This article is excerpted from the first chapter of a new book, Mindfulness and Psychotherapy. A collective effort of the Institute for Meditation and Psychotherapy, the book is edited by Christopher K. Germer, Ronald D. Siegel and Paul R. Fulton, and will be published by Guilford Press in the spring of 2005.
Psychotherapists are in the business of alleviating emotional suffering. Suffering arrives in innumerable guises: stress, anxiety, depression, behavior problems, interpersonal conflict, confusion, despair. It is the common denominator of all clinical diagnoses and is endemic to the human condition.
Some of our suffering is existential, such as sickness, old age and dying. Some suffering has a more personal flavor. The cause of our individual difficulties may include past conditioning, present circumstances, genetic predisposition, or any number of interacting factors. Mindfulness, a deceptively simple way of relating to experience, has long been used to lessen the sting of life’s difficulties, especially those that are seemingly self-imposed. In this volume we will illustrate the potential of mindfulness for enhancing psychotherapy.
People are clear about one thing when they enter therapy—they want to feel better. They often have a number of ideas about how to accomplish this goal, although therapy doesn’t necessarily proceed as expected.
For example, a young woman with panic disorder—let’s call her Lynn—might call a therapist, hoping to escape the emotional turmoil of her condition. Lynn may be seeking freedom from her anxiety, but as therapy progresses, Lynn actually discovers freedom in her anxiety. How does this occur?
A strong therapeutic alliance may provide Lynn with courage and safety to begin to explore her panic more closely. Through self-monitoring, Lynn becomes aware of the sensations of anxiety in her body and the thoughts associated with them. She learns how to cope with panic by talking herself through it. When Lynn feels ready, she directly experiences the sensations of anxiety that trigger a panic attack and tests herself in a mall or on an airplane. This whole process requires that Lynn first turn towards the anxiety. A compassionate bait and switch has occurred.
Therapists who work more in a more relational or psychodynamic model may observe a similar process. As connection deepens between the patient and the therapist, the conversation becomes more spontaneous and authentic, and the patient acquires the freedom to explore what is really troubling him or her in a more open, curious way. With the support of the relationship, the patient is gently exposed to what is going on inside. The patient discovers that he or she need not avoid experience to feel better.
We know that many seemingly dissimilar forms of psychotherapy work (Seligman, 1995). Is there an essential ingredient active across various modalities that can be isolated and refined? Mindfulness may prove to be that ingredient.
Mindfulness: A Special Relationship to Suffering
Successful therapy changes the patient’s relationship to his or her particular form of suffering. Obviously, if we are less upset by events in our lives, our suffering will decrease. But how can we become less disturbed by unpleasant experiences? Life includes pain. Don’t the body and mind instinctively react to painful experiences? Mindfulness is a skill that allows us to be less reactive to what is happening in the moment. It is a way of relating to all experience—positive, negative and neutral—such that our overall suffering is reduced and our sense of well-being increases.
To be mindful is to wake up, to recognize what is happening in the present moment. We are rarely mindful. We are usually caught up in distracting thoughts or in opinions about what is happening in the moment. This is mindlessness.
Examples of mindlessness are:
- Rushing through activities without being attentive to them.
- Breaking or spilling things because of carelessness, inattention, or thinking of something else.
- Failing to notice subtle feelings of physical tension or discomfort.
- Forgetting a person’s name almost as soon as we’ve heard it.
- Finding ourselves preoccupied with the future or the past.
- Snacking without being aware of eating.
(Adapted from the Mindful Attention Awareness Scale Brown & Ryan, 2003)
Mindfulness, in contrast, focuses our attention on the task at hand. When we are mindful, our attention is not entangled in the past or future, and we are not judging or rejecting what is occurring at the moment. We are present. This kind of attention generates energy, clear-headedness and joy. Fortunately, it is a skill that can be cultivated by anyone.
When Gertrude Stein (1922/1993, p. 187) wrote “A rose is a rose is a rose is a rose,” she was bringing the reader back again and again to the simple rose. She was suggesting, perhaps, what a rose is not. It is not a romantic relationship that ended tragically four years ago, it is not an imperative to trim the hedges over the weekend—it is just a rose. Perceiving with this kind of “bare attention” is an example of mindfulness.
