Tag Archives: mindfulness

When brain meets body

By Laurie Meyers February 22, 2017

Chinese medicine has always acknowledged the link between the body and the mind. In Western medicine, from the time of the ancient Greeks through the Elizabethan era, the thinking was that four bodily humors (black bile, yellow bile, phlegm and blood) influenced mood, physical health and even personality. Shakespeare built some of his characters around the characteristics of the humors (such as anger or depression). It sounds faintly ridiculous, but the idea that good health came from a balance of the humors — in essence, that the physical and the mental were closely related — was not so far off the mark. Then along came René Descartes and dualism — the school of thought that says that mind and body are separate and never the twain shall meet, essentially.

In the past few decades, however, Western medicine has once again begun to acknowledge that the body and mind don’t just coexist, they intermingle and affect each other in ways that researchers are only beginning to understand.

Counselors, of course, are well-aware of the mind and body connection, but it is becoming increasingly evident that a person’s thoughts can directly cause changes in physiological processes such as the regulation of cortisol. This cause-and-effect relationship suggests that in some cases, symptoms typically considered psychosomatic in the past might actually be indicators of physical changes that are having or will have an effect on the client’s physical health.

Take, for instance, something that most people have experienced at some point in their lives: a “nervous” stomach. It turns out that having a “gut feeling” and “going with your gut” are not just metaphors. Researchers have begun to refer to the stomach as the “second brain” and the “little brain.”

Although no one is going to be making reasoned decisions or solving algebra equations with the little brain anytime soon, the enteric nervous system (ENS) does possess some significant brainlike qualities. It contains 100 million neurons and numerous types of neurotransmitters, including serotonin and dopamine. In fact, researchers have found that most of the body’s serotonin (anywhere from 90 to 95 percent) and approximately half of its dopamine are found in the stomach. The main role of the ENS is to control digestion, but it can also send messages to the brain that may affect mood and behavior.

Researchers are still teasing out whether (and how) the gut-brain conversation causes emotion to affect the gastrointestinal system and vice versa, but a major area of focus is the microbiome — the vast community of bacteria that dwell primarily within the gut. So far, research suggests that these bacteria affect many things in the body, including mood. Gut bacteria may directly alter our behavior; they definitely affect levels of serotonin. (For more discussion of the microbiome and its possible influence on mental health, read the Neurocounseling: Bridging Brain and Behavior column on page 16 of the March print issue of Counseling Today.)

The bacteria in the gastrointestinal system may also play a role in depression and anxiety. Digestive issues such as irritable bowel syndrome and functional issues such as diarrhea, bloating and constipation are associated with stress and depression. Some researchers believe a causal connection may exist that is bidirectional — meaning it is not always the psychological that causes the gastrointestinal problems but perhaps vice versa. Interestingly, research has shown that approximately 75 percent of people who have autism have some kind of gastro abnormality such as digestive issues, food allergies or gluten sensitivity.

Most people have heard the injunction to “think with your heart, not your head.” And in Western culture, the notion of heartbreak is commonly understood not just as an emotional metaphor but as an actual sensation of physical pain. Once again, these aphorisms and metaphors represent an instinctive understanding of another significant connection: that between emotion and the heart.

Coronary artery disease (CAD) is linked to emotion and mental health — depression in particular. Research indicates that 25 to 50 percent of people with CAD have symptoms of depression. Some experts believe not only that depression can cause CAD, but that CAD may cause depression. Increased activity in the amygdala is associated with arterial inflammation, and inflammation is a factor in CAD.

Research indicates that inflammation in the body plays some kind of role in many chronic diseases, including asthma, autoimmune disorders, chronic obstructive pulmonary disease, obesity and type 2 diabetes. Some researchers believe that inflammation may also be a causative factor in mental illness.

Letting go

If physical and mental health are so tightly bound, what role do counselors play in balancing the two? A vital role, believes licensed professional counselor (LPC) Russ Curtis, co-leader of the American Counseling Association’s Interest Network for Integrated Care.

