Mindfulness

DOI 10.1007/s12671-012-0107-4

ORIGINAL PAPER

Don't Forget Your Body: Mindfulness, Embodiment,

and the Treatment of Depression
Johannes Michalak & Jan Burg & Thomas Heidenreich

# Springer Science+Business Media, LLC 2012

Abstract During the past decade, Mindfulness-Based Cognitive Therapy (MBCT) aiming at relapse prevention in
depression has been developed and empirically tested. All
exercises taught during MBCT are based on the development of a heightened awareness of one's body. The important role of the body is also stressed in a recently emerging
interdisciplinary field of research termed embodiment.
This research program focuses on the interactions between
bodily, cognitive, and emotional processes. Based on the
obvious role of the body in MBCT and on the theoretical
and empirical evidence highlighting the role of the body in
emotional processes, we argue that considering embodied
processes might be a useful perspective for research on the
etiology of depression and for mechanisms of action in
MBCT.
Keywords Embodiment . Major depression . Mindfulness .
Cognitive therapy . Relapse prevention

Introduction
The treatment of depression is a highly relevant goal for the
individual suffering from depression, the families caring for
J. Michalak (*)
Department of Psychology, University of Hildesheim,
31141, Hildesheim, Germany
e-mail: [email protected]
J. Burg
Ruhr-University Bochum,
Bochum, Germany
T. Heidenreich
University of Applied Sciences,
Esslingen, Germany

a depressed member as well as for our society. Major depressive disorder (MDD) is associated with high levels of
suffering and substantial functional impairments for the
individual affected by depression. Moreover, the economic
costs of MDD for our society are high, not only in terms of
the direct costs of treatment but also due to such factors as
premature mortality and morbidity and productivity losses
among workers with depression (e.g., Greenberg et al. 2003;
Panzarino 1998).
One of the most striking difficulties in the treatment of
depression is that chronic and recurring types of depression
are common phenomena (Hollon et al. 2005; Vittengl et al.
2007). Because of this, the need for developing and testing
approaches aiming at relapse prevention and treatment of
chronic forms of MDD has been widely recognized. During
the past decade, several psychopharmacological as well as
psychotherapeutic treatment approaches specifically aiming
at the prevention of relapse/recurrence in MDD have been
developed (e.g., Fava et al. 1998; Friedman et al. 2004;
Jarret et al. 2001).
One of these approaches is Mindfulness-Based Cognitive
Therapy (MBCT; Segal et al. 2002). One fundamental characteristic of mindfulness exercises taught during MBCT is
their focus on the body. All mindfulness exercises of the
MBCT program are based on developing or increasing the
awareness of one's body. For example, in breathing meditation, one of the fundamental practices in most meditation
traditions and also in mindfulness-based treatment approaches,
people practice awareness of their breathing. The instruction is
not to think of their breathing but instead to be bodily aware of
the entire process of inhaling and exhaling.
Though the role of the body is obvious in mindfulnessbased exercises, theoretical models integrating bodily processes into an understanding of the onset and maintenances
of depression and into an understanding of the mechanism

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of change of MBCT are rare. In this article, we will argue

that the focus of MBCT on the body is of no coincidence
and that a theoretical and empirical elaboration of the role of
the body might be a valuable way to deepen our understanding of the etiology of depression and of the effects of
MBCT.
However, the obviousness of the body focus in mindfulness practice is not the only reason that suggests rethinking the
role of the body in depression. Another reason is the accumulating theoretical and empirical evidence for the important role
of the body in basic research on emotion. In the past decade,
an interdisciplinary field of research has emerged, focusing
especially on the complex interactions between bodily, cognitive, and emotional processes (Niedenthal 2007; Niedenthal
et al. 2005). Under the term embodiment, researchers assume a complex reciprocal relationship between the bodily
expression of emotion and the way in which emotional information is processed.
In the following section, we will first give a short overview on mindfulness and its clinical application in the
treatment of depression. Then, we will present some basic
tenets of the embodiment perspective on emotion with special emphasis on embodiment and depression. In the final
section of this paper, we will elaborate on the role of the
body in MBCT and give some answers to the question on
why MBCT (and other mindfulness-based approaches)
stress the importance of the body.

