Mindfulness-integrated CBT

1. Introduction

Version followed: the 10-session, four-stage programme in Cayoun, Francis & Shires, The Clinical Handbook of MiCBT (Wiley, 2018/19), as shown in its published table of contents, the MiCBT Foundation-course outline (UCSD, taught by MiCBT Institute trainers) and the developers' 2024 review (Francis, Shawyer, Cayoun, Grabovac & Meadows). Two other versions exist. The original protocol is Cayoun (2011), Mindfulness-integrated CBT: Principles and Practice; it was first called "Equanimity Training" (2001) and was finalised as MiCBT in 2006. The 8-week group adaptation was used in the Francis et al. 2022 primary-care RCT. The 2025 self-help edition (Cayoun & Grabovac) calls Stage 4 the "Compassion Stage" instead of the "Empathic Stage". [source: Francis et al. 2024; Wiley handbook ToC; UCSD course page; Francis et al. 2022]

MiCBT is a manualised, transdiagnostic therapy. It combines Burmese Vipassana meditation (the Ledi Sayadaw, U Ba Khin and Goenka lineage, with heavy use of body scanning) with CBT, especially exposure. It is meant for acute and chronic conditions and for comorbidity, not for a single diagnosis. [source: Francis et al. 2024; Cayoun NovoPsych seminar 2022]

Core idea of change (the Co-emergence Model of Reinforcement):

The chain runs: stimulus → perception → evaluation of its personal meaning → co-emerging body sensations (pleasant, unpleasant or neutral) → reaction.
A reaction is reinforced when it reduces unpleasant sensations or increases pleasant ones. The locus of reinforcement is therefore interoception, not only the outer stimulus.
Problems persist when evaluation and reaction dominate and awareness of sensation is thin.
Training equanimity toward body sensations (feeling them fully without reacting) removes the reinforcement for reactive habits. It restores the balance between perception, evaluation, interoception and response, and it lets beliefs about experience be reappraised.
The developers summarise this as "There can be experiential acceptance only when there is experiential exposure". Body scanning is treated as generalised interoceptive exposure with response prevention.

[source: Francis et al. 2024; Cayoun & Shires 2020; Cayoun seminar 2022]

2. Framework

Format. MiCBT is delivered individually or in groups, and a pilot found the two formats similarly effective. The handbook gives separate individual and group guidance for every session.

Group (8-week RCT version): 2-hour weekly sessions with 8–13 people.
Session shape: review of home practice by Socratic dialogue, psychoeducation on the rationale, a guided meditation that introduces the next week's practice, and homework from a workbook of handouts and record sheets.
Home practice: two 30-minute meditations a day (about 7 hours a week) from the breath stage onward. In week 1 it is progressive muscle relaxation (PMR) twice daily. Practice minutes are logged and checked weekly.

[source: Francis et al. 2022, 2024; UCSD course page]

Pre-programme. Do a standard clinical assessment. Identify the target problems, set success indicators for each, and get commitment to self-care practice. [source: Francis et al. 2024]

Stage	Sessions (10-session version)	Goal	Core content
1 Personal	1–4	Self-regulation of attention and emotion; interoceptive and metacognitive awareness; response inhibition	S1: therapy contract, self-care commitment, PMR, mindfulness of posture and movement. S2: mindfulness of breath. S3: co-emergence model, Diary of Reactive Habits, part-by-part body scanning. S4: applied practice, withdrawal of audio guidance, the Mindfulness-based Interoceptive Exposure Task (MIET), recording equanimity in daily life
2 Exposure	5–6	Behaviour regulation: reduce avoidance and build self-efficacy	S5: symmetrical scanning, SUDS scale, exposure hierarchy, bipolar (imaginal) exposure. S6: partial sweeping, in-vivo exposure, systematic review of exposure results
3 Interpersonal	7–8	Apply equanimity to relationships	S7: sweeping en masse, experiential ownership, interpersonal insight. S8: transversal scanning, assertive communication, mindful assertiveness
4 Empathic / Compassion	9–10	Transpersonal regulation and relapse prevention through compassion and ethics	S9: sweeping in depth, loving-kindness meditation, five ethical challenges. S10: assessing results, "Ten Maturing Factors", maintenance of practice

[source: Wiley handbook ToC; UCSD course page; Francis et al. 2024]

In the 8-week group version the timing is: weeks 1–3 Personal, 4–5 Exposure, 6 Interpersonal, 7–8 Empathic. [source: Francis et al. 2022]

Criteria for moving on.

Each handbook session opens with "Checking Client Readiness", and Session 10 with "Checking Client Progress". The specific criteria are not stated in the sources. [uncertain]
Working criteria [synthesis]:
- Before body scanning: the client is doing the daily practice most days and can return attention to the breath without much struggle.
- Before exposure: the client can stay with unpleasant sensations for a few minutes without reacting, and reports some equanimity in daily-life MIETs.
- Before interpersonal work: the client has reduced their main avoidance and can use SUDS and equanimity during exposure.
- Before compassion: the client can stay non-reactive during interpersonal triggers.
- If a criterion is not met: repeat that week's practice instead of adding a new technique. The 2024 review supports slower pacing when needed.