Yes, counselors can help clients manage chronic health conditions and cope with stress and mental illness, Curtis says, but it’s the client-counselor relationship — the therapeutic bond — that he views as the most important element. He believes the simple act of listening, taking clients’ concerns seriously and becoming their ally can help jump-start their healing process. “Once you sit down and build a rapport with clients and treat them with respect and dignity, you are helping them heal,” says Curtis, an associate professor of counseling at Western Carolina University in North Carolina.

Curtis, who has a background in integrated care, doesn’t equate “helping” with “curing.” But he does believe that inflammation in the body strongly affects mental and physical health, and he says that counselors possess the tools to help clients ameliorate the factors that may contribute to inflammation.

For example, gratitude and forgiveness, and particularly letting go of anger, are essential to emotional wellness, and in some studies, Curtis says, they have been shown to have a physical effect. In one study, participants were instructed to jump as high as possible. Those who thought of someone they had consciously forgiven despite being wronged by them in the past were able to jump higher than participants who received no such instruction, he says. Another study found that cultivating forgiveness by performing a lovingkindness meditation produced a positive effect on participants’ parasympathetic systems.

Curtis, who also researches positive psychology, asks clients in his small part-time private practice to keep gratitude journals, which is something that he also does personally. In addition, he uses motivational interviewing techniques to help clients develop forgiveness.

If a client isn’t ready to forgive, the counselor might explore the ways in which anger may be affecting the person’s emotional and physical health and functioning in daily life, Curtis says. If the client is still resistant to the thought of issuing forgiveness, then the counselor can broach the idea of the client at least letting go of his or her anger, he adds.

Anger is particularly toxic to personal well-being, stresses Ed Neukrug, an LPC and licensed psychologist who recently retired from private practice, where he focused in part on men’s health issues. “Anger is a difficult topic for many clients to understand and address appropriately,” he says. “Usually, individuals who have angry outbursts have not learned to monitor their emotions appropriately. They most likely have had models who had similar outbursts. These individuals need to obtain a better balance between their emotional states and their thinking states.”

“Oftentimes, just teaching clients about mindfulness can be helpful because it begins to have them focus on what they are feeling,” continues Neukrug, a member of ACA and a professor of counseling and human services at Old Dominion University in Virginia. “Once they begin to realize that they have angry feelings, they can then talk to the person who they are angry at in appropriate ways, to reduce the anger and resolve the conflict early on. If they wait too long, they are likely to have an outburst.”

Anger, like stress, can cause physical changes in the body, such as a surge in adrenalin, cortisol and other stress hormones; raised blood pressure; and increased heart rate and muscle tension. Over time, as the body is constantly put into this “fight or flight” mode, the immune system may treat chronic stress or anger almost like a disease, triggering inflammation.

To help ameliorate the effects of toxic emotions, Neukrug recommends that counselors teach clients how to sit and engage in quiet contemplation. He notes that many people don’t realize that they are involved in a constant, almost unconscious, running mental commentary throughout the day. By taking time for self-reflection, clients can become better aware of how they are reacting to these thoughts, both emotionally and physically, and can then engage in stress reduction techniques such as progressive relaxation and mindfulness exercises.

Neukrug also recommends what he calls “life-enhancing changes” such as exercising, eating healthfully, journaling, confronting and resolving personal conflicts, and getting enough sleep. He also is a big proponent of nurturing personal relationships, taking regular breaks from work and going away on vacations to lessen the effects of stress.

Healthy habits

David Engstrom, an ACA member and health psychologist who works in integrative health centers, teaches his clients mindfulness exercises and recommends that they engage in daily gratitude journaling. But he also emphasizes a factor that is often overlooked despite its unquestioned importance to physical and mental well-being: sleep.

“It’s the first thing I focus on [with new clients],” he says. “There are few people who can be real short sleepers,” meaning less than six hours per night. “Most of us if we are [regularly getting] under seven hours a night have a higher risk of diabetes, obesity, heart disease, hypertension, chronic cardiovascular problems, depression and anxiety.”

