Mindfulness and Psychotherapy

1. Mindfulness and Psychotherapy Patrick M. Whitehead An interactive project based on the text by Germer, Siegel, and Fulton, 2005.

2. Introduction The term mindfulness comes from the English translation of the Pali word sati (the original Buddhist language) which has connotations of awareness, attention, and remembering.(Germer, et al) Moment by moment awareness (Germer, et al) Keeping one’s consciousness alive to the present reality (Hanh, 1976) The clear and single-minded awareness of what actually happens to us at successive moments of perception (NyanaponikaThera, 1972) Attentional control (Teasdale, et al, 1995) Subtle, non-verbal experience ungrasped by words. (Gunaratana, 2002) Image courtesy of mindfulcoaching.wordpress.com

3. Not to be confused with Mindlessness • 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 as soon as we have heard it • Finding ourselves preoccupied with the future or the past • Snacking without being aware of eating • (adapted from Brown & Ryan, 2003) image courtesy of saltar.com.au

4. Therapeutic Mindfulness Acceptance: From the mindfulness perspective, acceptance refers to a willingness to let things be just as they are the moment we become aware of them—pleasurable or painful. Non-judgmental: observing the present moment without evaluating it (as good or bad). Non-conceptual: awareness without absorption. Intentional: an exercise in awareness of, and control over intention. Liberating: mindful moments provide freedom from suffering. Photo courtesy of synergyofmind.org

5. Brief History • Freud’s “oceanic feeling” (1930) has been the object of many recent references to the perception of unity with all things. • Karen Horney spent several months in Japan studying the relationship of psychotherapy and Zen at the end of her career but unfortunately passed before completing her diaries. • Carl Jung had a lifelong fascination with Eastern philosophy and wrote a commentary on the Tibetan Book of the Dead. • Mark Epstein, New York psychologist, published Thoughts Without a Thinker, and Going to Pieces Without Falling Apart, sharing his paradigm of therapy including many Buddhist concepts (non-attachment, non-striving, emptiness, being present, etc) • The inclusion of mindfulness practices in psychotherapy has been around since the late 1970’s with Kabat-Zinn’s center for Mindfulness at the Umassmedical school, and Ron Kurtz Hakomi Therapy method, now taught at San Diego School of Professional Psychology and the Hakomi Institute.(www.hakomiinstitute.com) • Marsha LinehansDialectical Behavioral Therapy, 1993, has been successful with work on anxiety disorders and borderline personality disorder.

6. Mind and Life Institute • From their first meeting nearly two decades ago, this collection of scientists have collaborated to create a dialogue between the modern science and Buddhism. • Extended semi-private meetings between prominent scientists and leading figures from the contemplative traditions, most notably, the Dalai Lama of Tibet • Public conferences to stimulate interest in the potential of these scientific dialogues within the larger scholarly community • Intellectually rigorous yet accessible publications, based on Mind and Life meetings and conferences to share the power and potential of these collaborative exchanges with the general public • Collaborative research projects and meetings focused on designing research, between laboratory scientists, scholars and practitioners of Buddhism and other forms of contemplative practice • Educational programs based on our research findings that teach people proven, effective techniques to enhance human development and alleviate suffering • www.mindandlife.org

7. Clinical Applications • Mindfulness in Therapy • Depression • Anxiety Disorders • Psychophysiological Disorders • Working with Children • Research

8. Teaching Mindfulness in Therapy(1)awareness (2)of present experience, (3)with acceptance • M.B.S.R. • M.B.C.T. • D.B.T. • A.C.T. • Stopping Activity: this disengages one from the automatic trains of thought that accompany experiences • Observing as a participant to experience: avoid ruminations (or wandering thoughts) by focusing on an element of the moment (breath, for instance) • Returningawareness: returning from wandering thoughts to an anchored focus (breath) • Present experience: what is happening RIGHT NOW! Not what you expected, how it was perceived by you, or how it was perceived by them as perceived by you. • Attitude: Full awareness of the present moment depends on whole-hearted acceptance of our experience, with curiosity and kindness. Return

9. Mindfulness Based Stress Reduction • Developed in 1979 by Jon Kabat-Zinn at Umass medical school. • Mindfulness training aimed at regulation of breathing, heart-rate, destructive emotions, and anxiety. • Practices include mindfulness meditation and yoga. • Body-scan meditation is sometimes applied where patients lie down and observe their body. • Therapists can get training leading to certification in MBSR (http://www.umassmed.edu/cfm/oasis/index.aspx?linkidentifier=id&itemid=41256) Jon Kabat-Zinn Return to: Mindfulness in Therapy Clinical Applications

10. Mindfulness Based Cognitive Therapy • Therapist teaches the patients to practice mindfulness using the Three-Minute Breathing Space. • During practice, patients identify thoughts and identify their ephemeral and non-factual nature. (In this element it is similar to CBT, but thoughts are let go rather than rationalized). • Three Minute Breathing Space • Awareness: “What is my experience right now… in thoughts, feelings, and bodily sensations.” • Gathering: Gently re-direct attention to breathing. • Expanding: Expand focus to include a sense of body, posture, and surrounding Developed as an adaptation from Kabat-Zinn’s MBSR by Segal, Williams, Teasdale, et al. (www.mbct.com) Return to: Mindfulness in TherapyClinical Applications

11. Dialectical Behavior Therapy • Therapy paradigm based on the Zen tradition and that of ThichNhatHanh (1976). • Mindfulness practices include counting breath, adopting a half-smile, focusing awareness on present, labeling feelings, letting thoughts come and go, practicing nonjudgment • Helping patients live more successful lives interpersonally, in spite of their poor feelings. • Much of the research has been performed by Dr. Marsha Linehan, (http://faculty.washington.edu/linehan/). Return to: Mindfulness in TherapyClinical Applications

12. Acceptance and Commitment Therapy • Collection of skills taught to patients to • Main components include • Creative helplessness • Cognitive diffusion (thoughts are only thoughts) • Acceptance • Self as context(identify with observer of thoughts) • Valuing (rededicate life to what gives life meaning) • Techniques include experiential exercises that develop mindfulness; allowing experience to come and go while pursuing a meaningful life. http://www.contextualpsychology.org/act Return to: Mindfulness in TherapyClinical Applications

13. Depression • DBT is a paradoxical treatment applied in order to help patients to accept their emotions, including those associated with depression. This reduces avoidance through exposure (learning to feel before you feel better). • ACT therapists encourage patients to change their focus to pursuing life-goals , which showed significant and positive results (Zettle and Hayes, 1986) • Patients participating in MBCT’s 8-week group treatment show a reduction in overgeneralized memories and ruminative thinking (two common features of chronic depression). Patients practice “decentering” during MBCT training, where they remind themselves that thoughts are not facts. • Mindfulness practices for depressed patients includes: • Loving attention • Acceptance of pain • Understanding that thoughts are not truths • Recognizing that feelings change • Emotional engagement (being fully available) Return to: Clinical ApplicationsResearch

14. Anxiety Disorders • Anxiety is an unavoidable, evolutionary physiological experience: it would be counterproductive to attempt to eliminate it. • Patients often confuse anxiety (apprehension of incipient danger) with fear (response to imminent danger). • Mindfulness therapies help by teaching patients to notice anxiety as it occurs with acceptance. • Traditional CBT encourages patients to rationalize fears: a stomach ache is unlikely to be stomach cancer; MBCT would encourage the patient to be with the experience: my stomach is hurting. I feel a pinch at where I imagine the esophagus meets the stomach. Maybe it’s a mass of cells that is growing wildly out of control. I feel my throat constricting when I think that. Perhaps some milk will settle things. Clinical ApplicationsResearch

15. Psychophysiological Disorders • Understanding the Chronic Back Pain Cycle • An irrational fear (what if this exacerbates my bulging disc?) • Increased physiological arousal (corresponding muscle tension with anxiety) • Misinterpreted symptoms (anxiety-induced muscle pain interpreted as pinched nerve/bulging disc) • Behavioral avoidance (sitting on that couch inflames my back pain). MRI’s are so detailed and vivid that on any given picture of the spine multiple abnormalities can be found– this contributes to patients’ irrational fears. When fear accompanies pain, patients report pain as more intense than when feelings of security accompany pain (Robinson & Riley, 1999). Courtesy of sccofutah.com

16. Psychophysiological Disorders • *It’s important that patients undergo a thorough physical examination to rule out rare but serious causes for their pain before the psycho-physiological Recovery Cycle: • Cognitive Restructuring: Share the chronic back pain cycle with patients. This helps them understand the role of fear and anticipation in the pain they experience as well as their cognitive interaction with the pain on a daily basis. • Resuming full physical activity: Encourage the patient to return to regular activities that have been avoided, all while attending to thoughts an emotions • Working with negative emotions: When destructive emotions arise, be with them and understand them—not dismissing or avoiding them, but allowing them to be variable. Courtesy of healthhabits.wordpress.com Clinical ApplicationsResearch

17. Working With Children Mindfully • There has been an emergence of books in the genre of mindful parenting • Everyday blessings: The inner work of mindful parenting, KabatZinn • Buddha Mom: The journey through mindful mothering, Kramer • Buddhism for mothers: A calm approach to caring for yourself and your children, Napthali • As well as websites devoted to it • www.themindfulparent.org • While little research has been conducted on it, therapists believe that attending to the moment during interactions with children has a positive effect on connecting with them. • Children are mindful during play– in their incredibly intimate, albeit make-believe world. Davincimethod.com Clinical ApplicationsResearch

18. Research: Glass Half Dependently- Originated • Issues • Impractical to implement control-group • Difficulty controlling extraneous variables: for example social support or attention. • Long-term benefits analyses are misleading • Criticism that analysts seldom pay attention to research (Rogers) • Studies: • Anxiety • Kabat-Zinn et al. (1992) • Miller et al. (1995) • Depression • Teasdale et al. (2000) • Williams et al. (2000) • Pain • Kabat-Zinn (1982) • Kabat-Zinn (1985) • Fibromyalgia • Kaplan et al. (1993) • Goldenberg et al. (1994) • Cancer • Shapiro et al. (2003) Return to: Clinical Applications

19. Kabat-Zinn et al. (1992) Effectiveness of a meditation based stress reduction program in the treatment of anxiety disorders. http://proquest.umi.com/pqdlink?Ver=1&Exp=09-26-2014&FMT=7&DID=5032237&RQT=309&cfc=1 Uncontrolled study of Mindfulness Based Stress Reduction on Generalized Anxiety Disorder. Method: n=22. GAD patients take Beck and Hamilton scores for depression and anxiety, Fear Survey Schedule, and Mobility inventory for Agoraphobia pre- and post treatment. Results: Repeated measures analysis of variance displayed significant decreases in depression and anxiety pre- to post-treatment for 20 of the patients (and these were maintained for the three month follow-up). The number of patients experiencing fits of panic reduced. Miller et al. (1995) was a follow-up study that measured how subjects were sticking with the private MBSR practice. Of the 18 interviewed three years later, 16 subjects practiced the informal technique of breath awareness and reported the program had had lasting positive value; Seven still engaged in formal practice at least three times per week. Return to Research

20. Teasdale et al. (2000) Prevention of relapse/recurrence in major depression by mindfulness based cognitive therapy. http://wf2dnvr2.webfeat.org/nsyrM1473/url=http://content.ebscohost.com/pdf19_22/pdf/ddd/pdh/ccp/ccp-68-4-615.pdf?T=P&P=AN&K=ccp-68-4-615&S=R&D=pdh&EbscoContent=dGJyMNHr7ESeqLU40dvuOLCmrlGep7RSrq64SLCWxWXS&ContentCustomer=dGJyMPXd4Um549%2BB7LHjgfLt8QAA Method: n= 149. Random assignment of patients with recurring depression to treatment as usual or treatment as usual with Mindfulness Based Cognitive Therapy. Results: For patients with three previous depressive episodes (77% of sample), MBCT significantly reduced relapse/recurrence; for patients with only two previous depressive episodes, MBCT did not significantly reduce relapse/recurrence. Return to Research

21. Shapiro et al. (2003) The efficacy of a mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: an exploratory study. Method: Women who were experiencing sleep disturbance due to stress related to breast cancer were randomly assigned to MBSR or a free-choice (FC) control. Measures were self-report sleep satisfaction and efficiency. Results: Women in the FC condition reported satisfaction increase but not in efficiency; women in the MBSR condition reported strong sleep satisfaction increase as well as efficiency increase. There was a positive interaction between degree of sleep satisfaction and the number of times subjects practiced informal meditation between test groups. Return to Research

22. Selected Bibliography Brown, K., & Ryan, R. (2004). Perils and promise in defining and measuring mindfulness: Observation from experience. Clinical Psychology: Science and Practice, 11(3), 242-248. Gunaratana, B. (2002). Mindfulness in plain English. Somerville, MA: Wisdom Publications. Hanh, T.N. (1976). The miracle of mindfulness. Boston: Beacon Press. Nyanaponika T.,( 1972). The power of mindfulness. San Francisco: Unity Press. Teasdale, J., Moore, T., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70(2), 275-287. Zettle, R., & Hayes, S. (1986). Dysfunctional control by clinet verbal behavior: The context of reason-giving. Analysis of Verbal Behavior, 4, 30-38.