3. Guiding principles

Equanimity is the active ingredient. In practice: in every exercise, ask "Can you feel it fully without reacting to it?", not "Did it go away?" [source: Francis et al. 2024; Cayoun & Shires 2020]
Interoception is where reinforcement happens. In practice: trace each problem behaviour to the sensations it relieves or produces, and target non-reaction to those sensations. [source: Cayoun & Shires 2020]
Inhibit the learned response, not the experience. In practice: clients do not suppress thoughts or sensations; they refrain from engaging with them or acting on them. [source: Cayoun & Shires 2020]
Do not manipulate the experience. In practice: during scanning there is no visualising, no seeking relaxation and no changing of sensations. Relaxation is a by-product, except in week 1, which is PMR. [source: Francis et al. 2024]
Exposure underlies acceptance. In practice: acceptance is trained by repeated contact with the sensations, not by talking about acceptance. [source: Cayoun seminar 2022]
The sequence matters. In practice: build attention (breath), then interoceptive equanimity (scanning), then behaviour (exposure), then relationships, then compassion and ethics. Do not skip ahead. [source: Francis et al. 2022, 2024]
Commitment and self-care come first. In practice: start with a written therapy contract and a daily practice habit. Lack of practice is the first thing to address. [source: handbook ToC; Francis et al. 2024]
Non-pathologising, transdiagnostic framing. In practice: describe the work as recalibrating the nervous system and changing reactive habits, not fixing a disorder. [source: Cayoun seminar 2022]
Socratic, experiential learning. In practice: draw insights out of the client's own practice reports through questions, and do not lecture. [source: Cayoun seminar 2022; Francis et al. 2024]
Posture and alertness. In practice: clients sit upright, alert and still, not lying down drowsy. [source: Francis et al. 2024]
Experiential ownership. In practice: each person is responsible for their own experience and reactions; another person's hostility signals that person's suffering. [source: UCSD course page; Francis et al. 2022]
Ethics and compassion prevent relapse. In practice: harming self or others produces agitating sensations that feed reactivity, so ethical living is part of maintenance. [source: Francis et al. 2024]
The therapist practises. In practice: the therapist keeps their own daily practice and attends retreats (5–7 days are recommended). You cannot guide an equanimity you have not trained. [source: Francis et al. 2024; UCSD course page]
Pace to tolerance. In practice:
- Screen for trauma.
- Prepare clients for the unpleasant and pleasant sensations to come.
- Slow down, or switch from group to individual sessions, when practice destabilises the client.
[source: Francis et al. 2022, 2024]
The handbook chapter "Helpful Attitudes" (Ch. 3) is not drawn on, so its specific attitudes may be missing here. [uncertain]

4. Intervention inventory

Notes for the whole inventory:

Order and session numbers follow the 10-session handbook. The technique names come from the handbook ToC, the UCSD course outline and Francis et al. (2022, 2024).
Scripts: the handbook supplies audio scripts (Appendix 2) that are not drawn on. All instructions and wording below are my paraphrase. Where step detail goes beyond the sources, it is marked [synthesis] or [uncertain].
Licensing: use the official MiCBT audio recordings where licensed. The RCT used the developer's audio. [source: Francis et al. 2022]

Stage 1: Personal stage

4.1 Pre-programme assessment and target setting

Purpose: Establish suitability, the target problems and measurable success indicators before any practice.
- Sources: Francis et al. (2024); ANZCTR record.
- Handbook: "Client Suitability and Contraindications" is a Ch. 3 heading, but the chapter is not drawn on.
- Trial exclusions: current psychosis, current borderline or antisocial personality disorder, current substance dependence, pervasive developmental or organic disorder. These are trial exclusions, not necessarily clinical contraindications. [uncertain]
Steps:
1. Do a standard clinical assessment, including a trauma history and risk.
2. List 2–4 target problems in the client's words.
3. For each problem, define an observable success indicator, e.g. "drives on the motorway alone".
4. Take baseline measures. Developer-associated measures are the Equanimity Questionnaire (EQ-16) and the Mindfulness Self-Efficacy Scale (MSES); add standard symptom measures such as DASS-21 or K10. Do not reproduce items.
5. Explain the daily time commitment honestly (about an hour a day).
Example language (illustrative): "Let's write down what would tell us, concretely, that this has worked for you."
Watch for:
- Active trauma symptoms or dissociation: plan slower pacing, or individual rather than group format.
- A client who cannot commit time yet: address that before starting.