Engstrom has his clients keep a sleep log detailing information such as the number of hours of sleep they get each night, when they went to sleep, how often they woke up in the night and the overall quality of their sleep. He also has them track their alcohol intake and physical exercise. He notes that exercise can vastly improve sleep quality, whereas drinking any alcohol after about 5 p.m. hinders sleep.

For clients who are having trouble falling asleep, Engstrom recommends mindfulness techniques such as being still and present in the bedroom and practicing deep breathing. He also sometimes gives clients MP3 files and CDs that contain guided mindfulness activities.

Counselors also can also play a role in changing clients’ health behavior for the better through psychoeducation, Curtis says. He recommends the use of simple cards that list information such as the benefits of smoking cessation or strategies for preventing or controlling diabetes. Curtis believes that clients are best served physically and mentally by integrated health care, a model in which a person’s physical and mental health needs can be attended to in one location by multiple professionals from different disciplines, such as LPCs and primary care physicians. He currently serves on two integrated care advisory boards for local mental health centers and also supervises students serving internships in integrated care settings.

When he practiced in integrated care, Curtis says a significant percentage of the clients he saw had not just mental health issues but also serious physical issues such as diabetes or cancer. “I was part of providing real support,” he says. “Instead of just having a 20-minute session with the doctor and being told what to do, clients were able to sit with me and process their fears and what they were feeling. I was also making sure that they understood what to take, where to go for bloodwork and making sure they didn’t feel lost [in the process].”

Neukrug uses a structured interview intake process in which he asks clients about their medical histories, any past or current issues with substance abuse and any experiences of major trauma. He has found that many clients are more likely to reveal issues such as a history of trauma or concerns about their physical health in written form rather than verbally. He notes that men in particular can be hesitant to raise common health-related issues with which they are struggling, such as erectile dysfunction, sexually transmitted diseases and prostatitis.

“Men [are] fragile about their egos,” he says. “If they have a disease that affects how they view their manliness or impairs them, they may just not want to talk about it. But any of these diseases can impact their relationships, their ability to earn an income, which is related to male identity and being the provider, so counselors just need to have that attitude that they are open to hearing about anything.”

Trauma’s toll on the body

Examining the health of adults who have experienced childhood abuse and neglect paints a particularly vivid portrait of the connection between physical and mental health. A large body of research — most of it using information gathered from the joint Centers for Disease Control and Prevention-Kaiser Permanente study “Adverse Childhood Experiences” (ACE) — has demonstrated that early exposure to violence and trauma can lead to significant illness later in life.

The initial study was conducted in 1995-1997 and surveyed 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. Participants answered detailed questions about childhood history of abuse (emotional, physical or sexual), neglect (emotional or physical) and family dysfunction (for example, a parent being treated violently, the presence of household substance abuse, mental illness in the household, parental separation or divorce, or a member of the household who was engaged in or had engaged in criminal behavior). Respondents who reported one or more experiences in any of the “adverse” categories were found to be more likely to develop chronic conditions and diseases such as heart disease, obesity, cancer, chronic obstructive pulmonary disease, liver disease, depression, anxiety and other mental illnesses. The risk of developing these health problems also increased in correlation with the number of adverse incidents the study participants reported experiencing.

Although some of the health problems developed by adult survivors of trauma can be traced directly to injury or neglect, in many cases, specific cause and effect cannot be established. Nevertheless, the correlation between trauma and illness is significant, and some research findings — such as an increased incidence of autoimmune diseases among adult survivors of child abuse and neglect — suggest that the connection can be systemic and affect the entire body.

Causation versus correlation aside, clients who have experienced long-term trauma are often living with both mental and physical complaints, and the number of prospective clients who have a background of adverse childhood events may surprise some clinicians, say trauma experts. More than half of the ACE respondents reported experience with one adverse category, and one-fourth of participants had been exposed to two or more categories of adverse experiences.