Mindfulness and Mindfulness-Based Cognitive Therapy

(MBCT)
Definition of Mindfulness and Components of MBCT
Mindfulness can be defined as a mental state characterized by
nonjudgmental awareness of the present moment (Bishop et
al. 2004; Kabat-Zinn 2003). It can emerge when we pay
attention in a particular way: on purpose, at the present moment, and nonjudgmentally (Kabat-Zinn 2003). The cultivation of mindfulness is the core therapeutic principle of MBCT.
Originally, it was developed specifically for relapse prevention in depression. The group-based MBCT program consists
of eight weekly sessions of approximately 2.5-h duration. The
main part of each session consists of learning/practicing and
giving and receiving feedback about formal mindfulness exercises. The first formal mindfulness exercise taught is the body
scan. In this exercise, participants learn to sequentially attend
to each section of the bodybeginning with the toes of the
left foot and moving systematically through each body part,
ending with the top of the head. The instruction is to notice all
sensations in the various body parts mindfully. Thus, the entire
body is mindfully scanned. Also, sitting meditation, the second formal mindfulness exercise taught, has a strong bodily

focus. In sitting meditation, participants mindfully follow the

bodily sensations of their breathing. Moreover, when participants learn to be mindful of difficult emotions during sitting
mediation, the instruction is not to think or ruminate about the
emotion but instead to focus on the pattern of bodily sensations associated with the emotion (Segal et al. 2002, p. 226).
Moreover, the informal mindfulness exercises foster the
transfer of mindfulness into daily life. In the first week of
the course, for example, patients choose a routine activity
such as washing the dishes, climbing the stairs, or taking a
shower, which they do with moment-to-moment awareness,
thus connecting body and mind during the activities (e.g.,
being aware of body movements while climbing the stairs).
Several studies have shown that MBCT substantially
reduced rates of relapse for patients with three or more
previous episodes of MDD (Godfrin and van Heeringen
2010; Ma and Teasdale 2004; Teasdale et al. 2000) or
prolonged relapse compared to a TAU group (Bondolfi et
al. 2010). Moreover, Kuyken et al. (2008) and Segal et al.
(2010) found MBCT to be at least as effective in reducing
relapse/recurrence in MD as maintenance pharmacological
treatment, which can be regarded as the gold standard of
evidence-based relapse prevention in MD (NICE 2004).
Mechanisms of Change in MBCT
Several theoretical accounts on the mechanisms of change
have been developed. To date, cognitive models of the
mechanisms of MBCT have gained the strongest empirical
support. The development of MBCT was based on the
theoretical assumption that vulnerability to relapse and recurrence of depression arises from repeated associations
between depressed mood and patterns of negative, selfdevaluating, hopeless thinking during episodes of major
depression. It was postulated that the core skill that MBCT
aims to teach is the ability, at times of potential relapse, to
recognize and disengage from mind states characterized by
self-perpetuating patterns of ruminative, negative thought.
Several studies have shown that MBCT can indeed assist
patients to disengage from rumination (Eisendrath et al.
2008; Michalak et al. 2011) and to reduce the tendency to
identify with cognition (Hargus et al. 2010; Teasdale et al.
2002). In a recent study, Kuyken et al. (2010) could demonstrate that MBCT treatment effects are mediated by a
decoupling of the relationship between reactivity of depressive thinking and poor outcome. Another cognitive process
that might be relevant for the effects of MBCT is the
positive impact of mindfulness training on overgeneral
autobiographical memory of formerly depressed patients
(Williams et al. 2000).
Other accounts explain the effects of mindfulness training on a behavioral level (e.g., exposure to adverse internal
experiences, leading to desensitization; Kabat-Zinn 1982).

Mindfulness

However, although several theoretical explanations for the

effects of MBCT have been developed and empirically
tested, none of these approaches explicitly focuses on bodily
processesdespite their relevance in the concrete mindfulness practice. In the following section, we will introduce a
theoretical and empirical framework that might be useful in
modeling the role of the body in depression and in
mindfulness-based treatment of depression.