4.2 Therapy contract and commitment to self-care (Session 1)

Purpose: Turn motivation into a written, specific commitment. Build readiness for change. Introduce the "three ways of learning" and neuroplasticity as the rationale for daily practice. [source: handbook ToC; UCSD course page]
Steps:
1. Explore readiness: what the client is willing to do, and what has blocked change before.
2. Draft a written therapy contract together: goals, daily practice times and place, the session commitment, and what the client will do when practice lapses.
3. Give the neuroplasticity rationale: repeated practice changes habitual reactions, the way repeated exercise changes muscles.
4. Explain the "three ways of learning". The handbook section is not drawn on. A plausible reading is learning from hearing, from reflecting, and from direct experience, with MiCBT relying on the third. [uncertain]
5. Schedule this week's practice: PMR twice daily, plus mindful attention to posture and movement during routine actions.
Example language (illustrative): "This works like physiotherapy for the nervous system. The changes come from what you do between sessions, so let's agree on exactly when and where you'll practise."
Watch for: Vague contracts ("I'll try"). Make the times specific. A client who signs reluctantly may need a motivational conversation first [synthesis].

4.3 Progressive muscle relaxation and mindfulness of posture and movement (Session 1)

Purpose:
- Establish a daily self-care habit and anchor attention in the present.
- PMR is the one week where relaxation is the explicit aim.
- Mindfulness of the body in daily actions (posture, movement) starts the body-awareness training.
[source: Francis et al. 2022, 2024; UCSD course page]
Steps:
1. Seat the client comfortably. Guide them to tense a muscle group for a few seconds, then release, and to notice the contrast. Work through the body systematically.
2. Assign PMR twice a day with the audio, and log it.
3. Add brief mindfulness of posture and movement: noticing sitting, standing, walking and reaching while doing them.
Example language (illustrative): "Tighten your hands into fists ... hold ... and let go. Notice the difference between tension and release." "When you stand up from a chair today, feel the movement as it happens."
Watch for:
- Relaxation-induced anxiety in panic-prone clients: normalise it and proceed gently [synthesis].
- Muscle injury or pain: skip affected areas [synthesis].
- It is working when practice is logged on most days and the client notices tension earlier.

4.4 Mindfulness of breath (Session 2)

Purpose: Regulate attention and executive function. Build metacognitive awareness. Reduce self-referential evaluation. Differentiate mindfulness from mere attentiveness. Normalise intrusive thoughts. [source: Francis et al. 2024; Cayoun seminar 2022; handbook ToC]
Steps:
1. Set up the practice. Sit upright and alert, eyes closed, still.
2. Rest attention on the natural sensations of breath at the nostrils, without controlling the breath.
3. When the mind wanders, notice it, then gently and without self-criticism return to the breath. The return is the training.
4. Explain that thoughts will intrude. The skill is not engaging with them, not stopping them.
5. Home practice: two 30-minute sessions a day, with audio, logged.
Example language (illustrative): "Just feel the air touching the area around your nostrils. You don't need to breathe in any special way." "A thought has carried you away. Noticing that is mindfulness. Now come back to the breath."
Watch for:
- The client trying to make the mind blank or breathe 'correctly'.
- Self-judgement about wandering.
- Breath focus that triggers anxiety or panic: widen the focus, or open the eyes [synthesis].
- It is working when wandering is noticed sooner, there is less entanglement with thought, and the client reports being able to step back from rumination.

4.5 Teaching the Co-emergence Model (Session 3)

Purpose: Give the rationale for body scanning: reactions are driven by sensations co-emerging with evaluations. The handbook teaches it both didactically and experientially. [source: handbook ToC; Cayoun & Shires 2020; Cayoun seminar 2022]
Steps:
1. Draw the chain on paper (stimulus → perception → evaluation → body sensations → reaction) using a recent example from the client.
2. Make it experiential [synthesis]. Ask the client to recall a mildly upsetting event for a few seconds, then notice where in the body something changes and what they feel pulled to do.
3. Show how the reaction relieved, or chased, those sensations, and how that relief reinforces the habit.
4. Explain the remedy: feel the sensation fully, without reacting, so the habit loses its payoff.
Example language (illustrative): "When you checked your phone, what happened in your body just before, and just after? The relief is what keeps the habit going."
Watch for: Intellectual agreement without felt recognition; repeat the experiential part. The model is understood when the client spots co-emerging sensations in their own diary entries.

4.6 Diary of Reactive Habits (from Session 3)

Purpose: Self-monitor reactive episodes in terms of the co-emergence chain, so that targets for equanimity and exposure become visible. [source: handbook ToC, "Example of Use of the Diary of Reactive Habits"]
Steps: The format is not drawn on. The following is [synthesis] consistent with the model:
1. For each reactive episode, record the trigger, the thought or evaluation, the body sensations (where and what quality), the reaction, and the short-term effect on the sensations.
2. Review it in session. Look for recurring sensation patterns and for reactions that relieve them.
Example language (illustrative): "Let's look at Tuesday. What sensation came with 'they don't respect me', and what did you do with it?"
Watch for: Diaries that list only thoughts; prompt for body sensations.

