Synergy of Mindfulness and Psychotherapy – Part One

There is no stronger influence on psychotherapy these days than mindfulness.
– Michael Yapko, PhD

Mindfulness is coming out of the closet (or retreat centers) and into clinical sessions very, very rapidly these days. The synergy of mindfulness and the empathic relationship helps patients better trust, reflect, and heal, as millions of patients and therapists now attest. Neuroscience is helping to demonstrate why; the meaning of the data is increasingly accessible to us through resources like Dan Siegel’s The Mindful Therapist and Ron Siegel’s forthcoming Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical Practice. (See Resources below.)

Now the dialogues among practitioners from both paradigms are becoming more numerous and the investigations into how to skillfully integrate mindfulness into psychotherapy are becoming more sophisticated. The Sept-Oct 2011 issue of the Psychotherapy Networker “The Mindfulness Movement: Do We Even Need Psychotherapy Anymore?” challenges sacred cows on both sides of the confluence. (You can easily download most of the articles from the Networker website.) The Networker is also currently hosting a free webinar series “Is Mindfulness Enough?” with pioneers of the integration like Jack Kornfield, Ron Siegel, Tara Brach, Michael Yapko to date; Richard Schwartz, Mark Epstein, Sharon Salzberg by my November e-newsletter.

Another thoughtful and free teleseminar series is currently hosted by the National Institute of Clinical Applications of Behavior Medicine, featuring Rick Hanson, Ron Siegel, Dan Siegel, Sara Lazar to date; Tara Brach, Elisha Goldstein, Sharon Salzberg, Ellen Langer and others by my November e-newsletter.

The dialogues are stimulating; the inquiries are provocative. May the reflections and tools offered here be useful to you and yours.

REFLECTIONS on the Synergy of Mindfulness and Psychotherapy

It’s so easy to claim new phenomena are “cutting edge” when tools of the phenomena themselves (observing ego, even-hovering attention) have been around for 150 years, even 2,500 years (compassion practice to support training the attention of the mind).

But I do remember sitting at a daylong at Spirit Rock Meditation Center ten years ago with Roger Walsh, professor of psychiatry at U.C. Irvine, author of Essential Spirituality: The Seven Central Practices to Awaken the Heart and Mind, and one of the early pioneers in research of the effects of meditation on the mind, and hearing Roger counsel us to use meditation practice to clear our own minds on breaks between clients, but to not teach meditation to clients in sessions; too risky.

A short decade later, Jack Kornfield, clinical psychologist, co-founder of Spirit Rock Meditation Center, author of Wise Heart:A Guide to the Universal Teachings of Buddhist Psychology, is describing therapy as “meditation for two” and most of the voices emerging into the spotlight championing the synergy of mindfulness and psychotherapy have been dedicated, if invisible, practitioners of both paradigms for two or three decades themselves.

Here are some of the highlights I’m gleaning from the synergizing:

1. Mindfulness and psychotherapy are both experiential processes that use various tools to intentionally re-direct and focus the mind’s attention (which “lights up” the neural pathways in the brain so those pathways can both strengthen and re-wire) though what practitioners choose to focus attention on may vary greatly depending on their theoretical orientation or practice lineage. The current confluence is certainly aided by everyone focusing on practices and outcomes, not on theories or cosmologies that would lead the practices to focus on certain priorities or values but not others. As Jack Kornfield says bluntly, “Mindfulness leads to sanity.”

One of the major differences among practitioners is the widely different vocabularies for the same phenomena, describing the same tools or outcomes in very different terms. And, of course, therapists cultivating their own mindfulness practice, to steady their own awareness and acceptance of the client’s material, perhaps stabilizing their own sanity, is invaluable.

2. Between a stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom. The last of human freedoms is to choose one’s attitude in any given set of circumstances.
– Viktor Frankl

Both mindfulness and psychotherapy create a Pause where therapist and patient can stop, breathe, step back from the story-drama, the agitation, the denial; become present in this moment, in this room, in this inter-subjective field; “come home” to the safety of loving presence – empathic resonance – whatever the vocabulary; focus on the tremendous power of the senses and body sensations to return both therapist and patient to equanimity – the window of tolerance – whatever the vocabulary. Both therapist and patient come into a shared awareness and acceptance of the experience (a common vocabulary!) and then begin to discern the wholesome from the unwholesome – the adaptive from the maladaptive – whatever the vocabulary. We are so socially conditioned to keep many balls in the air all the time; the pause allows the brain to operate differently and thus respond differently. Tara Brach quoted an AA sponsor saying, “Five seconds of pause is more powerful than a year of AA meetings.”