Given the prevalence of traumatic exposure, ACA member Cynthia Miller, an LPC who has a private practice in Charlottesville, Virginia, believes it is important to ask about early childhood experiences as part of her intake process, and she urges other clinicians to do the same. She has clients fill out a written scale based on the questionnaire used in the ACE study. If clients indicate a history of abuse or neglect, Miller uses it as a way to explore how trauma has affected their lives.

“I think counselors need to know that trauma can affect the body in unexpected ways — ways in which the client may not even be aware,” Miller says. “I ask what impact they think these experiences had on their lives and then segue to asking, ‘What effect do you think this has had on your health?’”

Miller focuses on self-care practices for clients. For instance, clients might be using food to self-soothe, which can lead to obesity, diabetes and a whole host of other problems. Miller helps them to examine how the behavior is related to what they have been through and to identify what they are trying to soothe.

Miller also teaches her clients to tune in to their bodies. That can be extremely difficult because trauma survivors often use a kind of dissociation or “tuning out” as a survival mechanism, she explains. Clients who have been through physical trauma often exist, in essence, from the chin up, totally separating themselves from what is happening with their bodies, Miller says.

“Where in your body do you feel that anger?” Miller asks in trying to help them reestablish that whole-body connection. “Where do you feel the stress?”

According to Miller, yoga and mindfulness, particularly progressive muscle relaxation and diaphragmatic breathing, can be very useful for helping clients learn how to self-soothe and pay attention to how their bodies are responding to what they are doing.

On a more basic level, counselors can also play an essential role in ensuring that their clients get proper health care. “A lot of times I’ve found trauma patients don’t even go to the doctor,” Miller says. “Sometimes they may have issues with getting help, such as thinking there’s nothing they can do [to help the situation], and it all feels too hard. One of the questions I routinely ask is, ‘How long has it been since you had a good physical?’ If they say a year or more, I ask, ‘Would you go have one now? If not, why? What are your concerns? How can I help?’”

Miller says counselors can play an essential role in educating clients about the effects of trauma on the body and how that can cause chronic inflammation. Counselors can encourage clients to seek any needed medical care and also talk to them about what they can do personally to help counteract their bodies’ inflammatory responses, she says.

A partner in health

Another area where counselors can help clients with their physical health is by talking with them about why it is important to take medication, Miller says. She notes that in the general population, only about 50 percent of people who are prescribed medications for chronic conditions take them regularly. Counselors can uncover the legitimate concerns that get in the way of treatment compliance, Miller continues, such as the complexity of the regimen, whether the client has adequate access to obtain needed medication or treatment, and whether the client has easy access to the basics such as food, shelter and water.

It is also important for counselors to explore clients’ in-depth thoughts and feelings related to treatment, Miller says. For example, do they even believe in taking medication, or do they simply dislike taking pills?

Once counselors uncover the reasons that a client might not be adhering to medical regimens or engaging in healthy behavior, they should also consider whether the client is even ready to make a change, says Miller, adding that she finds motivational interviewing helpful in this regard.

Counselors can also help clients break down the change into small steps. For instance, Miller says, “When you talk about exercise, people think you are automatically talking about 60 minutes on the treadmill or kickboxing. [But] what is reasonable? If a person is very depressed, maybe you start [the process] in session. If it’s a decent day outside, can you do the session outside and maybe take a walk?”

Clients also need to be made aware that change is often slow, Miller says. If they did five minutes of exercise this week and didn’t exercise the week before, that five minutes is worth celebrating, she says.

Miller also works with clients on sleep hygiene, including tracking how much caffeine they ingest, how late in the day they stop consuming caffeine and the amount of sugar they eat. “Are they setting a sleep time?” asks Miller. “Are they being exposed to blue light? Is there a TV in the bedroom?”

She also helps clients develop a pre-bedtime routine and, if they have trouble going to sleep, encourages them to get up and do something boring until they feel sleepy again.