4.7 Part-by-part (unilateral) body scanning (Session 3)

Purpose: The core practice: interoceptive awareness and equanimity, emotion regulation, and generalised interoceptive exposure with response prevention. [source: Francis et al. 2024; Cayoun seminar 2022; UCSD course page]
Steps:
1. Begin with a few minutes of breath focus to steady attention.
2. Move attention through the body in small sections, one adjacent part after another, starting at the top of the head. Go down to the toes, then back up. Each part is scanned on its own (unilaterally: one side or part at a time).
3. In each part, feel whatever sensation is present (warmth, pressure, tingling, pulsing, numbness, or no apparent sensation) without labelling it good or bad and without reacting.
4. If no sensation is felt, stay a few moments, then move on.
5. Do not visualise the body, seek relaxation or try to change sensations. Remain upright and alert.
6. Home practice: two 30-minute scans daily with audio, logged.
[source: Francis et al. 2024; Cayoun & Shires 2020]
Example language (illustrative): "Move your attention to the left shoulder. Just feel what is there, whatever it is, and let it be as it is." "Pleasant or unpleasant, it's the same practice: feel it, don't react."
Watch for:
- Using the scan to relax, then feeling disappointed.
- Drowsiness.
- Blind spots.
- Strong unpleasant sensations or trauma memories, especially with trauma histories: shorten the sessions, reopen the eyes, return to the breath, and slow down.
- It is working when the client can stay with discomfort longer and calmer, and recognises the habit of reacting to sensations.

4.8 Applied practice, withdrawing audio and recording equanimity (Session 4)

Purpose: Increase practice efficacy. Move from guided to self-guided scanning. Transfer equanimity into daily life and record it. [source: handbook ToC]
Steps:
1. Review practice obstacles.
2. Start withdrawing the audio: the client increasingly scans without guidance. The withdrawal schedule is in the handbook script, which is not drawn on. [uncertain]
3. Ask the client to note moments in daily life when they noticed sensations and stayed non-reactive, and moments when they reacted.
4. Discuss what scanning reveals about patterns of reaction. The handbook calls this the development of insight.
Example language (illustrative): "This week, scan on your own for some sessions. You know the route now."
Watch for: Practice dropping without the audio; let the client mix guided and unguided sessions [synthesis].

4.9 Mindfulness-based Interoceptive Exposure Task, MIET (Session 4 onward)

Purpose: A brief, portable exposure for everyday stressors, pain or distress spikes. It cultivates equanimity toward the most intense sensation in the moment. [source: Francis et al. 2024; Cayoun & Shires 2020; UCSD course page]
Steps:
1. When distress or pain rises, pause.
2. Locate the centre of the most intense sensation.
3. For a short period, observe it as objectively as possible. In the chronic pain study the period was 30 seconds. Note its mass, temperature, movement and density (cohesiveness).
4. Do not try to push it away or escape it.
5. Optionally rate the sensation before and after on the Mindfulness-based Interoceptive Signature Scale, and track distress or pain ratings.
Example language (illustrative): "Find the strongest point of it. Is it heavy or light? Warm or cool? Still or moving? Dense or loose? Just watch it for half a minute."
Watch for:
- Using the MIET as a technique to make the sensation vanish; this is covert avoidance.
- It is working when ratings of anxiety, duration or intensity fall over repeated trials.
Note: The CPA workshop flyer lists "rapid distress reduction techniques" in Stage 1. Whether these are the MIET or separate methods was not established. [uncertain]

Stage 2: Exposure stage

General notes for this stage:

Safety and consent for all exposure [synthesis, standard exposure practice]:
- Get informed consent after explaining that distress will rise temporarily.
- Exclude or defer exposure with untreated psychosis, acute suicidality, unstable medical conditions that arousal could worsen (e.g. cardiac or seizure disorders, pregnancy complications: get medical clearance), active substance dependence, or current danger in the feared situation.
- Never use exposure to keep someone in a genuinely unsafe relationship or place.
- The client sets the pace and can stop at any time.
Equanimity framing: MiCBT frames exposure as equanimity plus response prevention. The aim is non-reaction to the sensations the feared situation triggers, not toughing it out. [source: UCSD course page; Francis et al. 2022, 2024]

4.10 Symmetrical (bilateral) scanning (Session 5)

Purpose: The first advanced scan. It widens attention and deepens equanimity before exposure work. [source: handbook ToC; UCSD course page]
Steps:
1. Scan as before, but feel paired parts on both sides at once: both shoulders, both upper arms, both thighs, and so on.
2. Move down the body and back up.
3. Do the midline parts (head, trunk) as before.
4. Same rules: feel the sensations, don't react, don't visualise.
The detailed handbook script is not drawn on. [uncertain]
Example language (illustrative): "Now feel both hands at the same time, left and right together, just as they are."
Watch for: Attention jumping between sides. Allow a brief alternation that settles into simultaneous awareness [synthesis].

4.11 SUDS scale and exposure hierarchy (Session 5)

Purpose: Quantify distress and grade the avoided situations. [source: UCSD course page; Francis et al. 2022, "graded" exposure]
Steps:
1. Anchor a 0–100 Subjective Units of Distress scale with the client's own examples at 0, 50 and 100.
2. List the avoided situations, internal ones (memories, sensations) and external ones, linked to the target problems.
3. Rate each item and order the list from low to high.
Example language (illustrative): "If 100 is the most distressed you can imagine being, where would standing in a supermarket queue sit?"
Watch for: Hierarchies with big gaps between items; add intermediate steps.