3. The trajectory of focusing attention on a specific object (like the breath but could be the resource of a person – therapist, partner, friend, spiritual figure, pet – that a person feels loved by and safe with), steadying awareness with that concentrated focus, then expanding awareness to a more open field where any experience is seen as “clouds moving through the sky of awareness” takes the person out of their regular thought stream. It’s possible to see thoughts, sensations, emotions, reactions, come and go, and to see that thoughts, sensations, emotions, reactions, everything that arises in consciousness, do come and go. The patient can also begin to learn how their mind operates – what perception leads to what reaction leads to what behavior leads to what suffering, discerning when to believe their mind and when not.

4. This self-awareness of the operations of the mind itself allows the patient to de-center and investigate their experience without being caught or embedded in it. (How do I generate anxiety? How do I mis-interpret a question from my boss or sister-in-law? How does one thought spiral into another into a vortex of catastrophizing or depression? How do I create the state of suffering I want relief from? This mindfulness of the mind, this stepping back to reflect, resting in a broader being, also helps the patient challenge their deeply held views of self and other, untangle the tangles – unstick the stuck negative thoughts – whatever the vocabulary – and re-frame those thoughts so that they can continue to evolve. (“Yup, I do get angry when I feel slighted or ignored.”) And that allows the patient to dis-identify from the thought as “me” (“I can feel the anger in my clenched jaw and fists” rather than “I am angry” or “I am an angry person.” and see clearly how maladaptive thought patterns, or deeply unconscious schemas, can distort perceptions and lead to suffering.

5. This awareness of how the mind works is necessary to counter the hard-wired “negativity bias” of the brain which evolved over millions of years to keep our ancestors alive and our species re-producing. (Our ancestors had to be super-vigilant to deal with daily threats to life and limb; we’ve inherited a nervous system that is “nervous;” it’s all too easy for our body-brain to react to a nasty memo from our boss or a delayed flight at the airport as a life threat.) Mindfulness is a practice par excellence to notice what is actually happening in this moment, now-not-then, here-not-there, and find equanimity again in the holding and reflecting on experience rather than reacting to it. This allows the patient to re-find their response flexibility which is the ground of wise effort – resilience – whatever the vocabulary.

6. It’s the radical acceptance and compassion for whatever our experience is in the moment that allows the patient to find a rhythm between turning toward safety and turning toward the sharp points. Therapists guide patients as needed to the safety of empathic resonance, relaxing the grip on the thoughts and strengthening the compassionate container, or to the growth edge of challenging defenses and dysfunction, unpacking the drama. (What Tibetan master Chogyam Trunga Rinpoche called “meet our edge and soften.”)

7. Part of what patients come to experience and accept with both mindfulness and compassion is the essential resourcefulness, courage, worth, goodness – whatever the vocabulary – of both their personal self and a more expanded awareness that is not limited to a separate self – “awake with knowing and tender with love” as Tara Brach says. Both mindfulness and the emerging positive psychology movement (gaining momentum from research that verifies that cultivating pro-social emotions and inner resources leads to increased resilience, well-being, and happiness) help therapists focus on and mobilize the client’s strengths and capacities. Both mindfulness and therapy can help “wake up” a client’s expectations of change and strengthen a sense of inner locus of control, a sense of a larger way of being, from which they can, indeed, effect change in a positive direction. Patients re-define themselves and their relationships to others and shift their identity; they subjectively feel transformed, that “a loving presence is who I am” – whatever the vocabulary.

8. Everyone cautions against using mindfulness as a spiritual bypass, finding the inner Buddha rather than becoming a better husband or neighbor.

You might be tempted to avoid the messiness of daily living for the tranquility of stillness and peacefulness. This, of course, would be an attachment to stillness and, like any strong attachment, it leads to delusion. It arrests development and short-circuits the cultivation of wisdom.
– Jon Kabat-Zinn

9. Everyone also cautions against “prescribing” mindfulness when there is unresolved trauma that might tip a patient from the openness of spacious awareness into the terrifying emptiness of the void. Sara Lazar, who did the pioneering research that demonstrated that sustained mindfulness practice thickens the cell volume of the insula, posterior cingulate, and parts of the brain stem and cerebellum involved in self-referencing (how am I doing?) and empathy with others, recommends yoga practice (which she has also researched) rather than mindfulness practice for patients with unresolved trauma or any history of psychosis, – taking refuge in the body, grounded, anchored to create the sense of safety that can then help hold the exploration and resolution of the trauma.

