher is drawn to, or those she may feel unsure of. Present moment attention helps the teacher to respond to what arises, sensitively noticing the moments that require a particular intervention, or times when skillful holding involves no words at all, except perhaps a pause held kindly (inside out embodiment).

Additionally, there is a need to oversee the complicated web of relationships that exist in a group in order that everyone feels included and able to encounter the learning offered (Mindell 1997). Every group has a way of marginalizing some behaviors and group members and valuing others. This may well reflect wider social attitudes and unconscious bias. Regardless of good intentions, the process of making quick perceptions based on race, gender, and other characteristics is part of our implicit and automatic patterning, which in turn is informed by social conditioning (Fiske 2002; Magee 2016). The MBP teacher needs to be alert to ways of including those who may be at the margins, for “the more ‘at home’ the margins feel, the more they can learn” (Lakey 2010, p. 32). A strong responsibility for each MBP teacher is to undertake training on the influence of social context, non-discriminatory practice, and unconscious bias and make it an ongoing practice to proactively bring awareness to these processes and their influence on how relationships are formed, and how they interrupt connection (See Magee 2016 for an exploration of engaging mindfully with personal bias). This awareness building is part of resourcing the teacher to recognize how their own personal patterning influences their capacity to hold the individuality of participants, while also holding the wider group process in ways that are responsive and respectful (inside out embodiment). It is by actively including all members in the group, and recognizing our own habitual biases as MBP teachers and how we might work with them, that we establish safety and a feeling of inclusiveness for all participants.

At the heart of skillful group holding is the capacity to notice those who withdraw to become almost invisible in the group circle, and seek to include them gently, even if they choose to stay on the side-lines. Importantly, there is no need for everyone to speak to develop a sense of sharing and participation. Throughout the teaching process, the teacher can draw out shared aspects of participants’ experiences in ways that are inclusive to the whole group; and can develop participatory teaching processes that do not require speaking into the whole group.

Case Example: Holding the Group

An MBSR course had been running for five weeks and the participants appeared to be doing well. After a full sitting practice, the teacher opened an inquiry process—starting with a “horizontal” invitation “Would anyone like to share a word or two that describes some part of their experience in that practice?”. The group were used to this process and someone offered “Sleepy and dull.” The teacher scanned around the circle with the question, “Anyone else felt sleepy and dull?” and acknowledged nods and “yes” from a few people. Then he asked, “Did anyone feel anything a bit different to sleepy and dull?” And a young woman, (let’s call her Jane) who tended to be quite reserved, caught the teacher’s eye and quietly said, “I felt very sad.” These words produced one of those moments familiar to MBP teachers, when the group as a whole appeared to hold their breath and there was a sense of time hanging, as if no-one knew (including the teacher) what might unfold next. The teacher kept his attention gently with the young woman, while being aware of feelings in the wider circle and within his own internal experience. “Might you bring the breath softly to this sadness?” he asked Jane. He then noticed her body language which signaled that she was uncomfortable being the focus of the group’s attention in this moment. So, in order to create a sense of safety for her and the group, he looked around and added “Let’s all of us turn towards whatever is going on for each one of us right now with a short practice.” A couple of minutes later, as he observed that things appeared to settle within Jane, and as the group also appeared to look and feel more grounded and steady, the teacher concluded with “This is an example of the way we can bring the breath and our practice to hold intensity gently—and how as a group we can support each other, connecting in kindness to hold whatever is going on.” And with some nods from the group acknowledging what had been said, the teacher sensed Jane was steadier, so did a short inquiry into the feel of the sadness and how she had been relating to it, before they moved on to the next part of the program. The teacher thus deliberately held the group to help participants feel safe in a tender moment, while also allowing for learning and connection within the space.

Befriending the Group

Befriending is defined for the purposes of this paper as the practice of actively cultivating an attitude of compassion and friendliness to all experience that arises while teaching (both inside and out). Befriending speaks to the relationship the MBP teacher has with the multitude of processes that occur while teaching—their own experience, the relations between the teacher and individual participants, the group as a whole, and the material of the curriculum.