4.12 Bipolar exposure (imaginal; Session 5)

What is confirmed: "Bipolar exposure" is MiCBT's named imaginal exposure technique, taught with symmetrical scanning and SUDS. It is extended in Session 6 to "Bipolar and in-vivo exposure". The developers describe the stage-2 methods as "equanimity-based imaginal and in-vivo exposure". [source: handbook ToC; UCSD course page; Francis et al. 2024]
What is not confirmed: The step-by-step procedure is not given in the sources. [uncertain]
Likely meaning: "Bipolar" probably refers to exposure to both poles of an imagined scenario, the feared or unwanted outcome and the desired outcome. Both aversion and craving reinforce reactions in the co-emergence model, so both would need equanimity. This reading is unverified; check it against the handbook before relying on it. [uncertain]
Purpose: Reduce avoidance and reactivity to an anticipated situation by staying equanimous to the sensations the imagery evokes.
Steps [synthesis, consistent with the sourced elements]:
1. Start with 10–15 minutes of scanning to establish equanimity.
2. Pick an item from the hierarchy (low to moderate SUDS).
3. The client imagines the situation in specific sensory detail.
4. Attention moves to the body sensations the image triggers. The client feels them fully, scanning or holding attention on the strongest area, without reacting.
5. Rate SUDS at the start, at the peak and at the end.
6. Stay with it until SUDS falls substantially, or for a set period, before letting the image go.
7. If the bipolar reading is right: also imagine the opposite pole, and observe any pleasant sensations, and any craving for that outcome, with the same equanimity.
8. Return to scanning to close.
9. Repeat until the item rates low, then move up the hierarchy. Assign imaginal practice as homework.
Example language (illustrative): "Picture yourself walking into the meeting room. Now leave the picture in the background and feel what is happening in your chest and stomach. You don't have to do anything with it."
Watch for:
- Distraction, or leaving the image as distress peaks; that is avoidance.
- SUDS not falling across trials: check the image is specific and the client is not using safety behaviours.
- Overwhelm: drop down the hierarchy.

4.13 Partial sweeping (Session 6)

Purpose: Detect subtle sensations and early cues of distress. [source: UCSD course page; handbook ToC]
Steps [uncertain: the handbook script is not drawn on; this is based on the technique's name and its Vipassana use]:
1. Where sensations are felt freely across a region, move attention through that region in one continuous sweep.
2. Where they are not, go back to part-by-part scanning.
3. Keep the same non-reactive stance throughout.
Example language (illustrative): "Where you can feel sensation all through the arm, let attention flow down through it. Where it's blank or patchy, go slowly, part by part."
Watch for:
- Craving for flowing, pleasant sensations, and disappointment when they go. Treat this as a reaction to equanimise [synthesis].
- It is working when the client picks up subtle early distress signals before they escalate.

4.14 In-vivo exposure with equanimity, and systematic review of results (Session 6)

Purpose: Overcome behavioural avoidance in real situations, generalise self-confidence and self-efficacy, and review results systematically. [source: handbook ToC; UCSD course page; Francis et al. 2022, 2024]
Steps [synthesis, standard graded exposure with MiCBT framing]:
1. Choose the next hierarchy item, agree a specific task and its duration, and identify the safety behaviours to drop.
2. During the task, attend to the body sensations (using the MIET or a brief scan of the strongest area), stay equanimous, and do not escape or use safety behaviours.
3. Record SUDS before, during and after, and note what actually happened against what was predicted.
4. Repeat each item until SUDS reduces, then move up.
5. Review the record systematically in session. Ask Socratic questions about what the client learned about their capacity.
Example language (illustrative): "As you stand in the queue, you'll feel that heat in your face rise. That's the moment to feel it rather than leave. Your job is just to stay present with it."
Watch for:
- Subtle avoidance: distraction, reassurance seeking, rushing.
- Tasks that are too large.
- It is working when SUDS falls within and across sessions, avoided situations are re-entered, and the success indicators move.
Specific applications:
- Compulsive or harmful behaviours (urges, compulsions, self-harm urges) are handled with the same logic: exposure to the urge-related sensations with prevention of the response.
- In Stage 4 this is applied to potentially harmful behaviours for relapse prevention. [source: Francis et al. 2022, 2024]

Stage 3: Interpersonal stage

4.15 Sweeping en masse (Session 7)

Purpose: An advanced scan that takes in larger areas, or the whole body, in a continuous flow. [source: handbook ToC; UCSD course page]
Steps [uncertain]:
1. Once sensations are felt throughout, sweep attention through the whole body (or large sections) from head to feet and back, as one continuous movement.
2. Where the flow is blocked by areas with no sensation or with intense sensation, return to part-by-part scanning there.
Example language (illustrative): "Let attention move down through the whole body at once, like water poured over you, and back up. Wherever it gets stuck, slow down and go part by part."
Watch for: Rushing through blank areas; seeking pleasant flow.