Embodiment
Theoretical Background
Traditional accounts of cognition assume that people represent
what is out there in the world in abstract symbols and then
think by manipulating these abstract symbols. According to
this position, thinking is inherently amodal because it would
be the same whether it was done by a computer or by a
disembodied brain in a vat. During the past decades, alternatives to this amodal perspective to cognition have been developed. The term embodiment is used by researchers in such
fields as psychology (Barsalou 1999; Glenberg and Robertson
2000), philosophy (Clark 1997; Fuchs and Schlimme 2009;
Varela et al. 1991), artificial intelligence (Pfeifer and Bongard
2006), and linguistics (Lakoff and Johnson 1999) to express
the notion that knowledge is embodied or grounded in bodily
states and in the brain's modality-specific systems (for a
review, see Niedenthal 2007; Niedenthal et al. 2005). According to this embodiment perspective, the way people think is
shaped and constrained by their physical bodies, which
move in particular ways through their environment. For
example, the way language makes use of bodily metaphors to convey abstract concepts (e.g., to grasp an idea
and break out of a daily routine) is one indicator of this
embodied perspective of cognition (Lakoff and Johnson
1999). According to an embodied perspective on cognitions, physical body position and movement can change
the way people think, the conclusions they draw, and
the decisions they reach (for a review of embodiment
and cognition, see Niedenthal et al. 2005).
Also, several theories of emotion stress the idea of embodiment (e.g., Damasio 1994; Niedenthal 2007; Niedenthal
et al. 2005; Teasdale and Barnard 1993). They propose a
complex reciprocal relationship between the bodily expression of emotion and the way in which emotional information
is processed. This idea can be traced back to the early days of
academic psychology (James 1884). Early critics of this position argued that bodily feedback is too undifferentiated and
too slow to represent emotional experience (Cannon 1929).
However, since then, research has shown that, in fact, the
motor system can support extremely subtle distinctions
(Niedenthal 2007).

As Goldman and de Vignemont (2009) and Wilson

(2002) have pointed out, there are different ways of using
the term embodiment in the literature. We will briefly
present two of the most central formulations of embodiment:
Bodily Activity Interpretation
One's body actions or body anatomy (e.g., posture) plays an
important causal role in cognition and emotion. A seminal
study that can be interpreted on the background of this
embodiment interpretation was conducted by Strack et al.
(1988). They required their participants to hold a pen in their
teeth, which unobtrusively creates a contraction of the zygomaticus major muscles, the muscles involved in the production of a human smile. They found evidence that participants
in the pen-in-teeth condition rated humorous cartoons as
being funnier than subjects in the control condition in which
zygomaticus contractions were inhibited.
Bodily Format Interpretation
In cognitive science, it is proposed that information is processed in different formats of mental representation (e.g., a
visual format and an auditory format; see, Jackendoff 1992).
For example, the memory for a situation is stored in different formats: visual information is stored in a visual format
and position and movements of the body in a bodily format.
By analyzing information from these sensory formats,
higher-order meaning structures can be gathered that use
more abstract and symbolical/verbal formats. When executing actions, different systems using different formats contribute to the regulation of the action. Bodily format
interpretations of embodiment assume that mental representations in various bodily formats or codes have an important
causal role in cognition. It is not actual body actions or body
anatomy that is central for this interpretation, but rather
cognitive and emotional processes are influenced by information encoded in a bodily format. Research on mirror
neurons is an example of this type of embodiment interpretation. Mirror neurons are neurons in the premotor cortex
which not only send movement instructions to the hand or
other effectors but also echo instructions for the same movements when one merely observes another person executing
that movement (Gallese et al. 1996, 2004; Rizzolatti and
Sinigaglia 2007). In empathy, for example, the output of the
mirror neuron system might inform an individual about the
state or the goals of another individual by allowing him or
her to feel the state of the other person from the inside
because the mirror neuron system provides information in a
bodily format (i.e., while interacting with another person
someone literately feels the physical or emotional pain
the other person is experiencing because similar painprocessing brain structures are activated in the person who