I would also recommend Sensorimotor Psychotherapy, which is Pat Ogden’s mindfulness-based, body-based therapy for trauma, cultivate the patient’s mindful self-empathy before focusing on the sensations and impulses where trauma is held in the body.

New wisdom and new questions will continue to emerge as this synergy gains momentum. More next month in Part Two.

POETRY AND QUOTES TO INSPIRE

If you’re reading these words, perhaps it’s because something has kicked open the door for you, and you’re ready to embrace change. It isn’t enough to appreciate change from afar or only in the abstract, or as something that can happen to other people but not to you. We need to create change for ourselves, in a workable way, as part of our everyday lives.
– Sharon Salzberg

* * * * *

The most fundamental aggression to ourselves, the most fundamental harm we can do to ourselves, is to remain ignorant by not having the courage and the respect to look at ourselves honestly and gently.
– Pema Chodron

* * * * *

There is no enlightenment outside of daily life. Feelings, whether of compassion or irritation, should be welcomed, recognized, and treated on an absolutely equal basis; because both are ourselves. The tangerine I am eating is me. the mustard greens I am planting are me. I plant with all my heart and mind. I clean this teapot with the kind of attention I would have were I giving the baby Buddha or Jesus a bath. Nothing should be treated more carefully than anything else. In mindfulness, compassion, irritation, mustard green plant, and teapot are all sacred.
– Thich Nhat Hanh

* * * * *

Meditation may be done in silence and stillness, by using voice and sound, or by engaging the body in movement. All forms emphasize the training of attention.
– Sharon Salzberg

* * * * *

Enough. These few words are enough.
If not these words, this breath.
If not this breath, this sitting here.

This opening to the life
we have refused again and again
until now.

Until now.
– David Whyte

* * * * *

Feelings come and go like clouds in a windy sky. Conscious breathing is my anchor.
– Thich Nhat Hanh

* * * * *

Listen, are you breathing just a little and calling it a life?
– Mary Oliver

* * * * *

We live in an ocean of air like fish in a body of water. By our breathing we are attuned to our atmosphere. If we inhibit our breathing we isolate ourselves from the medium in which we exist. In all Oriental and mystic philosophies, the breath holds the secret to the highest bliss.
– Alexander Lowen

* * * * *

You know that our breathing is the inhaling and exhaling of air. The organs that serves for this are the lungs that lie around the heart so that the air passing through them thereby envelops the heart. Thus breathing is a natural way to the heart. And so having collected your mind within you, lead it into the channel of breathing through which air reaches the heart and, together with this inhaled air, train your mind to descend into the heart and to remain there.
– Nicephorus the Solitary, 13th century Christain mystic

* * * * *

It is often more difficult to remember to be mindful than to be mindful itself.
– Donald Rothberg

* * * * *

If you woke up breathing, congratulations! You have another chance.
– Andrea Boydston

* * * * *

There is one way of breathing that is shameful and constricted. Then, there’s another way: a breath of love that takes you all the way to infinity.
– Rumi

* * * * *

Walking through the house at night is wonderful to me; a symphony of breath, each person a separate instrument as they collectively breathe in time to the metronome of life itself.
– Edwin Leap

STORIES TO LEARN FROM

When I’m working with a client, I may have a director’s commentary running in the background – oh, this moment needs some EMDR resourcing or AEDP meta-processing or CBT challenging a negative thought or EFT naming the cycle or NVC behavior change requests, but it’s all intuitively emerging in the flow of the moment. I may have another director’s commentary running – that here we need to discern the wholesome from the unwholesome, or evoke some self-compassion, or leave the story and re-ground in the present moment. It is the moment-to- moment feedback and moment-to-moment experimenting and then noticing how the experiment lands that is the practice – whatever the vocabulary.

In that context, I share the following story of working with a client well-versed in both mindfulness practice and using the shared consciousness of the therapeutic dyad for self-exploration and self-reflection.

Andre sat down in my office looking sleep-deprived and glum. At a time when all manner of things were going well – enough contract work to pay the mortgage, a ten-year marriage that was just getting sweeter and sweeter, astonishingly good health for his advancing years, the glumness was worth noticing and investigating.

Andre had spent the weekend visiting his grown but somewhat floundering daughter, Nancy, who had recently moved back in with her mother, Andre’s ex-wife Harriet. Even as Andre described walking into the front door of a home he had walked out of 15 years before, his body slumped on the couch. “What are you noticing?” Andre described the queasiness in his stomach, his urge to get up and bolt out of the room. We both noticed his right hand clenched in a tight fist.