4.16 Experiential ownership and interpersonal insight (Session 7)

Purpose: Apply the co-emergence model to relationships.
- Each person owns their own experience: sensations arise in me from my evaluation, so I am responsible for my reactions.
- Another's negative reaction reflects their own suffering.
- This supports setting boundaries without reactivity, and taking responsibility for one's own experience in interpersonal situations.
[source: UCSD course page; Francis et al. 2022]
Steps [synthesis built on these elements]:
1. Pick a recent interpersonal trigger from the diary.
2. Map both sides of the co-emergence chain: what the client evaluated and felt, and, hypothetically, what the other person may have evaluated and felt.
3. Help the client see their own reaction as driven by their own sensations. Help them see the other's behaviour as a reaction to the other's sensations, often suffering.
4. Separate ownership from blame. The client does not take on the other's experience, and does not excuse harm. Decide what boundary, if any, is needed.
5. Add interpersonal situations to the exposure hierarchy, and do imaginal then in-vivo exposure to avoided or conflictual interactions with equanimity.
Example language (illustrative): "What you felt when he shouted was your experience, and you can take care of it. His shouting tells us something about what was happening in him." "Owning your reaction doesn't mean accepting being treated badly. What limit do you want to set?"
Watch for:
- Clients in abusive relationships hearing "it's your responsibility" as self-blame. Screen for coercion and safety first [synthesis].
- Using "they're suffering" to suppress legitimate anger.
- It is working when the client has fewer reactive escalations and can describe the other's state without hostility.

4.17 Transversal scanning (Session 8)

Purpose: Scan through the body's depth, from surface to inner sensations, to address schematic (long-standing, pattern-level) emotional reactivity. [source: UCSD course page; Francis et al. 2024 ("transversally ... surface to internal")]
Steps [uncertain]:
1. Having scanned the surface, move attention through the body's depth, e.g. from front to back or from the surface inward through each part, feeling internal sensations.
2. Keep the stance non-reactive.
Example language (illustrative): "Now let attention pass through the chest, from the front, through the inside, to the back, and feel whatever is there."
Watch for:
- Deep, unfamiliar or intense internal sensations, and old emotional material surfacing. Prepare the client and pace it.

4.18 Assertive communication and mindful assertiveness (Session 8)

Purpose: Combine standard assertive communication with equanimity. The handbook teaches "Assertive Communication" and "Mindful Assertiveness" and relates them to the co-emergence model. The UCSD course describes "seven steps" of assertive communication. [source: handbook ToC; UCSD course page; Francis et al. 2022]
The seven steps are not given in the sources and are not listed here. [uncertain]
Steps [synthesis: a generic assertiveness sequence with the MiCBT stance, not the manual's seven steps]:
1. Before speaking, notice and equanimise your own sensations (a brief MIET).
2. Describe the specific behaviour factually.
3. Own your experience using "I" statements (experiential ownership).
4. State a clear request or boundary.
5. Listen to the reply while monitoring your own sensations, without reacting.
6. Acknowledge the other person's view.
7. Negotiate or restate as needed.
Rehearse in role-play: the UCSD course uses breakout role-plays. Then assign in-vivo practice.
Example language (illustrative): "When the report came back unread, I felt frustrated. I'd like us to agree a time to go through it."
Watch for:
- Assertiveness used to win or punish (a reaction driven by aversion).
- Passive collapse when the other pushes back.
- It is working when requests are made calmly and boundaries are held without escalation.

Stage 4: Empathic (Compassion) stage

4.19 Sweeping in depth (Session 9)

Purpose: The most advanced scan: the whole body, surface and interior, in a free-flowing sweep. The UCSD course describes it as possibly covering the whole body in one breath. [source: UCSD course page; handbook ToC; Francis et al. 2022 ("more advanced, flowing body scanning")]
Steps [uncertain]:
1. Sweep through the whole body, including its interior, in one continuous movement.
2. Go back to part-by-part scanning wherever sensation is absent or intense.
Example language (illustrative): "Let attention move through the whole body, inside and out, in one sweep, then back. Wherever it slows, go part by part."
Watch for: Pursuit of pleasant, free-flowing states, and clinging to them. The developers note that pleasant sensations are common at this point. Treat craving as just another reaction.

4.20 Loving-kindness meditation (Session 9, continued in Session 10)

Purpose: Cultivate self-directed and then other-directed compassion and connectedness, and prevent relapse.
- Pleasant body sensations, common by this stage, are paired with kindly affirmations. Two examples the authors give are "may I be peaceful" and "may I be kind to myself".
- This is a counterweight to the negative self-statements that co-occur with unpleasant sensations and maintain depression.
[source: Francis et al. 2024; UCSD course page]
Steps:
1. The practice follows a body scan. The handbook says loving-kindness comes after scanning, but the exact timing is not drawn on. [uncertain]
2. Notice any pleasant sensation present.
3. While feeling it, silently repeat brief wishes of wellbeing for oneself.
4. Then extend them outward to loved ones, to neutral people, to difficult people and to all beings. This extension order is the conventional loving-kindness sequence; the MiCBT order was not verified. [uncertain]
5. Home practice: add a few minutes of loving-kindness at the end of each scan [synthesis].
Example language (illustrative): "While you feel that warmth in your chest, let the words come quietly: may I be peaceful ... may I be kind to myself."
Watch for:
- Threat, grief or a sense of unworthiness. The 2024 review flags this especially in clients with depression or adverse backgrounds.
- If it appears: shorten the practice, start with someone easy to wish well, or go back to scanning and equanimise the reaction [synthesis].
- It is working when the self-talk is less harsh and the client feels more connected.