Befriending experience can occur in several directions, relationally, emotionally, and/or experientially. In particular, befriending uncomfortable experiences is central to the relational practice of the MBP teacher within their own being (inside), as well as out into the group and individual participants. Part of the intention of MBPs is to discover new ways to relate to difficulty so that the habitual patterns that are activated by aversion are less triggered. The process of inside out embodiment while teaching thus includes the teacher actively turning towards experiences both inside and out that are aversive—experiences that without the training of mindfulness they might have habitually turned away from. For many teachers this includes the sense of not being “good enough” to teach (Crane 2014). Although the group may not explicitly know the content of the challenges that the teacher is meeting within themselves, teachers can aspire to communicate an embodied kindliness through their manner and behavior in relation to the group.

Befriending underlines the importance of the particular quality of how the teacher attends—meeting what is arising without trying to push it away or hold onto it. The processes that occur in groups are not always easy. Teacher and participants alike will be activated by difficulties that arise. There may be moments of disconnection, challenges to the teacher or the curriculum from individuals in the group, and times when individuals go off track and/or take up a lot of time within the session. Indeed, individual participants may take on roles such as “the expert meditator,” “the advice giver,” or “the naysayer” (Sears 2015).

Befriending the group is supported by the MBP curriculum itself, in which shared processes such as the stress reaction cycle, communication patterns, and human habit patterns are explored, alongside an inquiry approach which encourages participants to meet their experience with curiosity, kindness, and acceptance (Crane 2017; Feldman and Kuyken 2011; Kabat-Zinn 2013). Alongside this, it is important that while exploring general patterns, the teacher allows for differences to be acknowledged within the group. An important part of befriending is to recognize that people may not experience emotion in the same way; some people may be able to articulate nuanced emotions, whereas others may not be able to distinguish between emotions, other than broad categories of feeling bad or good. These differences exist across cultures, within the same culture, and also within an individual at different times (Barrett 2009). An example of this is the concept of fear—which is a categorization which may encompass many different emotions, e.g., fear of missing a train vs. fear of social rejection will likely elicit different sensations in the body—all of which can be labeled as fear (Barrett 2009). There may also be culture-specific categorizations of emotions; for example, in Turkey sadness and anger are aspects of a single emotional label named “kizginlik,” whereas in the USA, sadness and anger are reportedly experienced as distinct emotions (Mesquita 1993). Similarly, when teaching the stress reaction cycle (Kabat-Zinn 2013), it is important to be aware of some general variations between males and females: “flight or fight” may be more common in males, whereas there is evidence that females are more likely to have a “tend and befriend” reaction pattern to stress, and draw on social support (Taylor et al. 2000).

A core role during inquiry is to draw the groups’ attention to how one participant’s experience points to processes that are often shared. Highlighting the universality of habits of mind facilitates group cohesion and normalizes experience (Yalom and Leszcz 2005). By befriending all participant experience, both universal and individual, the teacher facilitates participant’s learning about the similarities of fundamental patterns that humans share, alongside the differences between them and other members of the group.

The use of horizontal inquiry is one way of drawing out both shared and distinct aspects of experience. It also helps to warm up the group and facilitate wider participation even if it is very minimal and unobtrusive (Bartley 2012). The teacher invites a brief response to the experience of the practice—perhaps just one word—and then threads it around the circle acknowledging any signs of agreement, common experience, or difference. For example, a participant might express “sleepiness” after a body scan and the teacher might then visually scan around the group and ask—“Sleepiness—did anyone else feel sleepy?” or “did anyone notice anything different”? While acknowledging any nods or murmurs from the group, the teacher “harvests” a range of experience across the group. This is particularly helpful at the forming stage of a group (Tuckman 1965) where participants may be uncertain and not want to risk offering too much of their experience. They can step in to participate through something as minimal as a nod. Horizontal inquiry is contrasted with a “vertical inquiry” approach which explores one individuals’ experience in more depth. Both are fundamental to MBPs at different moments in the teaching process.

To support the connectivity of shared human experience, MBP teachers might deliberately use the first-person plural when speaking of patterns or habits of mind, e.g., “So we tend to eat without really tasting our food…” The group is thus intentionally referred to in order to learn about general patterns of mind. The teacher creates a learning context from the beginning that communicates that all participants’ experiences are valid. This transforms participants’ reports of practice about (for example) the wandering mind—often assumed by participants to be “wrong”—into fruitful objects of investigation for the whole group (Crane et al. 2014).