Mindfulness

empathizes and information is processed in a bodily and not

merely in a verbal or symbolic format).
In the following section, we will review some clinical
research pointing to the relevance of embodied processes for
depression. Both types of embodiment interpretations are
relevant in this field.
One example of a clinical theory that stresses the importance of bodily information in depression is the Interacting
Cognitive Subsystems (ICS) approach (Teasdale 1999;
Teasdale and Barnard 1993). One assumption of this complex theory is that sensory input (e.g., in a bodily format)
makes a direct and important contribution to emotional
states which distinguishes them from more intellectual and
rational processes. It is only when cognitive (e.g., thematic
semantic context of a situation) and sensory (e.g., proprioceptive) information is interlocked that the person will feel,
for example, sad or hopeless instead of just thinking about
sadness or hopelessness. In the so-called depressive interlock configuration, bodily and cognitive feedback loops
can become established that lock subsystems into a selfperpetuating configuration that maintains depression.
Empirical Findings on the Relevance of the Body
in Depression
Although the literature on brain mechanisms in depression
is flourishing, empirical research on the embodiment of
depression is relatively sparse. Some indirect evidence for
the significance of the body in depression comes from
studies on processing emotional material in nonclinical populations. Several studies have shown that the processing of
emotionally negative and positive material can be influenced by bodily manipulations. For example, as mentioned
above, Strack et al. (1988) demonstrated that manipulation
of the facial expression influences the degree to which
cartoons were rated as funny. In a study on the retrieval of
unpleasant autobiographical memories, Riskind (1983)
could show that different postures and facial expressions
modulated the latencies in the retrieval of positive vs. negative life experiences. In another study by Riskind (1984),
a slumped vs. upright sitting posture affected levels of
depression (Beck Depression Inventory scores; Beck et al.
1961) and behavior (i.e., persistence in insolvable tasks) of
individuals following failure or success. Duckworth et al.
(2002) demonstrated that instructions to push a lever away
from their body (i.e., avoidance movement) or pull it toward
their body (i.e., a consumption movement) have profound
effects on processing emotionally positive or negative pictures. Taken together, this evidence from basic research
indirectly supports the notion that bodily processes might
be relevant for the onset and maintenances of depressive
state because they subtly bias emotional processes. If this
biasing caused by the body is chronic, for example, because

individuals habitually show certain kinds of depressogenic

movement patterns or postures, it might be a constant source
of bodily feedback that increases emotional vulnerability.
Research on gait patterns of clinically depressed patients
has also highlighted the complex interactions between bodily and emotional processes. Some earlier studies have analyzed gait patterns in depressed patients (Bader et al. 1999;
Lemke et al. 2000; Paleacu et al. 2007; Sloman et al. 1982,
1987). In sum, the results of these studies showed that
currently depressed patients display reduced gait velocity,
stride length, increased standing phase, and gait cycle duration (Wendorff et al. 2002). However, these studies have
certain methodological limitations: they restrict the analysis
to the lower limbs and to forward and backward limb movementswhich means to one dimension.
In a recent study, Michalak et al. (2009) compared gait
patterns of 14 currently depressed inpatients and 14 matched
never-depressed control participants with a high temporal
and spatial resolution. Gait patterns of currently and neverdepressed participants showed considerable differences:
currently depressed patients walked more slowly and
showed smaller arm swings than healthy participants. Remarkably, depressed patients show larger amplitudes than
never-depressed people in lateral body sway. This means
that when a depressed patient approaches the observer, the
observer will see pronounced swaying lateral movements of
the upper body. Moreover, the gait of depressed patients was
characterized by a slumped posture and reduced vertical up
and down movements of the upper body. An animation visualizing this function can be viewed at http://biomotionlab.ca/
Demos/BMLdepression.html.
Moreover, Michalak et al. (2009, Study 2) were able to
show that a convergent gait pattern characterizes sadness in a
nonclinical population. Utilizing a within-subject design, sad
and happy moods were induced in a sample of undergraduate
students by a musical mood induction procedure. Again, the
analyses revealed that speed, arm swing, lateral body sway,
posture of the upper body, and the amplitude of vertical movements of the upper body were discriminating features.
In a further study, Michalak et al. (2010, 2011) examined
whether formerly depressed patients with a high risk of
depressive relapse show gait patterns that resemble those
of the currently depressed and sad individuals. It was proposed that deviant gait patterns might be a trait marker of
depression and thus not only be apparent in currently but
also in formerly depressed individuals. The effect size of the
differences between formerly and never-depressed participants were considerably smaller than those reported for
currently depressed inpatients. However, the gait of formerly depressed participants still differs in some parameters
from normal gait. Namely, formerly depressed participants
displayed reduced walking speed and reduced vertical
movements of the upper body.