Most people in psychotherapy are preoccupied with past or future events. For example, people who are depressed often feel regret, sadness or guilt about the past, and people who are anxious fear the future. Suffering seems to increase as we stray from the present moment. As our attention gets absorbed in mental activity and we begin to daydream, unaware that we are indeed daydreaming, our daily lives can become a nightmare. Some of our patients feel as if they are stuck in a movie theatre, watching the same upsetting movie their whole lives, unable to leave. Mindfulness can help us to step out of our conditioning and see things freshly—to see the rose as it is.
Definitions of Mindfulness
The term mindfulness is an English translation of the Pali word sati. Pali was the language of Buddhist psychology 2,500 years ago, and mindfulness is the core teaching of this tradition. Sati connotes awareness, attention and remembering.
Mindfulness can help us to step out of our conditioning and see things freshly.
What is awareness? Brown and Ryan (2003) define awareness and attention under the umbrella of consciousness:
Consciousness encompasses both awareness and attention. Awareness is the background “radar” of consciousness, continually monitoring the inner and outer environment. One may be aware of stimuli without them being at the center of attention. Attention is a process of focusing conscious awareness, providing heightened sensitivity to a limited range of experience (Westen, 1999). In actuality, awareness and attention are intertwined, such that attention continually pulls “figures” out of the “ground” of awareness, holding them focally for varying lengths of time (p.822).
You are using both awareness and attention to read these words. A tea kettle whistling in the background may eventually command your attention when it gets loud enough, particularly if you would like a cup of tea. Similarly, we may drive a familiar route “on autopilot,” vaguely aware of the road, but respond immediately if a child runs in front of us. Mindfulness is the opposite of being on autopilot; the opposite of daydreaming—it is paying attention to what is salient in the present moment.
Mindfulness also involves remembering, but not dwelling in memories. It involves remembering to reorient our attention and awareness to current experience in a wholehearted, receptive manner. This requires the intention to disentangle from our reverie and fully experience the moment.
The word “mindfulness” can be used to describe a theoretical construct (mindfulness), a practice of cultivating mindfulness (such as meditation), or a psychological process (being mindful). A basic definition of mindfulness is “moment-by-moment awareness.” Other definitions include: “Keeping one’s consciousness alive to the present reality” (Hanh, 1976, p. 11); “The clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception” (Nyanaponika Thera, 1972, p.5); attentional control (Teasdale, Segal & Williams, 1995); “Keeping one’s complete attention to the experience on a moment-to-moment basis” (Marlatt & Kristeller, 1999, p.68); and, from a more Western psychological perspective, a cognitive process that employs creation of new categories, openness to new information, and awareness of more than one perspective (Langer, 1989). Ultimately, mindfulness cannot be fully captured with words because it is a subtle, non-verbal experience (Gunaratana, 2002).
When therapists are working with intense emotions…it is essential that we maintain an open, compassionate, and accepting attitude.
When mindfulness is transported to the therapeutic arena, its definition often expands to include non-judgment: “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment to moment” (Kabat-Zinn, 2003). In her summary of the mindfulness and psychotherapy literature, Baer (2003, p. 125) defines mindfulness as “the non-judgmental observation of the ongoing stream of internal and external stimuli as they arise.” Non-judgment fosters mindfulness when we are dealing with difficult physical or emotional states. By not judging our experience, we are more likely to see it as it is.
Mindfulness and Acceptance
“Acceptance” is an extension of non-judgment. It adds a measure of kindness or friendliness. When therapists are working with intense emotions such as shame, anger, fear or grief, it is essential that we maintain an open, compassionate and accepting attitude. Empathy and positive regard are important relational aspects of successful therapy (Norcross, 2001, 2002) that overlap with acceptance. If either the therapist or the patient turns away from unpleasant experience with anxiety or revulsion, our mutual ability to understand the problem is likely to be compromised.
