Mindfulness and Psychotherapy

Mindfulness and Psychotherapy – Some Thoughts

I recently attended a day long at Spirit Rock hosted by Daniel Siegel. To those of us with a background in Existential/Contemplative perspectives on therapy, the concept of mindfulness is not new. What is new is the interest that the “scientific community” is taking in mindfulness and how research is demonstrating the effects the practice has on neurological structure and psychological outlook. For more on this, please see Dr. Siegel’s book, The Mindful Brain. Thousand year old practices are now being researched and the effects verified scientifically. The current level of interest and writing about mindfulness and its efficacy is exciting. Personally, it has renewed my commitment to this important practice in my work

Since I have been including the term “Mindfulness” as part of my therapeutic approach, I have received a number of questions about what that means in practice. This is, of course, a complex subject and I will over simplify my response for this article by saying that there are two major components of mindfulness in therapy: mindfulness practices for the client and mindfulness practices for the therapist. Since it is outside of the scope of this article to go into detail about the clinical application of mindfulness practices for the client, let’s talk about mindfulness for the therapist.

So what is to be mindful as a therapist? In his book Psychotherapy and Process, James Bugental, a well-known existential/humanist oriented therapist, speaks of “presence” as “essential for psychotherapy”. Presence is the ability to be open to what is arising in the moment. For an experiential perspective on presence and being in the moment, read Eckhart Tolle’s books. From existential/humanistic therapy, the idea of contemplative or non-dual therapy evolved (or maybe more aptly, was rediscovered). Peter Fenner in the The Sacred Mirror , describes one of the hallmarks of non-dual therapies as the “unconditioned mind” or “beginners mind”. The idea of presence and unconditioned mind are even alluded to in analytic circles. Freud described the need to employ “evenly suspended attention”. W. R. Bion, a past president of the British Psycho-analytic Society has referred to “truth in the moment” and “working at the edges between knowing and not-knowing”. I believe that the ability to work with presence and mindfulness is referred to in the literature by many different terms and is nearly always alluded to in the great works about psychotherapy.

For me, mindfulness refers to the developed ability to hold awareness of self and client interactions in the moment. This encompasses the ability to be aware of transferential and counter-transferential material and goes beyond it as well. It allows for neutrality without distance and cold observation, what I like to call “connected neutrality”. Mindfulness allows the therapist to embrace the expansiveness of what is arising with the client without the need to explain, narrow or diminish. Having said all this, it is probably useful to reflect on a certain tone of grandiosity and idealization about this practice. In this context it becomes important to note that mindfulness is usually referred to as a “practice” not a state of being. Practicing mindfully requires an ongoing commitment to training and practice mixed with a large amount of humility. For me, mindfulness is, as Bugental noted, “essential for psychotherapy.

Please feel free to send me comments, corrections or any other feedback about this article. For a bibliography of books on Mindfulness, see my website.

Mindfulness and Psychotherapy – Part 2 – Mindfulness Practices with the Client
Copyright 2009 Drew Hutchinson

In my previous article on Mindfulness and Psychotherapy, I put forth some ideas about using mindfulness from the therapist’s perspective, counter-transference and the therapeutic posture that I refer to as “connected neutrality”. (The format of this discussion is informal and does not include references.)

What does it mean to practice mindfulness in therapy with the client? What is a “mindfull” intervention or how can we interact with our clients to bring them to a deeper level of mindfulness, to help them make it a useful tool? First of all, I want to reiterate that mindfulness practices include meditation but are not limited to meditation. In fact, for many clients, meditation is contraindicated as it may reinforce dissociation and dissociative habits. I do not teach meditation or practice meditation with my clients. If clients are utilizing meditation elsewhere in their lives, then it may be useful to discuss this with them, understand how it works for them, and help them to incorporate perceived benefits into a larger strategy of self-awareness. Additionally, although some therapeutic approaches such as DBT inter-weave mindfulness into a fairly structured interaction, I do not believe a highly structured or directed approach is necessary for results (although it may be for some clients). Nor do I believe it is only applicable to the treatment of certain types of personality disorders but can be effective for most clients including couples.