“And as you sit with that queasiness, as you breathe into that urge to bolt, as you slowly unclench the fist, what do you notice?” Andre slumped further into the couch, then threw his head back in, after three years of working together, we both knew was his gesture of helplessness and defeat in the face of other people’s helplessness and defeat.

I asked Andre to bring his awareness back to the present moment, sitting in the room with me, feeling the strength in his body in this moment of his life. Then we explored the “story” that began cascading in his mind as soon as he walked into his old home that past weekend. “Nothing was ever going to change; nothing was ever going to make a difference.” Andre maintained a kind of dual awareness, exploring that old thought stream, aware in this present moment that that thought stream was a thought stream, and was old.

We spent a few moments resourcing from what Andre knew to be true about his life now – he was successful, he was happy, he was re-connecting with his daughter in ways that felt solid and enriching to both of them. Then we looked at whether his thought stream had even been true then. He did change; he did leave a bitter, loveless, stagnant marriage. He had supported both of his kids through a confusing, thankless time. His mind was triggered by the visual cues of walking into his old house, seeing the same couch and rug in the same bay window – that hadn’t changed. His ex-wife’s complaining and blaming hadn’t changed. But Andre could shift his attention back to the felt sense of the present moment, and then evoke a sense of compassion, even forgiveness, for himself – how understandable it was that he sunk into the trough of the old hopelessness and despair three days ago.

As Andre understood just how the whole spiral-down happened, he began to hold his experiences differently. Not so bad. He had lost a few nights good sleep; he hadn’t been able to hold on to his new self in the old circumstances as well as he would have liked. But he had had two good conversations with his daughter; he had come through as a dad, and deep down he knew he had come through. Andre left the session with a plan to e-mail his ex-wife with his discoveries. Not that that would change anything, but he knew he would be approaching their old patterns from a larger sense of being, and he knew that would bring him a peace of mind and heart he could live with.

EXERCISES TO PRACTICE the Synergy of Mindfulness and Psychotherapy

Research data don’t yet show us which practices will be most useful for a specific patient with a specific symptom-suffering they want relief from at a specific moment in their life trajectory, though the research is ramping up in that direction: demonstrating that Mindfulness Based Cognitive Therapy significantly reduces relapse into depression and demonstrating the efficacy of the “wise mind” of Dialectical Behavioral Therapy in regulating emotions and tolerating distress. All of the practitioners advocating the integration of mindfulness into psychotherapy agree: there are countless states of mind that cause a patient to suffer. There are many practices to address many causes. Certainly any practices have to be customized for each patient with exquisite attention to feedback moment by moment; no one size fits all, moments or people.

1. The first question is how to introduce mindfulness practice to patients in a clinical setting. Of course, simply asking clients “What do you notice? What are you aware of?” is mindfulness practice. Suggesting taking a moment to “arrive” in the session, taking a breath to pause, taking a deeper breath to relax, taking several breaths to “re-settle the molecules” is mindfulness practice. Starting where the client is – a variation of “my baby done left me” – is mindful attention to the experience of the moment. (Early on, some clinicians called mindfulness “attention training” or “intentional noticing” to avoid triggering resistance to something that had religious or woo-woo connotations.) All mindfulness practices – whatever the vocabulary – help the client shift the direction of focusing attention, help open awareness and acceptance of the experience of the moment, help the client access and track their experience through various channels – notice the heartache, notice the feeling of the heartache, notice where you sense that feeling in your body, notice what happens when you notice that much.

2. The clinician can guide the focusing of the patient’s attention. If there’s a lot of agitation or distraction, simply “Where are your feet?” If the patient is more present and relaxed, “Where do you sense that heartache in your body?” When practice deepens, a more subtle “Notice the orchestra of the mind playing without a conductor” – the spaciousness of no separate sense of self experienced in expanded states of consciousness.

3. The clinician can suggest informal practice to train the attention of the mind during the 167 hours the patient is not in the office. “Practice noticing the sensations when you shower in the morning: the pleasure of the warm water, the fragrance of the soap or shampoo, the ease of bodily movements, the sensuality of gently rubbing all parts of the largest organ of the body, your skin.” Or a practice to shift the intention of their attention. A patient can get irritated when stopped in gridlocked traffic, or can use the moments to send wishes of loving kindness or compassion to fellow drivers caught in the same moment.