From the mindfulness perspective, acceptance refers to a willingness to let things be just as they are the moment we become aware of them—accepting pleasurable and painful experiences as they arise. Acceptance is not about endorsing maladaptive behavior. Rather, acceptance precedes behavior change. “Change is the brother of acceptance, but it is the younger brother” (Christensen & Jacobson, 2000, p. 11). Mindfulness-oriented clinicians see “radical acceptance” as part of therapy practice (Brach, 2003; Linehan, 1993b).
Mindfulness in Psychotherapy
The short definition of mindfulness we will use in this volume is (1) awareness, (2) of present experience, (3) with acceptance. These three elements can be found in most discussions of mindfulness in both the psychotherapy and the Buddhist literature. (For detailed consideration of the construct of mindfulness within psychology, please see Bishop et al. (2004) and Brown and Ryan (2004) and Hayes and Feldman (2004).) Although our definition has three distinct components, they are irreducibly intertwined in the experience of mindfulness.
The presence of one aspect of mindfulness does not automatically imply the presence of others. For example, awareness may be absorbed in the past, such as in blind rage about a perceived injustice. Awareness may also be present without acceptance, such as in disowned shame. Likewise, acceptance can exist without awareness, as in premature forgiveness; while present-centeredness without awareness may exist in a moment of intoxication. All components of mindfulness—awareness, present-centeredness, and acceptance—are required for a moment of full mindfulness. Therapists can use these three elements as a touchstone for identifying mindfulness in therapy.
The value of a stripped-down, operational definition of therapeutic mindfulness is twofold. First, if mindfulness indeed reveals itself to be a key ingredient of effective psychotherapy (Martin, 1997), clinicians will want a conceptual tool to guide their movements in the consultation room. Second, if outcome research continues to show mindfulness to be a promising treatment strategy (Baer, 2003), researchers will need a definition with clearly defined component parts to design new interventions.
Mindfulness and Levels of Practice
Mindfulness has to be experienced to be known. People may practice mindfulness with varying degrees of intensity. At one other end of a continuum of practice is everyday mindfulness. Even in our often pressured and distracted daily lives, it is possible to have mindful moments. We can momentarily disengage from our activities by taking a long, conscious breath. After gathering our attention, we can ask ourselves, “What am I feeling right now?” “What am I doing right now?” “What is most compelling to my awareness right now?” This is mindfulness in daily life and is how mindfulness commonly occurs in psychotherapy.
At the other end of the continuum we find monks, nuns and lay people who spend a considerable amount of time in meditation. When we have the opportunity to sit over sustained periods of time with closed eyes, in a silent place, and sharpen concentration on one thing (such as the breath), the mind becomes like a microscope and can detect minute mental activity. This is illustrated by the following meditation instruction:
Should an itching sensation be felt in any part of the body, keep the mind on that part and make a mental note itching…Should the itching continue and become too strong, and you intend to rub the itching part, be sure to make a mental note intending. Slowly lift the hand, simultaneously noting the action of lifting, and touching when the hand touches the part that itches. Rub slowly in complete awareness of rubbing. When the itching sensation has disappeared and you intend to discontinue the rubbing, be mindful of making the usual mental note of intending. Slowly withdraw the hand, concurrently making a mental note of the action, withdrawing. When the hand rests in its usual place touching the leg, touching (Sayadaw, 1971, pp. 5-6).
This level of precise and subtle awareness, in which we can even detect “intending,” clearly requires an unusual level of dedication on the part of the practitioner. Remarkably, the instruction above is considered a “basic” instruction. Sayadaw writes that, at more advanced stages, “Some meditators perceive distinctly three phases: noticing an object, its ceasing, and the passing away of the consciousness that cognizes that ceasing—all in quick succession” (1971, p. 15).
When we have the opportunity to sit over sustained periods of time with closed eyes, in a silent place, and sharpen concentration on one thing (such as the breath), the mind becomes like a microscope and can detect minute mental activity.
Moments of mindfulness have certain common aspects regardless of where they lie on the practice continuum. The actual moment of awakening, of mindfulness, is the same for the experienced meditator as for the beginner practicing mindfulness in everyday life. The experience is simply more continuous for experienced meditators. Mindful moments are:
- Non-conceptual. Mindfulness is awareness without absorption in our thought processes.