The teacher builds participants’ capacity to befriend their experience via personal mindfulness practice, which includes kindness and compassion as an integral aspect. The practice of inside out embodiment allows the teacher to be aware of her own state of body/mind during teaching so that appropriate emotional and behavioral responses can be offered to herself as teacher and to all participants. To support the teacher in this process, it is important that she plans a space to pause and practice mindfulness before the start of each class. Deliberately leaning into the befriending aspect of mindfulness practice is particularly supportive for teachers.

Case Example: Befriending the Group

An MBCT program was being taught to people with cancer, there were seven people with cancer in the group, and a partner of one of the participants. Several of the group were fairly young, were experiencing considerable anxiety, and had somewhat low levels of self-confidence. The partner of a participant (we will call her Mary) was an older woman who had recently retired from a senior position in which she had considerable authority. She contributed her views rather stridently in the sessions, often repeating that mindfulness wasn’t her thing but that she wanted to be there for her partner. During the inquiry process, the teacher found it hard to engage Mary and observed that she was asleep during most of the formal practices and was doing very little home practice—yet she dominated the small groups and wider discussion. The teacher took her concerns to her mindfulness supervisor, admitting she felt frustrated and unnerved by Mary. She and her supervisor considered various approaches, which the teacher tried without much impact “Well,” said her supervisor, “There is only one option. Maybe you need to consider letting go of trying to approach this differently and open your heart to this woman who is clearly motivated by her love and concern for her partner. Practice kindness towards her and the others in the group as best you can.” The teacher followed this advice and was surprised to find feelings of genuine befriending towards Mary. She no longer felt nervous of her and realized that Mary’s intentions for attending the course were loving. In week seven, Mary fed back that something rather surprising had happened. A close friend phoned her following a very sad traumatic event. Mary told the group that she had sat and listened to her friend—and unusually for her—hadn’t offered any advice but had just been there for her. “It was a new experience for me,” she said. “I was just mindful I suppose.” The group stepped in to affirm her and there was a definite sense of warm connection in the room.

Befriending was cultivated first within the teacher’s practice. Mary herself would not have been aware of this process, but it enabled the teacher to open to Mary and her situation rather than see her as a difficult participant. The teacher was able to be more wholeheartedly accepting of Mary, which impacted her inside process, and supported her to be a more skillful teacher within the group. The direct impact of this befriending process upon Mary is unknown, although she experienced a significant shift towards the end of the course, which she attributed to mindfulness.

Discussion

The IOG model offers a framework within which MBP teachers can deliberately engage with the group process to facilitate optimal learning during an MBP course. At the center of the model (Fig. 1) is the inside out embodiment of the teacher, which arises from her own meditation practice. Here, teachers maintain awareness of what is occurring inside (emotions, thoughts, body sensations), and out (what is going on outside the body of the teacher; sights, sounds etc.,), and deliberately shift attention between the inside and the outside, according to what serves the group and the teacher in that moment. Connected to the inside out embodiment of the teacher are the three capacities of reading, holding, and befriending, which the teacher stays in contact with during teaching. Although the three capacities have been described separately in the IOG model, it is important to acknowledge their interconnectedness; for example, befriending is inherent in holding and reading, and skillful holding is facilitated by being able to read the group. When first learning to work with the IOG model, the teacher may need to hold it in concious, explicit awareness, which will develop into unconcious, implicit awareness  when the capacities have become an intrinsic part of the being of the teacher. Reading requires the teacher to acquire knowledge of key group process theories, and to apply this knowledge to support her teaching and understanding of the group process during the MBP. Holding requires the teacher to create a safe space—particularly in the early weeks of the MBP by establishing group boundaries—in order to enable participants to feel safe enough to take risks with new learning. Befriending requires the teacher to meet experience in a kindly way; both within herself as teacher (inside) and in relation to the experience that emerges from the participants and the group during the MBP (out).