4.21 Grounding compassion in ethics: the five ethical challenges (Session 9)

Purpose: Minimise harm to self and others, and use behavioural experiments to notice the interoceptive effects of ethical and unethical behaviour. Agitating sensations after harmful acts feed reactivity, and harmlessness supports equanimity and self-worth. [source: Francis et al. 2024; UCSD course page; Francis et al. 2022]
What is confirmed and what is not:
- Confirmed: clients take on five basic ethical challenges for one week as an experiment. [source: Francis et al. 2024]
- Not confirmed: the content of the five. They are commonly understood to be secular versions of the five traditional Vipassana precepts: refraining from harming living beings, from taking what is not given, from harmful sexual conduct, from harmful or false speech, and from intoxication. This is unverified. [uncertain]
Steps [synthesis around the sourced experiment]:
1. Introduce harm minimisation in non-moralising terms.
2. Agree the five challenges for the week, adapted to the client's life.
3. Ask the client to notice and record the body sensations when they keep a challenge, when they break one, and when they feel tempted.
4. Review in session. What did honest, harmless conduct feel like in the body, compared with its opposite?
Example language (illustrative): "This isn't about being good or bad. It's an experiment: notice what happens in your body when you hold back from a white lie, and what happens when you tell one."
Watch for:
- Scrupulous or perfectionistic clients turning this into self-punishment; keep the frame experimental.
- Cultural or religious sensitivities; frame the challenges as secular.
- For substance-using clients, the intoxication challenge needs a proper clinical plan [synthesis].

4.22 Assessing results, the "Ten Maturing Factors" and maintenance (Session 10)

Purpose: Review outcomes against the success indicators. Support continued growth through the "Ten Maturing Factors". Plan long-term practice. Link ethical intentions and actions to self-worth. [source: handbook ToC; UCSD course page]
What is not confirmed: The content of the Ten Maturing Factors is not given in the sources. They may correspond to the ten traditional Theravada "perfections" (generosity, ethical conduct, renunciation, wisdom, effort, patience, truthfulness, determination, loving-kindness, equanimity). This is unverified. [uncertain]
Steps:
1. Re-administer the baseline measures (e.g. EQ-16, MSES and the symptom measures).
2. Go through each target problem and its success indicator.
3. Help the client identify which practices helped most and their personal early warning signs, especially sensation-level cues picked up by partial sweeping.
4. Agree a maintenance plan: daily practice (developer guidance favours continuing daily meditation), what to do at signs of relapse, and options such as practice groups or retreats [synthesis].
Example language (illustrative): "What will tell you, in your body, that an old pattern is starting up, and what will you do in the first five minutes?"
Watch for: Abrupt cessation of practice after therapy ends; plan booster sessions [synthesis].

Cross-cutting techniques

4.23 Socratic practice review (every session)

Purpose:
- Turn each client's practice experience into insight.
- Challenge resistance and self-defeating thoughts about practice, and encourage practice.
- Support cognitive reappraisal of beliefs once equanimity develops.
- MiCBT does not list formal cognitive restructuring as a separate named technique in the sources. Its "cognitive" component is delivered largely through this dialogue and through reappraisal arising from equanimity. [uncertain]
[source: Cayoun seminar 2022; Francis et al. 2024; UCSD course page]
Steps:
1. Start each session by asking how practice went: amount, obstacles, what was noticed.
2. Ask open questions that lead the client to their own conclusions (what happened, what did you do with it, what did you learn).
3. Link observations to the co-emergence model.
4. Problem-solve obstacles.
Example language (illustrative): "You said the itch was unbearable. What happened when you didn't scratch?" "What does that tell you about the thought 'I can't stand this'?"
Watch for: The therapist explaining instead of asking; a client who reports only 'good' or 'bad' sessions. Steer them toward describing what they observed.

4.24 Group delivery adaptations

Purpose: Run the same 10-session (or 8-week) sequence in a group. [source: Francis et al. 2022; handbook ToC "Application with Groups"]
Steps:
1. Each session: guided meditation introducing the new practice, then a round of practice review, psychoeducation and homework setting.
2. Use role-plays in pairs for the interpersonal skills.
3. Follow up absent members.
4. Check practice logs weekly and suggest individual practice modifications where needed.
Watch for:
- Members whose practice destabilises them: offer individual sessions.
- Drop-out in the first weeks. In the RCT, 23% attended fewer than 4 sessions.

