Mindfulness as a Therapeutic Tool

Published in Éisteach, Journal of the Irish Association for Counselling and Psychotherapy, September, 2008

Introduction
Five years ago, Margaret’s brothers convinced their mother to cut her out of a promised inheritance, a share in the farm on which they had all grown up. Her mother died the following year and the farm went to her brothers who sold it with a planning permission for a housing development. Her brothers are now rich while Margaret continues to work hard for a modest income.

The injustice of what was done to her took away Margaret’s peace of mind. For nearly three years following her mother’s death, she thought of little else. She lost sleep, she was distracted and her husband and children grew sick of listening to her talking about “the farm.”

Then she learned the practice of mindfulness. As she practiced, her obsessive thinking about the farm and her brothers began to fall away. She began to notice what was going on around her, to pay attention to what she was doing and to keep more and more of her awareness in the present moment.

Margaret gradually got back her peace of mind, accepted that she had been out-manoeuvred and conned by her brothers and that she could do nothing about it, and got involved again with the life of her own husband and children.

Definition and explanation
What is mindfulness? In a handout I give to clients and other interested parties, I explain the process of mindfulness as follows:

Mindfulness involves taking your attention away from the past and future and away from your imagination – and instead becoming aware of what is going on right now. You can do this as you go about your daily life. Notice where you are, what you are doing, what you are seeing and hearing, notice that you are breathing, standing, walking or sitting or lying down.

Your mind will keep drifting out of the present so you need to keep bringing it back. It is bringing your mind back to the present that makes up the practice of mindfulness. Never criticise your mind for drifting away: just bring it back kindly and gently.”

Note that mindfulness involves maintaining awareness about what is going on, whatever that might be. So it doesn’t matter that somebody is drilling on the street outside (not from a mindfulness point of view at any rate!) that somebody in the apartment above you is playing the bongo drums or that you can hear your tummy rumbling.

If you are practicing mindfulness you simply take it all into awareness without getting into a mental drama about it. So you note that these things are going on and you may even be annoyed by them but you don’t make speeches to yourself about how they’re always digging up the roads for no reason at all, how people should go out and get a job instead of playing bongo drums in an apartment block or how embarrassed you feel when your tummy starts rumbling during your meditation class.

You simply note the bongo drum, the drill, the tummy sounds, your annoyance and you leave it at that and get on with whatever you’re doing.

Example: Awareness exercise
To get into this state of mind it can help to do an awareness exercise now and then. Here is one I go through with my clients:

From time to time, notice your breathing.
Notice your posture.
Notice the length of your spine.
Notice the points of contact between your body and the chair, floor, ground.
Notice your clothes touching your body.
Notice the sounds around you.
Notice the nearest sound you can hear.
Notice the furthest away sound you can hear.
Now notice your breathing again.”

This simple exercise can take thirty minutes or thirty seconds as you wish. I find that clients tend to use it as a sort of brief checklist if they find themselves distracted as they go through their day.

Background to mindfulness practice
Clients who give a little time to this exercise can find it very relaxing but there’s more to mindfulness than that. Mindfulness has been used for thousands of years in the Buddhist tradition to sharpen people’s awareness of their patterns of behaviour so that they can step outside these patterns. Mindfulness provides an antidote to brooding (which can lead to, or maintain, depression) and helps people to avoid endlessly repeating distressing or unhelpful thoughts, images and mental scenes. This, in turn, helps avoid repeating unhelpful behaviours.

According to Buddhist psychology, we build up patterns of reactions to events. First, we perceive an event which could be something external or which could be a memory or thought. We then have a reaction which is made up of physical, mental and emotional associations with the event. We are swept away by the reaction, sometimes as if in a trance. This process distorts our future perceptions with the result that we are no longer fully aware of the reality around us. (Brazier, 2003).

Let us say it’s Saturday morning and I’m angry at that drilling going on down the street. The doorbell rings and there stands the young lady I fell madly in love with last month and who has so lost her common sense as to fall (temporarily) in love with me. Suddenly my mind and emotions are overwhelmed by all the pleasurable things I associate with her and by the infantile emotions she summons up. The drilling no longer exists. I may be wide awake but I am also in a trance.

Even when we are not infatuated, we spend much of our day in one trance or another, daydreaming, fantasising, remembering, resenting and so on. Buddhism sees mindfulness as a way to step out of that process and to get in touch with reality. I leave it to the philosophers to debate the merits of the Buddhist assumption that being in touch with reality is always better than being out of touch with it.

