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My Use of Mindfulness in Clinical Practice

May 4, 2015

When I was a very busy doctoral student, our curriculum director decided to test-drive a one-credit course called “Mindfulness.” The entire cohort was rather chilly on the notion, given our already overloaded internship and course work schedules. Me, I was downright crabby about it, especially after seeing the syllabus with all the papers our instructor, Dr. Donna Rockwell, had assigned. But, ever the “A” student, I buckled down and participated fully, turning in my papers, while regularly registering my protest.

As so often happens, by the end of the term, that very thing I so resisted had become a basic staple of life: I have continued mindfulness meditating ever since, and recently apologized to my dear teacher for my past, regrettable reactivity.

Additionally, in my psychotherapy practice, I teach every client who is open to learning—and has even a minimal tolerance for affect—a simple mindfulness meditation during either the second or third session. I have found this practice a useful addition to the several other modalities I use, depending on the individual’s diagnosis.

The goal of psychotherapy is change. Whether the client is experiencing intrusive or compulsive thoughts or behaviors, suffering from overwhelming levels of emotion, or even long-term anhedonia or depression—the desired outcome is change. In order to change, in any way, the person must be able to stop—even for a fraction of a second —whatever behavior he or she is engaged in. In order to change, the person must be able to pause long enough to recognize and attend to his or her current condition, which is the first step to accepting it, which seems to be the next step of change: accepting the current condition.

Mindfulness is the act of consciously pausing to witness our thoughts and feelings, accepting them just as they are, and learning to have compassion for ourselves and our discomforts. I find this practice is also helpful in establishing therapeutic alliance because it helps clients to more accurately characterize their symptoms, and articulate their particular discomforts and dysfunctional ways of being.

Prior to teaching the mindfulness meditation, I speak to them a little about how directing our own thoughts and feelings is possible, with some amount of instruction, attention and learning, much like driving our cars: We wouldn’t get behind the wheel without learning to drive and direct our car, but we haven’t been taught to drive our selves. Rather, we let our impulses drive us. When we learn to pause and witness, then accept, gradually we can begin to learn to direct our thoughts and feelings rather than reacting to them, automatically.

Additionally, I talk a bit about the evolution of our human brain, the organ that evolved both to direct and control our other physiological organs, but also to protect us. Because humans are (however defended by a healthy amount of denial) uniquely aware of our own mortality, our brain prioritizes protection. It is inclined to focus on negativity, to be scanning for threats. Bringing this to awareness normalizes some of the client’s symptoms and reactions, because it becomes understandable how we humans are uniquely vulnerable to anxiety and depression.

I then show them a picture of the triune brain, and show how much of our brain is being powered by two-thirds instinctual, mammalian, and genetic impulses; and only one-third reason. I describe how, depending on our particular wiring, and genetic make-up (given the findings that many mental illnesses develop from genetic predispositions) that two-thirds can be very powerful. Pointing to the limbic system, I show how our five senses are plugged directly into that part of the brain, perhaps an evolutionary adaptation allowing the reasoning part—the prefrontal cortex—to be bypassed when a threat is detected, or negativity is evoked in memory. Theoretically, when that occurs, our limbic system can “highjack” the reasoning part of us and “trigger” us, causing thoughts, feelings, and behaviors that may be reacting to things stored in memory, or over-responding to things our rational mind—if it had time to engage—would find less negative or threatening. I explain how mindfulness practice can help us develop a habit of attuning to our reactions, allowing us a fraction of attention to our breath in response to the first sign of up-regulation, in hopes of interrupting the triggered reaction. That tiny bit of time might allow the prefrontal cortex to engage, allowing us to choose better responses. Over time, it may even be possible to retrain, and thus, rewire our brains into new, healthier ways of being.

After having taken a thorough biopsychosocial history in the initial session, at this point I often use examples from the client’s own history to talk about how some of their particular ways of being, or past ways of coping may have become over-learned, and habitual. I explain that mindfulness practice may help build his or her intentional muscles and help them learn to resist impulsive or over-learned reactions, and direct her/his own course into more positive thoughts, feelings, and behaviors.

I tell them how, when the breath passes quickly through the bridge of the nose, the pituitary gland senses that breath and directs the central nervous system to down-regulate, decreasing respiration and heart rate. Additionally, breathing all the way out, as instructed below, encourages fully in-breathing, oxygenating the bloodstream, especially the brain.

Mindfulness Meditation

Sit up straight and imagine your spine as a stack of golden coins. Don’t close your eyes, but rather fuzzy-focus on the floor about three feet in front of you. Relax your shoulders, let them fall away from your ears, and rest your hands on your thighs. Notice your feet on the floor: That is where you’re grounded to earth by gravity, grounded and centered. Notice the weight of your hands on your thighs: That’s where you’re grounded to yourself, your body.