- Present-centered. Mindfulness is always in the present moment. Thoughts about our experience are removed from the present moment.
- Non-judgmental. Awareness cannot occur freely if we would like our experience to be other than it is.
- Mindfulness always includes an intention to direct attention somewhere. Returning attention to the present moment gives mindfulness continuity over time.
- Participant observation. Mindfulness is not detached witnessing. It is experiencing the mind and body more intimately.
- Non-verbal. The experience of mindfulness cannot be captured in words because awareness occurs before words arise in the mind.
- Mindful awareness is always investigating subtler levels of perception.
- Every moment of mindful awareness provides freedom from conditioned suffering.
These qualities occur simultaneously in each moment of mindfulness. Mindfulness practice is a conscious attempt to return awareness more frequently to the present, with all the qualities of awareness listed above. Mindfulness per se is not unusual; continuity of mindfulness is rare indeed.
Mindfulness per se is not unusual; continuity of mindfulness is rare indeed.
Everyday mindfulness allows us to develop insight into psychological functioning and to respond skillfully to new situations. Mindfulness in deep meditation provides insights into the nature of mind and the causes of suffering. These insights, such as awareness of how impermanent things really are, help us become less entangled in our ruminations and thereby foster more mindfulness.
Psychotherapists and Mindfulness
Clinicians are drawn to the subject of mindfulness and psychotherapy from a variety of directions: clinical, scientific, theoretical and personal. In addition, psychotherapy patients are increasingly seeking therapists who might understand their meditation practice. These developments are not surprising, given that Buddhist psychology and its core practice, mindfulness, have been growing in popular appeal in the West.
A Brief History of Mindfulness in Psychotherapy
The field of psychoanalysis has flirted with Buddhist psychology for some time. Freud exchanged letters with a friend in 1930 in which he admitted that Eastern philosophy was alien to him and perhaps “beyond the limits of [his] nature” (in Epstein, 1995, p. 2). That did not stop Freud from writing in Civilization and its Discontents (1930/1961) that the “oceanic feeling” in meditation was an essentially regressive experience. Franz Alexander (1931) wrote a paper entitled “Buddhist Training as an Artificial Catatonia.” Other psychodynamic theorists were more complimentary, notably Carl Jung, who wrote a commentary on the Tibetan Book of the Dead in 1939 and had a lifelong curiosity about Eastern psychology. Later, Erich Fromm and Karen Horney dialogued with Zen scholar, D.T. Suzuki (Fromm, Suzuki, & DeMartino, 1960; Horney, 1945). In 1995, Mark Epstein wrote Thoughts Without a Thinker, which triggered new interest in Buddhist psychology among psychodynamic clinicians.
Many practicing therapists took to Eastern philosophy or meditation as a way of improving their lives before beginning their professional careers. Some started to meditate in the late Sixties at a time when ideas of enlightenment followed the Beatles and other famous pilgrims back to the West from India. Former Harvard psychologist Ram Dass’ book, Be Here Now (1971), a mixture of Hindu and Buddhist ideas, sold over a million copies. Yoga, which is essentially mindfulness in movement (Boccio, 2004; Hartranft, 2003), also traveled West at the time. Some therapists began trying to connect their personal practice of meditation with their clinical work.
Studies on meditation flourished, including cardiologist Herbert Benson’s (1975) use of meditation to treat heart disease. Clinical psychology kept pace with numerous articles on meditation as an adjunct to psychotherapy or as psychotherapy itself (Smith, 1975). In 1977, the American Psychiatric Association called for an examination of the clinical effectiveness of meditation, such as Transcendental Meditation and Benson’s program. In the last ten years, the preponderance of studies has switched to mindfulness meditation (Smith, 2oo4). Jon Kabat-Zinn established the Center for Mindfulness in 1979 at the University of Massachusetts Medical School to treat chronic conditions for which physicians could offer no further help. Over 15,000 patients have completed this Mindfulness-Based Stress Reduction (MBSR) program, not counting participants in over 250 MBSR programs around the world (Davidson & Kabat-Zinn, 2004).