I hope, though, that this explanation will show readers why it is that Margaret was able to derive such a benefit from mindfulness. The practice of mindfulness helped her to step out of a series of reactions that was ruining her life far more effectively than her brothers’ sharp practice had done.

Practice and research: Pain and Depression
In recent times the work of Dr Jon Kabat-Zinn at the University of Massachusetts Medical Centre has given a huge boost to the use of mindfulness in mainstream health settings. His clinic teaches mindfulness and yoga to people suffering chronic pain and stress. His work has enabled patients suffering permanent pain to re-gain control over their lives though the pain, of course, persists. In addition to helping patients live more satisfactorily with chronic pain, his clinic has achieved significant and sustained reductions in levels of anxiety, in reducing the severity and frequency of panic attacks and in improving the management of psoriasis. Kabat-Zinn has written up his work in an accessible way in his book “Full Catastrophe Living” (1990). Similar work is done in Ireland through Blue Sky, which works out of the Dublin Buddhist Centre and one of whose principals is a GP, Dr Kate Healy (see Sources & References below).

The uses of mindfulness in western psychology have been studied for some years now at the Centre for Mindfulness Research and Practice at the University of Wales, Bangor. Some Irish counsellors and psychiatric nurses have undertaken courses at the centre. Researchers in Wales and elsewhere have found mindfulness to be helpful in reducing the risk of relapse in persons who have had a number of episodes of depression (Segal, Williams and Teasdale, 2002). They suggest that persons with relapsing depression have created a link in their minds between low mood, fatigue and negative thoughts. When one of these occurs, as happens to all of us from time to time, the person who has made this link assumes that the depression is back, they suggest. The person then triggers the other components of depression. So a person who wakes up in a low mood may immediately indulge in negative thinking about the supposed return of the depression, stay in bed and, as a result, feel fatigued on finally getting up. Before long, the depression really has returned. But the person who practices mindfulness, they suggest, can spot what is going on and interrupt the sequence by getting the right amount of sleep and striving to steer their thinking away from the negative.

Some other applications in counselling
Anxiety. In my own work, I have found mindfulness to be helpful to people with excessive anxiety and panic attacks and, to a lesser extent, to people with depression. In relation to panic attacks, it can help the client to maintain awareness of what is going on during the panic attack instead of “awfulising” to himself or herself about it. The aim is to make the panic attack a less frightening event than before so that the client begins to live without avoidance of places and situations which might trigger attacks.

Parenting. I have also found mindfulness to be of immense benefit to a parent who was being ‘driven demented’, as he put it, by his three children until he developed presence of mind in the face of their antics. He did so through using mindfulness which gave him the ‘mental space’ to avoid having his emotional buttons pressed by three very skilful young button-pressers!

Anger. A person who had learned the destructive habit of being angry at the smallest departure from what he wanted changed his behaviour when he became aware of what was going on in his mind before he flew off the handle. Again, mindfulness gave him that ‘mental space’ and the opportunity to think twice.

Work problems. A businesswoman developed resilience in dealing with some nasty colleagues by learning to spot them pressing her emotional buttons. Others were able to be more assertive in the face of workplace bullying by practicing mindfulness. Mindfulness opens users’ eyes to the fact that they have choices about how they react to their tormentors.

Counselling. As a counsellor you probably already practice mindfulness in the counselling room by maintaining awareness both of your client and of your own reactions to your client. Any counsellor who deliberately uses attending skills is using mindfulness even if he or she does not call it that.

A note of cautionThe following are a few notes of caution for therapists introducing mindfulness to their work with clients.

Mindfulness is not the answer to everything. It is too easy to over-sell the benefits of mindfulness, especially at a time when its use is becoming more popular. I have seen mindfulness bring about major benefits in the lives of some clients – and make no difference at all to others. In many of the cases mentioned above, mindfulness revealed to the client what he or she needed to work on – in doing so, mindfulness practice performed a valuable service but it was not the beginning and end of a solution.

Different people need different kinds of mindfulness. People who live in their heads, endlessly analysing their own thoughts need to be steered towards mindfulness of the external world, of sights, sounds and other people. On the other hand, if you are doing CBT with a client, mindfulness of thoughts or of emotions may be helpful – this is similar to the practice of ‘spotting’ as used by members of Recovery Inc.

Mindfulness is not an anaesthetic. Mindfulness is sometimes promoted as a means of relaxation and stress reduction. But while mindfulness reduces stress, its main value is in revealing what needs to be done and sometimes what needs to be done is painful. For instance, the person who uses mindfulness during panic attacks – an approach I advocate – can expect to feel emotional distress during the attack.