“If they are still having disrupted sleep and nightmares [even with sleep hygiene], I refer to a physician,” Miller says. “I’m not against someone taking a sleep medication if all other routes have failed because not getting sleep becomes a self-perpetuating cycle.”

Miller, like the other experts interviewed for this story, is an advocate for integrated care because it provides a more complete picture of — and a stronger connection between — clients’ physical and mental health. “If we have counselors who are embedded in primary care, we get a better picture of the client,” she says. “If we are separate, we’re not necessarily going to hear about how long they’ve been struggling with obesity or keeping their blood sugar down. We might not know that they’ve told the doctor that they’re struggling to take medicine regularly.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Wellness” by Dodie Limberg and Jonathan Ohrt
  • “Complex Trauma and Associated Diagnoses” by Greg Brack and Catherine J. Brack

Books and DVDs (counseling.org/publications/bookstore)

  • Relationships in Counseling and the Counselor’s Life by Jeffrey A. Kottler and Richard S. Balkin
  • A Counselor’s Guide to Working With Men edited by Matt Englar-Carlson, Marcheta P. Evans and Thelma Duffey
  • Stress Management: Understanding and Treatment (DVD) presented by Edna Brinkley

Podcast (counseling.org/knowledge-center/podcasts)

  • “The Brain, Connectivity and Sequencing” with Jaclyn M. Gisburne and Jana C. Harr

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Cultivating a practice of mindfulness

By Laurie Meyers December 21, 2016

In 1979, Jon Kabat-Zinn, author and professor emeritus of medicine at the University of Massachusetts Medical School, founded the Mindfulness-Based Stress Reduction Clinic, which uses a combination of mindfulness meditation and yoga to promote healing. In the ensuing decades, interest in mindfulness — not just for physical healing but also for emotional healing — has mushroomed. In a reader poll taken at CT Online (ct.counseling.org) in November, 87 percent of respondents said that they regularly use mindfulness techniques with their clients.

Meditation is perhaps the best-known mindfulness-based practice, but there are actually numerous techniques, says national certified counselor Danielle Richards. Her research, which she has presented at American Counseling Association conferences, focuses on mindfulness and self-compassion.

“There are clients and clinicians who benefit most from guided imagery and contemplative practices, while for others what is most helpful is sitting and walking meditation,” Richards says. “One individual may benefit from brisk walking meditation, while another from slow. Another individual may find that chanting or utilizing a mantra anchors them, while another the breath.”

At root, mindfulness is simply the practice of being present in daily life, explains Richards, an instructor in psychology and mental health/developmental disabilities at the College of Southern Nevada. “It encompasses being present with those around you and with what you are doing,” she says. “Overall, what I have seen as most helpful, across settings and populations, are practices that help individuals bring mindfulness into their daily lives.”

Walking meditation is one of the activities Richards recommends for cultivating awareness. “It can be applied to normal activities one does in a day, such as opening a door or walking between classes or brushing one’s teeth or washing clothing,” she says.

Richards teaches two types of walking meditation. “One involves lifting, moving, placing … where the individual focuses on being mindful of each aspect of the movement as they perform it slowly,” she explains. “The other type involves counting while walking at a comfortable pace, so it can happen as part of daily activity rather than as an isolated formal practice. It involves a sequence such as 1, 1-2, 1-2-3, 1-2-3-4, and goes up to 10. The counting serves as a placeholder for the present moment — just as the breath does in sitting meditation — so that as one’s mind wanders, the counting allows [the person] to come back to the present moment.”

Richards, a former counselor practitioner who presents workshops on mindfulness and mindfulness meditation, recommends that clients try out different walking paces to see which works best for them.

“Notice Five Things” is another simple method that counselors can use with clients to help them tune in to their surroundings, Richards says. The steps are as follows:

1) Pause for a moment.

2) Look around and notice five things that you can see.

3) Listen carefully and notice five things that you can hear.

4) Notice five things that you can feel in contact with your body.

Noting or describing — silently putting words to experience — is a technique that can be incorporated into any mindfulness practice, but it is particularly helpful for those who ruminate or are simply stuck in their own heads, Richards says.