4. The clinician can suggest formal mindfulness practice which, when sustained over time, will change brain structure and functioning: focusing attention on a specific object at first to concentrate and steady the mind and heart, then opening to a more spacious awareness of experience unfolding in the moment, noticing how experience does change moment to moment, always with acceptance and compassion rather than judgment, even for the judgment. Everyone agrees, the clinician needs to assess the capacity of the patient to tolerate “holding” whatever comes up, because often when patients start “seeing clearly,” what they see first can be emotions, memories, beliefs, that were intolerable before. Before someone signs up for a meditation class, daylong, retreat, they need to be well-resourced with a direct experience of their own innate goodness – whatever the vocabulary – and a toolbox of tools to get “back home” when they get hijacked.

All Western practitioners now also advocate the cultivation of loving kindness practice and compassion practice along with mindfulness practice, to “hold” the reactivity and judgments almost guaranteed to arise at the beginning of formal practice and return the practitioner to a sense of safety, trust, equanimity again.

5. Michael Yapko suggests the next area of research on mindfulness and psychotherapy should be: how the shared consciousness of therapist-patient impacts the operations of the patient’s mind. We know from subjective experience: the patient feeling accompanied or companioned in working with the previously unworkable does create the trust and engagement that allow for healing. How does that work in the brain? What tools can the therapist use to pro-actively change the patient’s “social brain” functioning? Can that relational consciousness be strengthened through mindfulness?

From a 30-year career in social psychology and hypnosis, Dr. Yapko suggests that in guided meditations or guided visualizations or hypnotic suggestions – whatever the vocabulary – the therapist is directing the attention of the patient in certain ways for certain purposes. We need to know, does thickening the insula and anterior cingulate cortex through mindfulness practice really make us a better husband or neighbor? Since those brain structures are integral to the “resonance circuit” that seems to be the neural substrate of empathy, probably yes. Intuitively yes. But the data linking the mind training with cortical change with behavioral change is just beginning to come in.

Therapists can guide their patients to become more aware of their social brain interacting with other social brains. In the sessions: “What do you notice when I ask you to focus on your breath? Relief? Resistance? Compliance?” Outside the session: “What do you notice when you walk in the door at night? Anticipation? Tension? Ease? Are you comfortable with the quiet or the chaos? What would help you arrive?”

The best approach to integrating mindfulness into psychotherapy seems to be an attitude of curiosity and an openness to learning. Experiment; get feedback from the client. “Monitor and modify,” as Dan Siegel would say. Moving back to the safety of empathy, and then re-opening the process to mindfully noticing and compassionately allowing what is, as it is, as the gateway to transformation – whatever the vocabulary.

RESOURCES – BOOKS AND WEBSITES

Books

The Mindful Path to Self-Compassion: Freeing Yourself from Destructive Thoughts and Emotions by Christopher Germer, PhD. Guilford Press, 2009.

The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration by Daniel J. Siegel, M.D. W.W. Norton, 2010

The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness by Mark Williams, John Tasdale, Zindel Segal, and Jon Kabat-Zinn. Guilford Press, 2007.

Mindfulness and Hypnosis: the Power of Suggestion to Transform Experience. By Michale Yapko, PhD. W.W. Norton, 2011

Mindfulness and Psychotherapy, edited by Christopher Germer, Ronald Siegel, Paul Fulton. Guildford Press, 2005.

Mindfulness Based Stress Reduction Workbook by Bob Stahl, Elisha Goldstein, Saki Santorelli and Jon Kabat-Zinn. New Harbinger Publicatioins, 2010.

The Mindfulness Movement: Do we even need psychotherapy anymore? Psychotherapy networker, Sept.-Oct. 2011.

The Mindfulness Solution: Everyday Practices for Everyday Problems by Ronald D. Siegel, PsyD. Guilford Press, 2010.

Real Happiness: The Power of Meditation – a 28-Day Program by Sharon Salzberg. Workman Publishing, 2010

Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical Practice by Christopher Germer and Ronald D. Siegel. Guilford Press, Feb. 2012.

Websites

www.psychotherapynetworker.org.

Access to both the Sept-Oct 2011 issue on The Mindfulness Movement (you can easily download most of the articles) and the webinar series Is Mindfulness Enough? (You can access the webcast free when it is streamed on Wednesdays; there is a fee to access it on-demand.)

www.nicabm.com/mindfulness2011

You can listen to the teleseminar free when it is streamed on Wednesdays. There is a fee to access the podcasts on demand or to download a transcript of the teleseminar.)