An exciting, more recent area of integration for mindfulness and psychotherapy is in empirically-validated mindfulness-based interventions. The impetus seems to stem from the pioneering work of Kabat-Zinn’s (1990) MBSR program and Marsha Linehan’s Zen-inspired Dialectical-Behavioral Therapy (1993a). The publication by Teasdale et al in 2000 of an effective mindfulness-based treatment for chronic depression kindled further interest in mindfulness among clinical researchers. The potential of these mindfulness and acceptance-based approaches has ushered in a new wave of cognitive-behavioral treatments for familiar problems (Hayes, Follette, & Linehan, 2004; Hayes, Masuda, Bissett, Luoma, & Guerrero, 2004),
Where is the current interest in mindfulness heading? We may be witnessing the emergence of a more unified model of psychotherapy. We are likely to see more research that identifies mindfulness as a key element in treatment protocols, as a crucial ingredient in the therapy relationship, and as a technology for psychotherapists to cultivate personal therapeutic qualities and general well-being. Mindfulness might become a construct that draws clinical theory, research, and practice closer together and helps integrate the private and professional lives of therapists.
Although mindfulness appears to enhance general well-being (Brown & Ryan, 2003; Reibel et al, 2001; Rosenzweig, 2003), therapists may be drawn to mindfulness for the simple reason that they would like to enjoy their work more fully. Psychotherapists choose to witness and share human conflict and despair many of their waking hours. Sometimes we are asked by a sympathetic patient, “How do you do it?” What do we do when a clinical situation appears impossible to handle? How do we stay calm and think clearly?
Doing psychotherapy is an opportunity to practice mindfulness in everyday life. The therapy office can be like a meditation room in which we invite our moment-to-moment experience to become known to us, openly and wholeheartedly. As the therapist learns to identify and disentangle from his or her own conditioned patterns of thought and feeling that arise in the therapy relationship, the patient may discover the same emotional freedom. The reverse is also true; we can be moved and inspired by our patients’ capacity for mindfulness under especially trying circumstances.
Practicing clinicians are reminded regularly about the importance of the therapy relationship in treatment outcome (Crits-Christoph et al., 1991; Luborsky et al., 1986, 2002; Wampold, 2001). Clinicians also struggle with “transfer of technology”—making a bridge between treatment protocols developed in our universities and their application in the field. When focused primarily on implementing an empirically-derived protocol, to the exclusion of a vital, interesting and supportive therapy relationship, therapists and their patients can both lose interest in the work. In the coming years, mindfulness practice may prove to be a tangible means for building empirically-supported relationship skills. This may help return our focus to the therapeutic connection, since there is something we can do to improve it. How we plan interventions may even be guided by a common therapeutic principle—the simple mechanism of mindfulness.
Does Mindfulness Matter to Therapists?
The grand tradition of contemplative psychology in the East and the powerful scientific model of the West are finally meeting.
It is difficult to predict just what the impact of mindfulness on our profession will be. Padmasambhava, an eighth-century Tibetan teacher, said that “when the iron bird flies, the dharma [Buddhist teachings] will come to the West” (in Henley, 1994, p. 51). Although it is now over one hundred years since Buddhist psychology made it to our shores (Fields, 1992), it is only fairly recently that the ideas have captured the imagination of the clinical and research communities in psychology. The grand tradition of contemplative psychology in the East and the powerful scientific model of the West are finally meeting.
Scientifically, what we know is preliminary, but promising. Clinicians are on the vanguard of exploration, and even marginal success in the consultation room can be an important beginning (Linehan, 2000). We have many more questions than answers; we need to determine which mindfulness-based interventions work, and for whom. We should explore the impact of a meditating therapist on therapy outcome. We may wish to understand better the cognitive, biochemical, neurological, emotional, and behavioral factors that contribute to mindfulness. It may also be fruitful to investigate the outer reaches of mindfulness—what human beings are capable of in terms of attentional control and emotional regulation, and how this translates into the way we live our lives.
To have psychological techniques at our disposal, drawn from a 2500-year-old tradition, which appear to change the brain, shape our behavior for the better, and offer intuitive insights about how to live life more fully, is an opportunity that may be difficult for psychotherapists to ignore. Only time will tell what we make of it.