“For instance, when feelings arise, one can silently note those feelings,” she says. “[You] could use a phrase like, ‘It’s a feeling,’ or be much more specific and note each individual feeling by name: anger, boredom, calm. For example, in a tense situation, one might observe a feeling of anxiety and simply note it as ‘I’m feeling anxious’ or ‘I’m noticing a feeling of anxiety.’”

This kind of mental noting of emotions helps clients to identify feelings and thoughts that they want to resist and instead learn to accept them through methods such as breathing exercises. “For example,” Richards says, “‘Breathing in, I am feeling worried. Breathing out, I am taking care of my worry.’”

Awareness is central to mindfulness practices. Richards explains that becoming truly aware of what is distressing to an individual and how that stress affects him or her is a key part of stress management.

As part of becoming aware of emotions, and stressful feelings in particular, Richards likes to use journaling with clients. “Individuals can become truly aware of the stress in their life and how they engage with it. This is a first step to choosing a response rather than acting on gut reaction,” she says.

“We all have unique patterns of how we respond when we are distressed and a unique set of stressors,” Richards explains. She encourages counselors to have their clients discuss or journal on the following questions:

  • When you feel stressed out, how does the stress manifest in you? Do you experience it physiologically — tightness in your throat, rapid heartbeat, sweating? Behaviorally — crying, yelling? Emotionally — sadness, depression, anger? Cognitively — negative thinking patterns? Or some combination?
  • Notice how much time out of the day you feel out of control, overwhelmed and stressed. Where have your thoughts taken you? The past, present or future? What are your experiences with past, present and future thinking?

Richards is also a big proponent of mindfulness meditation but notes that it is sometimes a misunderstood practice. “Many people think that mindfulness is a practice that involves emptying one’s mind of thoughts. This misconception can leave people feeling like poor meditators,” she says. “Mindfulness meditation is not about emptying the mind, but rather focusing one’s attention and training one’s mind to be more focused, effective and skillful in everyday life. Mindfulness is not about trying to make anything happen or getting to some special state of relaxation, although relaxation may be a byproduct.”

“When teaching formal sitting meditation,” Richards continues, “I stress that when one’s mind wanders, one gently brings it back to the breath, which is representative of the present moment.” In fact, she adds, noticing that the mind has wandered and then bringing it back to the present moment is itself a sign that the person has accomplished mindfulness.

Mindfulness for college students

Richards has also conducted a series of research studies with undergraduate students to determine whether brief mindfulness interventions affect measures of well-being and have the potential to increase self-compassion and decrease thought suppression. The most recent study, consisting of three stages over a period of roughly two weeks, combined group instruction and individual activities.

In the first stage, 15 students participated in a five-hour group meeting during which mindfulness was defined for them and they received instruction on how to practice sitting mindfulness. The group also engaged in a guided sitting mindfulness exercise together. Participants then learned about and engaged in several types of walking mindfulness exercises, followed by a mindful eating activity. In addition, the students were taught about stress, stress reduction and how mindfulness could help them become more aware of the relationship between thoughts, feelings and behaviors.

The participants also learned about lovingkindness mediation, which works by extending lovingkindness to oneself, to a person one loves and cares about and then to a person who is challenging to love, in that order. The actual meditation involves silently repeating the phrases, “May I be happy, may I be healthy, may I be safe and may I have the ease of well-being.” Individuals then say these phrases again, replacing “I” with the name of the person they love and care about and then with the name of the person who is challenging to love.

In the study’s second stage, participants were tasked with performing different mindfulness activities on their own over the course of two weeks and completing the online diary that kept a daily record of these activities. Every other day, the students received online “booster” activities that assisted them in their independent mindfulness practices. For example, for the lovingkindness meditation, the booster treatment consisted of answering the following questions: What arose in your mind as you practiced lovingkindness for yourself? Describe the images or feelings that came up. What are the easiest and most difficult aspects of this practice? What was your experience in working with a difficult person?