5. Handling problems

What the sources say is limited:

Adverse effects: 31% of RCT participants reported unexpected or difficult meditation experiences, including:
- intense sensations, anxiety and irritability
- mood swings and relationship changes
- wanting to avoid meditating
- triggered PTSD symptoms and surfacing of unprocessed trauma
Developer guidance covers screening for trauma, preparing clients, pacing more slowly, offering individual rather than group format, and the risk of compassion work triggering threat or grief.
Each handbook session has a "Frequently Asked Questions" section that is not drawn on.

[source: Francis et al. 2022, 2024]

Everything else below is [synthesis] unless tagged.

Low or no home practice (the most common problem).
- Revisit the therapy contract and the hour-a-day expectation.
- Use Socratic dialogue on the client's beliefs about practice, e.g. "I'm no good at this" or "it isn't working". [source: Cayoun seminar 2022; UCSD course page]
- Problem-solve the logistics: time, place, using the audio.
- If 2×30 minutes is truly impossible, agree a smaller, fixed amount and build up. Hold the next stage until practice is established.
- In the RCT, participants averaged about 64% of the recommended practice. Expect partial adherence and track it. [source: Francis et al. 2022]
"It isn't relaxing" or "it makes me feel worse".
- Re-explain that relaxation is not the goal. Unpleasant sensations are the material for equanimity training, and reacting to them is the habit being retrained.
- Normalise both pleasant and unpleasant sensations in advance; the RCT forewarned participants of both. [source: Francis et al. 2022, 2024]
Overwhelm, trauma memories, flashbacks or dissociation during scanning.
- In session: stop the scan, open the eyes, orient to the room, feel the feet on the floor and the breath at the nostrils, and talk.
- Afterwards: shorten scans, practise with eyes partly open, scan only more neutral areas (hands, feet) for a while, move to individual format, and extend Stage 1. [source for pacing and format: Francis et al. 2024]
- Consider trauma-focused treatment first, or alongside, if PTSD symptoms dominate.
Intense or frightening sensations (tremors, heat, flowing energy, numbness) and pain.
- Treat them as objects of equanimity using the MIET dimensions (mass, temperature, movement, density). [source: Cayoun & Shires 2020]
- Rule out medical causes for new physical symptoms.
- For pain, use the MIET as in the chronic-pain study. [source: Cayoun & Shires 2020]
Drowsiness or dullness. Sit upright, open the eyes slightly, practise at a more alert time of day, and scan faster through 'blank' areas. [upright-alert posture: Francis et al. 2024]
Rumination disguised as practice (analysing sensations, narrating). Return to bare feeling of the sensation, and to breath focus if the mind is very busy.
Craving for pleasant states (in sweeping stages). Point out that craving is the other half of the reinforcement loop, and equanimise it like aversion. [model: Cayoun & Shires 2020]
Exposure stalls (SUDS does not fall).
- Check for safety behaviours, distraction and avoidance inside the image.
- Check that the item is not too high.
- Check the duration: stay until distress falls.
- Go back to the MIET on the dominant sensation.
Exposure refusal. Revisit the target problems and success indicators, go lower on the hierarchy, start imaginally, and let the client choose the pace. Never coerce.
Resistance or scepticism about the 'Buddhist' origins. Use the secular, nervous-system framing ("recalibrating" reactive habits). [source: Cayoun seminar 2022] Treat ethics as a behavioural experiment, not as moral teaching.
Compassion work triggers threat, grief or unworthiness. Slow down. Start with wishes for a benefactor or a pet, keep the phrases very simple, and equanimise the resistance as sensation. The risk is flagged in Francis et al. (2024); these responses are synthesis.
Interpersonal stage in abusive or coercive relationships.
- Experiential ownership must not become self-blame.
- Prioritise safety assessment and planning.
- Do not do assertiveness or exposure tasks that increase risk.
Ruptures (the client feels pushed, judged on practice, or lectured).
- Acknowledge it openly and own your part. Return to asking rather than telling.
- Revisit the contract as a shared agreement, not a test.
- Use the co-emergence model collaboratively on the rupture itself, if the client is open to it.
Group problems (dominant members, comparison of 'progress', distress in the room).
- Set ground rules.
- Normalise variation in experience.
- Have a plan for one-to-one follow-up if someone becomes distressed.
- Follow up non-attenders. [follow-up of absentees: ANZCTR record]
Suicidality or self-harm.
- Conduct a standard risk assessment and safety plan before starting, and review risk regularly.
- Self-harm urges can later become targets of urge-sensation exposure with response prevention, but only once the client is stable and a safety plan is in place.
- If means are at home, use lethal-means counselling (safe storage or removal).
- Acute suicidality: defer the programme and treat the crisis.
Psychosis, mania, severe dissociation, current substance dependence. These were trial exclusions [source: ANZCTR]. Do not start standard MiCBT in an acute phase. Consider adapted, specialist-supervised delivery only once stable. [uncertain: the handbook's contraindications section is not drawn on]
Therapist-side problems. If you lack your own regular practice, you will struggle to guide equanimity. The developers recommend personal practice, retreats and formal training with supervision before delivery. [source: Francis et al. 2024; UCSD course page]

Sources

Sources: