Mindfulness in therapy

Mindfulness has become increasingly popular as a third wave therapy in psychological treatment.

Unlike traditional cognitive therapy, which emphasizes more on changing negative thoughts that maintain our mental difficulties, mindfulness practice focuses on acceptance of our thoughts.

It is based on the idea that what we resist, persists. The more try to run away from our anxiety, the stronger anxiety gets. The more we try to sleep, the further away sleep gets. By simply observing our negative thoughts non-judgmentally – i.e., not giving it emotional fuel or believing in it – the power of the thought decreases dramatically and we become better able to act in a way that is consistent with our values. In the same vein, when we accept the fact that sleep might never come, that is when sleep finally comes.

Meta-analytic studies have found that mindfulness is helpful across a number of psychological and medical conditions, such as depression, anxiety, insomnia, emotion regulation, chronic pain, among many other disorders (Khoury et al., 2013).

Mindfulness is incredibly helpful. However, learning mindfulness can be somewhat challenging because it requires us to adopt a new way of relating to our thoughts and emotions. Many people practice mindfulness for the wrong intention, thinking to it is meant to relax us.

However, mindfulness is not relaxation. Assuming that all mindfulness practices will be positive experiences can lead to people terminating early because they think that mindfulness is not working.

Therefore, it is vital that therapists understand how to engage and lead mindfulness practices with patients in individual and group therapy to transition patients into a new way of thinking and practice that can be widely beneficial.

The goals of mindfulness

Firstly, to understand how to lead practices, it is important to understand the goals of mindfulness. Three goals of mindfulness include:

  • Attending to the present moment and noticing internal (thoughts, emotions) and external (sounds, tastes, touch) sensations.
  • To accept the current experience as it is and taking a non-judgmental approach to internal and external events
  • To get out of one’s automatic pilot to better respond to emotions, rather than react emotionally

As you can see, mindfulness is about seeing thoughts and emotions as they truly are – simply thoughts and emotions. They do not have to mean anything and we do not have to react to it. By attending to the present moment, we become better aware of how our thoughts and emotions and affect our behaviours and make a decision to respond instead of immediately reacting.

For example, our automatic pilot may have previously taken us to using substances anytime we are anxious. Through regular mindfulness practice, we may become much more aware of these behaviours and choose to adopt healthier habits to reduce stress – such as regular relaxation exercises or increasing emotional vulnerability.

Embodying attitudes of mindful practice

Mindfulness is an elusive concept and can be best understood experientially. Therefore, to be fully effective in teaching mindfulness means that it is important to practice mindfulness. I would encourage you to set aside some time every day to try out mindfulness practices for yourself. For those pressed for time, there are practices that are as short as 3 minutes!

Beyond personal practice, it is also helpful to adopt an attitude of embodied mindfulness to work with patients in a way that consistent with the teachings of mindfulness. A few examples below:

A non-judgmental attitude. After a mindfulness practice, we typically ask patients to share their experience. During this time, we adopt a curious and non-judgmental attitude towards their experience. We are simply interested in hearing what their experience was regardless of whether it was positive or negative. This embodiment of a non-judgmental attitude allows others to understand that it’s okay – and even good – to have bad experiences and be more open to sharing. The reason that bad experiences are useful is because they allow us to practice our ability to simply observe, acknowledge, and dismiss negative thoughts or sensations.

Adopting a beginner’s mind. Although we may be leading the mindfulness practice, it is important to take a beginner’s mind to each mindfulness practice and the patient’s respective experiences. If we are fixed in our beliefs, then we may miss essential components because of our limited worldview. By adopting a beginner’s mind, we are much more open and curious about the patient’s experiences.

Being kind. We show compassion to our patients’ and our own experience and provide copious empathy to each person’s journey. Showing genuine positive regard increases trust and is a key component of Carl Roger’s humanistic psychology.

Non-striving and letting go. We are not forcing anything to happen or trying to make patient’s change their minds about anything. In this practice, we let go of wants, needs, wishes, to simply notice what is going on in our experience, making note of their existence, and then letting them go.

This post can be helpful to learn more about specific attitudes of mindfulness.

Layers of mindfulness inquiry

The structure of mindfulness practice in group therapy is that a therapist will typically lead a mindfulness meditation or mindfulness practice. Afterwards, each patient will have a chance to share their experience. The specific questions that the therapists asked are based on a specific structure (known as ‘layers of inquiry’) that help guide our questioning to support a mindfulness approach.

Layer 1: In layer one, the teacher attempts to understand a person’s experience, acknowledging its presence and allowing space for it. Example questions include: “What did you notice?”, “What were you aware of?”, and “What showed up for you?”. Many experiences can come up, but you may hear things like: “I noticed my mind kept going off into different places”, “I felt a lot of anxiety in my chest”, and “I was feeling very calm and focused”. In none of these cases the patients are doing something wrong – we take a non-judgmentally attitude towards all experiences!

Layer 2: Layer 2 focuses on expanding this awareness to the sensations and how it relates to their current habits or behaviours. For example, a question could include “how might this be different than when you normally pay attention?”. The patient may have insight into how these sensations typically increase urge to engage in certain behaviours or notice that simply observing their anxious sensations actually helped them to focus their breath on the anxiety.

Layer 3: Layer 3 is about understanding how this break from the automatic pilot helps us with our mental health. From noticing these thoughts and sensations and recognizing associated urges to engage in certain behaviours, how we do use that to increase well-being? Perhaps, for some, noticing and holding these thoughts non-judgmentally weakened their strength and made them feel more in control of their subsequent behaviours. In other cases, understanding that a thought is just a thought – and labelling it as such – helped to reduce their distress. Layer 3 asks questions about how mindfulness might be helpful in improving their psychological challenges.

Layers of mindfulness inquiry

An example of mindfulness inquiry after practice

Therapist: So Sarah, what was the experience like for you? What did you notice? (Layer 1)

Patient: I noticed my mind was running back and forth about all the things I had to do after today’s session. I feel like I didn’t do a good job.

Therapist: So you noticed that your mind was jumping around a lot and you had a judgment that “you were not doing a good job”, is that right?

Patient: Yes, that’s right. I feel like I should have been able to focus better.

Therapist: Yes, I think we can all agree that we have times in our lives that our brain sends a bunch of signals about things we need to worry about and we notice it’s hard to focus on the task at hand. That’s just what the brain does! And mindfulness is really about noticing that our mind is running, even thanking the mind for doing what it does, and then going back to our practice. What about you Sarah – did you notice anything different when your mind was running compared to usual?

Patient: Yeah, I noticed I was frustrated when my mind kept going to all the appointments and tasks I had to attend to. But, I just tried to get back to focusing on the breath. I noticed by the end of the practice I was able to keep my concentration a lot better.

Therapist: Wonderful! I’m glad to hear that Sarah. And how do you think this practice might benefit you in the future.

Patient: For me, I think this practice is helpful for me to not get so frustrated when I am having a lot going on. I can always go back to the breath, which gives me more space to think about what I need to do first instead of just getting overwhelmed.

Final thoughts

And that’s it! Leading mindfulness practice is really about helping patients experience things going in their lives in a non-judgmental and present manner. This gives them the space to respond according to their own goals and values and not give negative thoughts and emotions the fuel to hurt us. Adopting a specific set of attitudes, using the layers of inquiry, and practicing mindfulness yourself can help you to become an excellent mindfulness therapist!

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Best wishes,