Mindfulness

In summary, these studies on gait patterns of depressed and

formerly depressed individuals show that emotional processes
and the motor system are closely interconnected. The exact
nature of this embodiment of depression has yet to be clarified.
The experimental design of the mood induction study
(Michalak et al. 2009; Study 2) allows us to infer that mood
states can have causal effects on the way people walk. However, embodiment theories of emotion assume more complex
interactions between bodily and emotional processes. As described above, the ICS approach (Teasdale 1999; Teasdale and
Barnard 1993) proposes that proprioceptive information
causally influences the emotional state of individuals.
Preliminary evidence for effects of changes in proprioceptive information on depression was gathered in a study by
Koch et al. (2007). Thirty-one currently depressed patients
were assigned to one of three conditions: (1) a dance condition
in which participants performed a traditional upbeat circle
dance characterized by pronounced up and down movements
for 2030 min, (2) a condition in which participants just
listened to the music without dancing, and (3) a condition in
which participants moved on a home trainer bike (ergometer)
up to the same level of arousal as the dance group. Depression
scores most strongly decreased and vitality scores most
strongly increased in the dance condition, which was the only
condition in which patients show pronounced up and down
movements of the body. Pure bodily arousal, as in the home
trainer bike condition, did not affect depression and vitality
scores very much. These results indicate that even short
changes of movement patterns might causally influence depressive mood. Moreover, basic research on the influence of
posture, facial expression, and movement on emotional processing in nonclinical populations which we reported above
lends strong support for the assumption of bodily feedback
loops affecting emotions. In future research, further studies
investigating the causal effects of body manipulations on
depression are needed.
Why is the Body Important in Mindfulness-Based Cognitive
Therapy (MBCT) for Depression?
In the following section, we will link mindfulness and
embodiment research and give some tentative explanations
why the body is an important focus of MBCT (and other
mindfulness-based approaches). Interweaving these new
developments within basic and clinical research is a challenging task; thus, much that will be said remains largely
speculative. However, we will present empirical evidence
supporting our view whenever possible.
The Body as an Anchor of Mindfulness
In every formal mindfulness exercise taught in MBCT, the
body is the anchor of mindfulness. In breathing meditation,

for example, the living and experiential contact with breathing is used as a reference point of awareness. This reference
point makes it easier to realize when the mind wanders away
from this present moment experience into the past, the
future, or diffuse states of mind such as daydreaming or
fantasizing. Practitioners are instructed not to think of their
breathing but instead to be aware of the body during the
entire process of inhaling and exhaling.
In a recent study, Burg and Michalak (2010) investigated
the clinical relevance of staying in contact with one's body
during mindful breathing. Specifically, the authors examined the associations between a mindful breathing exercise
(MBE) and depression-related variables, namely rumination
and depressive symptoms. Rumination, as defined in the
Response Styles Theory (RST), means responding to sadness by focusing repetitively and passively on the meaning,
causes, and consequences of one's mood and is considered a
central risk factor for depressive relapse (Michalak et al.
2011; Nolen-Hoeksema 1991; Nolen-Hoeksema et al. 2008.
A sample of 42 undergraduate psychology students was
asked to complete the MBE and measures of rumination
and depressive symptoms. In the MBE, participants are
instructed to observe and sense their breathing for about
18 min and to return to their breathing whenever they lose
the mindful sensation of it. Within this time period, participants are prompted 22 times at irregular intervals to indicate whether they have lost mindful contact with their
breathing as a result of mind wandering. Moreover, they
are requested to indicate states of mindlessness every time
they notice them on their own during intersignal intervals.
This makes it possible to calculate the sum of all phases in
which the participant's mind never wandered (no click within a phase and a mindful response at the end upon a signal)
and stayed in contact with the bodily sensation of breathing.
The close alignment of the MBE with one of the most
central mindfulness exercises, namely breathing meditation,
might enhance the ecological validity of assessing mindfulness in comparison with self-reports. The results showed
negative correlations between mindful states in the MBE
and measures of rumination and depressive symptoms (Burg
and Michalak 2010). Thus, people who were more able to
stay mindfully in contact with their body during breathing
meditation reported less rumination and fewer depressive
symptoms. Correspondingly, the ability to mindfully stay in
contact with the body might be an antidote to rumination.
However, it should be noted that other possible causal
interpretation of this correlational pattern are also possible.
For example, it might be easier for nonruminators to stay
focused on their breathing.
Moreover, further evidence for the importance of the
ability to mindfully stay in contact with one's body is demonstrated by a new questionnaire (Body Mindfulness Questionnaire, BMQ), focusing specifically on self-attributed