When participants submitted documentation of having completed the booster activity through related homework assignments, they also submitted their online diaries. The instructor provided individualized feedback to each participant through email.

The third stage consisted of another five-hour group session that included conflict-resolution activities and explored incorporating formal mindfulness practices into daily living.

The study showed that the mindfulness program was effective for increasing wellness and self-compassion and decreasing thought suppression, according to Richards. This is particularly significant, she says, because college counseling centers are typically short on both time and money, making brief treatment methods particularly attractive.

ACA member Tamara Knapp-Grosz, director of the counseling and testing center at the University of North Texas, has also found mindfulness practices useful for helping college students. “Students transitioning to college are inundated with so many changes that they may feel a true sensory overload at times, which can translate to a ‘freeze’ stress reaction where they shut down,” she says. “Mindfulness practices teach students how to slow down and give time to pause and observe rather than feeling the pressure to react immediately. I typically will do lots of psychoeducation on how strategies can be utilized and have homework between sessions where students can try out or practice what we have discussed in session.”

Knapp-Grosz, president of the American College Counseling Association, a division of ACA, uses a variety of mindfulness strategies with students. Among her favorite activities:

  • Mindful hand exercise. Hold your hands together tightly for 10 seconds and release. Pay attention to the sensations of tension and release.
  • Mindful writing. Find a favorite place and focus on the sounds, smells and tactile experiences around you. Write these down in as much detail as you can. This helps you to be fully present in the moment rather than racing to the past (depression) or to the future (anxiety).
  • Mindful awareness. This is similar to mindful writing, but instead of writing about the things around you, simply slow down and take in every detail in your surrounding area. Look at things as if you are seeing them for the first time.
  • Stop and breathe. As your mind wanders, bring yourself back to focusing on your breath.
  • Mindful balloon. “When something challenging is bombarding us, using [our] breath can also get us unstuck and [help us] move on rather than ruminating,” Knapp-Grosz says. “I teach students to visualize letting go of whatever challenge they are struggling with and cannot move on from as they exhale each breath. Sometimes even seeing a balloon floating away, with each breath going higher and higher.”

Mindfully managing addiction

ACA member Mark Schwarze finds mindfulness practices a helpful addition to the traditional group format used in addictions counseling. The group format is typically based on techniques rooted in cognitive behavior therapy (CBT) and motivational interviewing.

“From a biopsychosocial model, those with innate vulnerabilities to addiction have high levels of anticipatory thinking and reactivity,” explains Schwarze, an assistant professor and director of the clinical mental health program at Appalachian State University in North Carolina. “Mindfulness can be a way of ‘being’ in the world that, at first, feels difficult. Over time and with practice, the mindful client can develop a passive response to triggers and leave more time to make choices that will lead away from impulsive behavior. In traditional CBT-based relapse prevention, clients are required to dispute an illogical/irrational or impulsive thought and replace it with a more logical/rational one. Mindfulness-based relapse prevention only asks for acknowledgment and [a] return to the present.”

Schwarze, who presented at the ACA 2016 Conference & Expo in Montréal on mindfulness in addictions counseling, describes three specific exercises counselors can use with these clients: basic breathing meditation, a SOBER breathing space exercise and the practice of urge surfing.

“[Breathing] meditation typically focuses the client on their breath with instruction to acknowledge distractions without judgment, and then to return focus to the breath,” Schwarze says. “It is the ability to be aware of your mindlessness and return focus to the present that is really the skill to be developed.” He adds that counselors can find many examples of breathing meditation scripts or prerecorded guided meditations to help clients learn this type of meditation.

Schwarze says the other two techniques he favors are borrowed from mindfulness-based relapse prevention therapy. “The SOBER breathing space is designed to be a short exercise to break stimulus-response patterns that can happen in high-risk times for recovering clients,” he explains. During these times, clients are taught to take a three- to five-minute timeout and follow the prompts in the acronym SOBER:

S: Stop what you are doing and focus.