The IOG model encourages teachers to include the group as almost another presence to be aware of in the room, with its own development process, character, and possibility. Unlike psychotherapeutic contexts (Yalom and Leszcz 2005), group dynamics are not directly addressed during an MBP. However, MBPs are usually delivered in a group format and it is very helpful for teachers to understand how typical group processes unfold so that they can be skillfully navigated and supported. The model points to the importance of training MBP teachers to recognize and best utilize the group aspect of teaching an MBP. The IOG model draws from and builds upon existing group process theories (e.g., Berne 1963; Tuckman 1965; Yalom and Leszcz 2005), and MBP practitioner and research literature (e.g., Bartley 2012, 2017; Crane et al. 2013; Crane 2017; McCown et al. 2010; McCown 2016). The IOG model does not contradict previous approaches to this work; rather, it offers a re-visioning of group processes in MBPs, and distils and articulates key elements of group process in the context of MBP teaching. The IOG model offers a clarifying framework for trainee MBP teachers to base their learning about group processes in MBPs, and may also be useful for experienced MBP teachers to facilitate working with group processes more explicitly as they teach.

Limitations and Future Research

The IOG model is primarily intended as a pedagogical tool for MBP teachers and their trainers, rather than a model which can be empirically tested. However, it is possible that it could make contributions to the latter by offering a framework within which MBP group processes can be further investigated. For example, further research could be conducted to identify any observable characteristics of reading, holding, and befriending to build upon the MBI:TAC research by Crane et al. (2013). This could be used as a basis to investigate and pinpoint the observable teacher qualities in action within MBP group work, and whether, if an MBP teacher uses the IOG model as a framework for their practice, this manifests in improved participant outcomes. This may clarify the extent to which skillful group work forms a part of the pathway by which participant change occurs.

While MBPs are exponentially expanding in terms of contexts, specializations, participant ages, and population (Dimidjian and Segal 2015), the field has been relatively unsuccessful in widening accessibility to the full diversity of society. It is a significant challenge for MBP teachers to have the skills to facilitate group processes skillfully in ways that include and serve everyone regardless of color, background, gender, sexuality, creed, and ability. There may indeed be times when it is wise for a teacher to recognize their lack of cultural competence with certain contexts and seek another colleague to take on the work, or work alongside an experienced colleague. While MBP curricula place considerable emphasis on universal human tendencies and processes, it is important to hold these within a sensitive honoring of difference. In a wider context, knowledge about how to facilitate a group is important since individualistic tendencies in society are amplifying the likelihood of seeing “other” as different—often as a threat—adding to patterns of increasing isolation and defensiveness (Magee 2016). MBPs are formulated to enable an individual and a collective exploration of the patterns that create and perpetuate human distress. These patterns are fuelled by internal reactive patterns but are also highly influenced by the social context we are embedded in. It is critically important that the MBP group context does not inadvertently recreate wider patterns of distress through processes of unconscious bias and exclusion. Being in a well held community, while coming into connection with the direct experience of others who suffer “just like me” can be immensely helpful in countering these tendencies. The MBP teacher can optimize the way an MBP group is worked with by normalizing individual experience by bringing it into the wider context of the group process. The more skilled the MBP teacher is in facilitating the group process, the stronger the potential of the group as a source of experiencing a connected and open way of relating to self and others.

Notes

Acknowledgements

The authors would like to thank all the MBP participants and trainees at the Centre for Mindfulness Research and Practice, Bangor University, who helped shape the Inside Out Group model over many years. We would also like to extend thanks to Jody Mardula for her insightful original work on groups in MBPs, Eluned Gold for suggesting the shape of the Inside Out Group Model, and other teaching colleagues in the UK and further afield (especially at Bangor University, Oxford University, Exeter University, University of Massachusetts Medical School, and colleagues at See True in the Netherlands) for developing this work with us.

Author Contributions

GG: led the write-up of the article for publication and co-developed the IOG model. TB: co-wrote the article and co-developed the IOG model. RC: co-wrote the article and contributed to the IOG model. All authors approved the final version of the manuscript for submission.

Compliance with Ethical Standards

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Conflict of Interest

GG declares she has no conflict of interest. TB declares she has no conflict of interest. RC is a non-salaried director of a not for profit charity providing mindfulness services.

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© The Author(s) 2019

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  1. 1.Centre for Mindfulness Research and Practice, School of PsychologyBangor UniversityBangorUK

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