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body-related mindfulness (Burg et al. submitted). The questionnaire comprises two factors: experiencing body awareness and appreciating body awareness. The first factor,
experiencing body awareness, captures the extent to which
the respondent mindfully stays in contact with his body in
everyday life. More precisely, the negatively worded items
measure how often respondents lose the awareness of their
body in everyday activities, as a result, for example, of
slipping into an automatic pilot mode, mind wandering,
ruminating, and so on. For example, items include, I'm so
absorbed in my thoughts that I do not pay attention any
more to my body, and I forget my body in everyday
stress. Results show moderate positive associations of this
factor with all facets of the Kentucky Inventory of Mindfulness Skills (Baer et al. 2004; German version by Strhle et
al. 2010) and negative correlations with clinical variables,
such as perceived stress, neuroticism, and rumination as
well as depressive and dissociative symptoms. Thus, there
is evidence that the ability to use the body as an anchor of
mindfulness might be a healthy quality.
Mindfulness of One's Emotions
Early Detection of Escalating Emotional Patterns As embodiment theories propose, the body plays a central role in
emotions. Correspondingly, mindfully coming into contact
with one's body also means coming into contact with one's
emotions. This might help people with emotional vulnerabilities to realize very early when dysfunctional emotional processes are escalating. Individuals with a history of depression
very often report that they became aware of their negative
mood only after their mood had grown to a full-blown episode
of depression. When mood states are fully escalated, it is very
difficult to take steps towards healthy de-escalation. As Segal
et al. (2002) pointed out, training in mindfulness might assist
formerly depressed individuals to be aware of more or less
subtle bodily signs of depressive mood such as lethargy,
tension in the neck, or lump in the throat at an early stage.
This might help them to react to this escalation with awareness
and to take deliberate steps to care for themselves, instead of
acting out dysfunctional automatic reactions to their mood
states (negating or suppressing the current state, excessive
rumination, panic because of the dysphoric mood, etc.).
Moreover, as Fuchs and Schlimme (2009) emphasize,
psychological disorders, such as depression, affect a prereflective embodied sense of self. This means that psychological disorders might affect the person's being-in-the-world
or, in systems terms, cause disturbances in the ecological
interactions of an individual with his or her environment.
From this perspective, psychological disorders always manifest themselves in particular disturbances of embodied existence, even if only in the way of very basic existential
feelings (e.g., feelings of disembodiment and existential

feeling of encapsulation). These existential feelings are

forms of body memory resulting from condensed past experiences of interactions with other persons and with the
nonsocial environment. Although these states are prereflective (i.e., beyond simple verbal descriptions) and people are
often unaware of these existential feelings, they are not
principally unconscious. As mindfulness might shape the
awareness of these existential feelings (i.e., the prereflective
sense of self as connected with the environment), it could be
expected that mindfulness training can help patients to identify these subtle forms of disturbance very early. For example, a person who gets mindfully in contact with the
embodied self might, for the first time, sense a feeling of
encapsulation on a concrete and embodied level. Moreover,
as mindfulness opens the mind and enhances an experiential and lived contact with the body and with its connection
with the environment, it might reduce tendencies towards
disembodiment and existential feeling of encapsulation often found in psychological disorders. Evidence for the reciprocal nature of mindfulness and depersonalization (a
condition characterized by subjective experiences of unreality in one's sense of self) was found by Michal et al. (2007).
In a sample of patients suffering from pain syndromes and
students, a substantial negative correlation between mindfulness and depersonalization was found, indicating a disturbance of sense of self in less mindful individuals.
Mindful Body Awareness as an Antidote to Emotional
Avoidance Of course, getting in touch with one's emotions
is often challenging, especially when these emotions are
negative. All of us very often have the tendency to avoid
inner experiences such as sadness, shame, jealousy, or anger. However, excessive and inflexible experiential avoidance has been shown to be a key transdiagnostic factor
leading to escalation and chronification of various psychological disorders (Hayes et al. 1996, 1999, 2004; Kashdan et
al. 2006). Mindfulness increases an intensive contact with
the here-and-now experiences of emotions on a bodily level.
Instead of ruminating or thinking about emotions or the
situations that elicited these emotions, practitioners learn to
attend to the bodily manifestation of emotions in the here
and now (Segal et al. 2002; p. 226). They are invited to let
go of the mental film in their heads (e.g., Why did this
happen to me?; What are the consequences if I cannot
control this feeling?) and to turn towards experiences on a
bodily level. The task is to allow the bodily felt sense
(Gendlin 1981) to unfold in the present moment and to feel
how, for example, the sadness or anxiety makes itself manifest in the chest or in the stomach. This should be done with
a gentle and curious stance and in a way that is not defensive
but also acknowledges one's limits.
Empirical evidence for the notion that mindfulness might
reduce experiential avoidance and ways of dealing with