Breathe in through your nose, then breathe all the way out: Try to touch your belly button to your spine on the out-breath, then breathe in again through your nose. About 60% of your attention is on the ambient sounds in the room, the ticking of clock, the noises outside in the street, and about 40% of your attention is on your out-breath. The mission is to focus on the out-breath.

As your thoughts arise, just notice them. Don’t try to stop them or change them. Simply label them “thinking,” and gently return your focus to the out-breath. If you have an urge to move, or scratch an itch, simply label it, “thinking,” and gently return your focus to our outbreath.

I’ll watch the clock: Five minutes.

Now, gently begin to come back into the room. Scan your body from the top of your head, down through your neck and shoulders, down through your arms, hands, torso, your legs, and your feet—and tell me where you feel the most energy in your body, right now. Focus on that part. Take one more breath into that part. Breathe in healing and peace. Breathe out stress and tension.

I give them the directions, above, on a handout and ask them to practice 5-15 minutes a day, when possible. I begin most sessions with this mediation for 3-5 minutes, and many clients have expressed they like how this “centers,” “calms,” or “focuses” them on making the most of the session.

At three-month intervals, and when clients are transitioning out of treatment, I ask them to identify which aspects of our work have been most and least helpful to their progress. Most clients report that starting sessions with mindfulness meditation has helped them cultivate this practice at home, and find it “calming,” “helps relationships,” and “helps me slow down and enjoy life more.” Unfortunately, clients experiencing high levels of anxiety, and/or high levels of physical energy— for instance, adolescents and teens—find it difficult or uncomfortable to be still or quiet, to resist the impulse to use that energy for expression.

Over a year ago, I began treating a 15 year-old female client, a young woman struggling with social anxiety. I initially taught her the mindfulness practice (above) and began our first several sessions that way. After we’d developed a relationship, however, and she began to trust both me—and herself— more, she said, “I really don’t like sitting still and being quiet like that. Can we just talk?” So we suspended that practice, and continued therapy along cognitive behavioral lines, identifying and labeling uncomfortable thoughts and feelings; practicing replacing negative thoughts with positive ones.

She is 16 years old now, and has made remarkable progress, has a strong peer support/friend group, and is making excellent grades in high school. Two weeks ago, she came into our weekly session and said, “You know that meditation you taught me when I first came here? Will you do it with me again? Teach me the way to do it, again?”

I asked her what had happened to bring this topic up, and she said, “Well, I really do use that breathing, sometimes, and it really does help calm me down. I notice how I just talk fast when I’m anxious, and blab out the wrong thing, but if I get one breath in, it really helps calm me down so I can say what I mean, and no more. I can just notice my breathing instead of talking.”

The take-away for us, in session, was that the very energy that arises for self-expression was driving her social anxiety. She reported the “blabbering” was causing her to speak before she had formulated her thoughts, and memories of embarrassing moments when that had happened were reinforcing her fear of social interactions. Though she initially resisted the practice in sessions, over the course of the year she had recalled and practiced focusing on just one breath several times, and experienced herself as more centered in those moments. She said she had wanted to bring it up for some time, but was “embarrassed about changing her mind.” Ironic, isn’t it? In the course of reteaching the practice, I reminded her of the instruction to “witness our thoughts and feelings with compassion—toward self.”

As I mentioned, earlier mindfulness meditation has become a basic staple of my own personal life. In conclusion, I just believe, hope, and anticipate a time when we will begin teaching our children early, mindfulness meditation. The earlier, the better, because the hope is we can begin learning to direct our attention easier when young brains are naturally pliable and growing—much like it is easier to learn languages when we’re young. Goldie Hawn has a foundation and is trying to get it into as many schools as possible, and I just love Dan Siegel’s work, too (see below).

“Breathe in healing and peace…. Breathe out stress and tension.”

Additional information is available at:

http://donnarockwell.com

http://thehawnfoundation.org/mindup/

http://www.drdansiegel.com/about/interpersonal_neurobiology/

This is story originally appeared in the Spring 2015 edition of Connections — for Communities that Care a publication of the Michigan Association of Community Mental Health Boards.

Brooks, D. L. (2015, Spring). My use of mindfulness in clinical practice. Connections– For Communities That Care, 5; 11-12.

 

Denise BrooksDenise L. Brooks, PsyD, PLLC (PsyD 2010)

Dr. Brooks graduated from the Michigan School of Professional Psychology in 2010.