There are three basic vehicles for enhancing mindfulness in the therapeutic setting. For me, the most important is the posture of the therapist. Talking about mindfulness is one thing. Embodying the practice of mindfulness so that it can be modeled is quite another and a worthy goal. This requires education, practice and commitment on the part of the therapist. Mindfulness is an ongoing practice and not something that can be achieved and then forgotten. Fortunately we live in an area with access to many teachers and retreat centers that it is fairly easy and inexpensive to get the exposure, education and reinforcement needed for individual practice. You can also get CEUs!

The second vehicle for working with mindfulness is to use interventions oriented to slowing reactivity down and helping the client become aware of her own process. This type of intervention is different from analytic confrontation, object relations interpretation or emotionally focused interpretations. However, I do not consider mindfulness to be a theoretical perspective or alternate for other types of interpretation, rather, it can enhance the theoretical approach being applied. It does require the therapist to suspend her own agenda for a moment and for some therapists this may create a dilemma. (Elucidating this would require more depth and detail than I can include in this article.) Let me provide a brief example using a hypothetical case example. I do realize that presenting a case in such an abbreviated manner leaves me open to a variety of criticisms. However, it is necessary to try to ground this discussion in some context.

Client has been in weekly therapy with me for more than a year. The primary symptoms include social anxiety, trouble in personal relationships in the workplace, obsessive tendencies and difficulty maintaining intimate relationships. The DSM IV diagnosis would likely be Obsessive/Compulsive Personality Disorder. From my relationship with the client, I know that she was not emotionally mirrored as a child but was met with criticism and disdain by emotionally distant parents who also struggled with alcoholism. In the current session, she describes the difficulty she has understanding how to respond to people at work when a conflict occurs. She is overly distraught about her own reaction, is unable to label her emotions and cannot comprehend the motives of the other person resulting in some paranoid ideation.

A number of interpretations could come to mind. An analytically oriented interpretation targeting the transference might be, “I imagine you might be confused in here about how to respond to me and wonder what my motives are”. Another, focused more on the early relationship with the primary caregiver might be “I remember you telling me about the way your mother was there for you. It seems that you never quite knew how you would be received when you approached her, I imagine that was very confusing for you.”

To encourage mindfulness, I would approach things from the here and now and encourage the client to slow down. I might say, “I understand that you become anxious when you have a conflict with someone at work. What if you slowed your process down and took a few breaths before responding. (pause) Try it here. See if you can recall your experience and just feel what you are experiencing without labeling it for a moment. . .” How this intervention might continue would depend on the client’s ability to tolerate their experience in the moment. A client might become overwhelmed and deflect the experiencing by returning to discussing the details of the interaction. If so, I would make a mental note of it and determine whether to gently return to the experience or come back to it in another session when similar material presents itself. The ability to be mindful and curious deepens with practice. The first step is awareness. Next, the ability to tolerate somatic sensations increases. Later the client becomes able to re-interpret their own sensations and choose a response with me in therapy. Eventually, this skill is transferred to the real-world situation wherever it is occurring.

The third vehicle for encouraging mindfulness is to have the client bring their own experiences of slowing down and being curious into the therapy. Once the practice starts to be transferred into real-life experience, exploring mindfull experiences will help to reinforce and expand the capacity for non-reactivity, self-awareness and choice in day to day interactions.

I am enthusiastic about the possibilities for mindfulness in therapy. I also hope that it is clear that I consider mindfulness as a component of an overall therapeutic approach determined by the client’s level of functioning, self-awareness and developmental needs. No practice or intervention should attempt to substitute for the therapist’s ability to be presence, attune to the client and model meaningful relationship.

Thanks,

Drew Hutchinson, MFT

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