Mindfulness

emotions that might be subtle forms of emotional avoidance

(rumination, worry, and thought suppression; Borkovec and
Inz 1990; Cribb et al. 2006 stems from different strands of
research. Studies assessing self-attributed mindfulness with
self-report measures have consistently shown that trait
mindfulness is negatively associated with experiential
avoidance, dissociation, rumination, thought suppression,
and worry (e.g., Baer et al. 2006; Brown and Ryan, 2003,
Hayes and Feldman 2004; Strhle et al. 2010). More specifically, as reported above, Burg et al. (submitted) found a
negative correlation between experiencing body awareness
assessed with the BMQ and rumination.
Moreover, various studies on the effects of MBCT
and MBSR have demonstrated that mindfulness-based
approaches reduce the tendency to ruminate (Eisendrath et
al. 2008; Jain et al. 2007; Kingston et al. 2007; Michalak et
al. 2011; Ramel et al. 2004). In addition, in a study with
functional MRI, Farb et al. (2010) were able to show that
training in mindfulness (i.e., MBSR) results in a greater
right-lateralized recruitment, including visceral and somatosensory areas associated with body sensation after induction
of sadness. Specifically, they found reduced deactivation in
the insula during dysphoric challenge in participants of an 8week mindfulness training compared to a waiting list control
group. This reduced deactivation might be an indicator
of increased interoceptive awareness in the meditating
group. Moreover, they found that the greater somatic recruitment during evoked sadness was associated with decreased depression scores. This finding supports the notion
that (a) mindfulness training indeed increases body awareness and (b) that heightened body awareness has beneficial
effects on depression.
Intuitive Insight into the Interplay between the Body and
Emotional Processes By means of mindfulness practice,
individuals might increase the awareness of the complex
interaction of body states with cognitive and emotional
processes. This heightened awareness might not only assist
people in recognizing and disengaging from negative cognitive states (as cognitive theories of mechanisms in MBCT
postulate) but also in recognizing and disengaging from
negative bodily patterns (e.g., posture or movement patterns) that increase the risk of escalating negative emotional
states. For example, when an individual mindfully realizes
that a certain posture (e.g., a slumped posture) or a certain
style of movement (e.g., walking in a sluggish way) has
deleterious effects on his or her mood and well-being, he or
she might be able to change this bodily pattern into one that
is more beneficial.
In support for this notion, Michalak et al. (2010) found
that depressive gait patterns changed during a course of
MBCT. In an uncontrolled study with 23 formerly depressed
patients, they could show that patients who were trained in