Mindfulness may be unhelpful to some psychiatric patients. When the Buddhist teacher and writer Jack Kornfield worked at a state mental hospital in the US, he tried to teach meditation to some of the patients. “It quickly became obvious that meditation was not what they needed. These people had little ability to bring a balanced attention to their lives, and most of them were already lost in their minds. If any meditation was useful to them, it would have to be one that was earthy and grounded: yoga, gardening, tai chi, active practices that could connect them to their bodies.” (Kornfield, 2002).

Caution clients about the temporary euphoric effect. Sometimes persons beginning to practice mindfulness experience a beautiful sense of calm and clarity. It does no harm but it doesn’t last. If a client reports that he or she is having this experience it is worth telling them gently that the effect will fade and that there is nothing to be gained from trying to get it back.

When introducing mindfulness, get the timing right. As with everything else in counselling, there is little point in introducing mindfulness until the client feels heard and understood. Sometimes it is helpful to introduce mindfulness towards the end of the first session as a technique which might help. At other times it may only become appropriate to introduce mindfulness at a second or subsequent session. And at times it may not be appropriate at all. This is a matter of judgement and of that sense of what it is right to do and when it is right to do it that counsellors gradually develop.

Mindfulness of the body may be too difficult following physical attack or torture. I am indebted to a participant in one of my workshops for the information that persons who have been tortured can find mindfulness of the body or of breathing quite difficult and frightening. In such cases, mindfulness of one’s surroundings, of sounds, of colours and of other aspects of external reaction may be helpful.

Further exercises
Earlier I described an exercise from a handout on mindfulness which I give to my clients. There are two other exercises on the handout and you might like to try them out yourself:

The first is to establish what I call “mindfulness cues”. This involves using habitual behaviours to remind you to practice mindfulness. Choose one or two and then decide that when performing them you will maintain awareness of what you are doing, rather than daydreaming or getting caught up in fears or anxieties. Examples of mindfulness cues include: Using the telephone, going up or down stairs or steps, arranging your desk or other workspace, tidying, washing up or taking a shower.

The second is mindfulness of breathing and you can do this for five minutes or forty five minutes as you like. Begin by sitting still. Notice that you are breathing in and out. Notice the in-breath and the out- breath. When thoughts come into your mind just let them float on by. Do not get involved with them. Simply go back to noticing your breathing in and out. If you like you can count your breaths, counting from 1 to 10 and then back to 1 again.

And finally…
If you want to use mindfulness with your clients, begin by using it yourself. Only then can you answer the questions your clients will have.

Sources & References:
Websites
The Institute for Meditation and Psychotherapy
http://www.meditationandpsychotherapy.org/

Centre for Mindfulness Research and Practice, University of Wales, Bangor
http://www.bangor.ac.uk/mindfulness/

Center for Mindfulness in Medicine, Health Care, and Society (CFM)
http://www.umassmed.edu/cfm/
This is the website of the ground-breaking mindfulness centre run by Dr Jon Kabat-Zinn at the University of Massachusetts Medical Centre.

Dublin Buddhist Centre
 http://www.dublinbuddhistcentre.org/index.html
The centre runs mindfulness courses at various times through the year.

Wildmind
http://www.wildmind.org
Offers a reasonably-priced mindfulness of breathing course and many free resources.

Books

A Path with a Heart, by Jack Kornfield, Rider, London, 2002. Covers a broader range than mindfulness and not an easy read in my view though it contains many interesting meditation exercises.

Buddhist Psychology, by Caroline Brazier, Robinson, London, 2003. A general introduction to Buddhist psychology by a psychotherapist.

Mindfulness and Psychotherapy, edited by Christopher K. Germer, Ronald D. Siegel and Paul R. Fulton. The Guildford Press, New York and London, 2005. Expensive (about €40 but worth it if you’re interested in the topic).

Full Catastrophe Living, by Dr Jon Kabat-Zinn, Bantam, New York, 1990.
A detailed introduction to Kabat-Zinn’s pioneering work at the University of Massachusetts Medical Centre.

Mindfulness–based Cognitive Therapy for Depression, Segal, Z.V., Williams, J.M.G. & Teasdale, J.D, Guilford Press, 2002. The main focus of this important book is on preventing relapse into depression.

Calming Your Anxious Mind, Jeffrey Brantley MD. New Harbinger Publications, 2003. Applying mindfulness to anxiety, fear and panic.

Reference to this article:

O’Morain, Padraig (2008) Mindfulness as a therapeutic tool, Éisteach, September, 2008. Dublin: Irish Association for Counselling and Psychotherapy