mindful body awareness during MBCT showed normalized

walking speed (prepost effect size: d00.4) and lateral body
sway (d00.2). While walking speed increased, lateral body
sway was reduced. In addition, vertical head movements
showed a marginally significant increase toward normalization (d00.2). Even though the sizes of these changes were
small, formerly depressed patients approximately halved the
discrepancy between their performance and that of normal
controls with regard to speed and vertical head movements.
Since the changes were not simply attributable to changes in
levels of depression, this finding might indicate that MBCT
increases a feeling for the effects of the body on emotion
and might help patients to change dysfunctional movement
patterns.
Embodied Compassion and the Body as the Place of Bliss
Mindful contact with the body is not just a means of coming
into contact with avoided and negative emotional patterns.
Rather, the body is or can be a valuable positive resource and
the place where peoplewhile practicing mindfulnesscan
experience deep states of calmness and joy. It would be a
misunderstanding of mindfulness practice to equate it with
exposure and habituation to negative and unwanted internal
feelings. Even though it is important to be experientially open
to all experiences that become manifest in the field of awareness, this should not be done in a cold or detached way.
Instead, people are invited to cultivate a sense of compassion
for themselves and others. Because of the bodily focus of
mindfulness, the kind of compassion cultivated in mindfulness practice is not abstract or diffuse but has to be manifested
within the concrete bodily experience.
Some indirect support for the notion that mindfulness is
embodied through a compassionate stance comes from findings (Baer et al. 2006) that trait mindfulness is associated
with self-compassion (Neff 2003). Moreover, a recent study
by Kuyken et al. (2010) analyzed how MBCT works. In the
randomized controlled trial (Kuyken et al. 2008), 123
patients were randomized either to maintenance antidepressants or a MBCT condition. The analysis revealed that
treatment effects of MBCT were mediated by an enhancement of self-compassion over the course of treatment. However, it should be noted that this result does not make it
possible to draw unambiguous conclusions about the role of
the body in developing self-compassion during MBCT because body-related variables were not assessed in this study.
Contact with Organismic Needs and Limits
We often lose contact with our organismic needs and limits
when we are entangled in an inflexible doing mode. We
are so preoccupied with striving for goals that we do not
realize that we are hungry or thirsty or that we are exhausted

Mindfulness

and tired. The important capacity of humans to act intentionally towards long-term goals detached from current need
states can have detrimental consequences if this capacity is
used inflexibly and by default. Mindful contact with the
body can bring people into touch with their current needs.
Thus, people can decide more flexibly and deliberately how
they want to react to the current need state in concert with
their long-term aspirations. Of course, it should be noted
that these assumptions remain highly speculative and empirical studies investigating whether people trained in mindfulness are more aware of their organismic needs and limits
are needed. For example, a study using an experience sampling method to assess how often people are aware of their
organismic needs could compare people trained in mindfulness with a waiting list control group.

Conclusion
In the present, article we have argued that the body is highly
relevant in mindfulness-based treatment approaches. On the
basis of the theoretical proposals and empirical findings on
the embodiment of emotions, we assume that bodily processes are relevant for the etiology of depression and its
treatment. However, future research is required to draw firm
conclusions about the role of the body in depression. In
particular, more research with currently and formerly depressed patients is needed utilizing research designs allowing unambiguous causal inferences about embodied effects
on depression. Studies conducted in basic research on the
embodiment of emotion might be a template for the analysis
of embodied processes in clinical research. Moreover, future
research should also clarify whether embodied processes are
also relevant in other psychological disorders.
Mindfulness-based approaches, with their explicit focus
on the body, might be especially suitable to tap the embodied dimension of psychopathology. However, there is no
research unambiguously showing that the effects of
mindfulness-based approaches are indeed (at least partially)
mediated by changes in bodily processes. Future research
should analyze whether mindfulness-based approachesin
contrast to other treatment approachesare specifically mediated by embodied processes. It should be noted that
changes on a bodily level might also be possible in treatment approaches not explicitly targeting the body, simply
because bodily changes are epiphenomena of other processes (e.g., symptom change) or because the body is implicitly
targeted during the therapeutic process (e.g., implicit reinforcement of certain bodily postures by the therapist and
emotional contagion in nonverbal communication). Consequently, research designs allowing formal mediation analyses (Kraemer et al. 2002) are needed to elucidate the role of
the body in mindfulness-based approaches. In summary,

although it is too early to draw firm conclusions about the

role of the body in depression and its treatment, based on the
theoretical and empirical evidence reported, we argue that
the analysis of the embodied effects of MBCT might be a
promising way to deepen our understanding of the etiology
of depression and of the way mindfulness treatment
approaches work.
Acknowledgments This work was supported by a German Science
Foundation Grant DFG: Mi 700/4-1 awarded to Johannes Michalak
and a fellowship awarded to Jan Burg by the Studienstiftung des
deutschen Volkes.

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