O: Observe the sensations in your body.

B: Breathe and focus on your breath.

E: Expand your awareness.

R: Respond mindfully.

The other technique, urge surfing, teaches clients struggling with addiction to see their cravings in a different way, Schwarze says. “Often we think of cravings as increasing in intensity over time when, actually, cravings crest and trough like a wave. At the crest of the urge, clients are asked to observe without judgment. The client observes what is happening at that point and time and doesn’t place values on those thoughts as good or bad. Alternately,” he says, “the bottom of the craving holds equally important information that may help clients root themselves in this less-anxiety-inducing space.”

Schwarze points out that clients can download recordings to guide them through both the SOBER breathing space and urge surfing exercises. “Having recordings can be a great way to encourage clients to engage in mindfulness practice on a daily basis,” he says.

Schwarze is a firm believer in the benefits that learning to live mindfully can have for clients struggling with addiction and substance abuse problems. “I suggest that counselors work with their clients to develop a realistic plan for mindfulness practice. Daily practice is ideal, but counselors should see what clients are willing to do,” he says. “Technology has made practice much easier. There are multiple apps, websites, recordings and videos that provide clients with guided meditations and other mindfulness-based exercises. Some techniques might be helpful during a craving or other difficult time but, really, developing an orientation to the experience of mindfulness provides a wider benefit.”

A source of counselor clarity

Of course, mindfulness isn’t reserved solely for clients. Counselors can benefit too, both personally and professionally.

In his pursuit of a greater overall sense of wellness, counselor Jeffery Cochran began seeing an acupuncturist in his late 30s. After doing a holistic evaluation of Cochran, the acupuncturist told him, “You need to spend some time just sitting and staring.”

“I realized that I was never still, or at least never inactive, internally or externally,” says Cochran, a professor of counseling at the University of Tennessee. “I had been highly successful being goal directed, but maybe that driven approach to life was beginning to have its limits, and [I] was not fully who I wanted to be. So, I embraced meditation to learn to be still, to learn to quiet my mind, to learn to react to fewer impulses.”

“I look at my meditation time as a counterbalance to my fairly driven, goal-oriented personality,” says Cochran, who presented on meditation and counselor self-awareness and well-being at the 2016 ACA Conference. “It is time set aside each day in which my intent is to be without tasks to check off. Time to simply ‘sit and stare’ while bringing my focus only on a meditation that I have selected [such as] breath counting or watching thoughts. I try to have the mindset that if there is some positive outcome, that’s nice, but whether there is any positive outcome or not, my purpose is served in taking some time to focus the mind away from my work tasks, away from my impulses and racing thoughts — time to just sit with myself.”

Cochran emphasizes that he does not consider himself an expert on mindfulness, but he believes that his personal practice has given him a better sense of balance in his life and also made him a better counselor. He wrote about meditation exercises in the second edition of The Heart of Counseling: Counseling Skills Through Therapeutic Relationships, a book that he co-authored with his wife, Nancy.

“Sitting with one’s own emotions [and] listening to one’s own thoughts without judgment is great training for attending to the emotions and thoughts of another without judgment,” Cochran explains. “Meditation is also about acceptance — learning to accept experience, learning to accept self. I think that sometimes our lack of acceptance of aspects of others stems from areas of the self that are
not accepted.”

Since beginning a regular practice of mindful meditation about 15 years ago, Cochran has noticed other differences in his counseling too. He says he is more at ease with the silences that are a natural part of counseling and better able to sit with the most painful and intense emotions.

“Meditation can help the counselor share the client’s experience as needed without defenses or hesitation, but with a steady awareness of one’s self as separate,” Cochran explains. “Any negative influence from the counselor’s unspoken or unrealized agenda or bias is decreased as the counselor comes to the session with a greater awareness of self, making clearer [those] choices of how best to help and what responses to provide.”

Knapp-Grosz also believes that mindful practices can be a boon to counselors. “We are all super busy as counselors and are managing multiple stressors. Learning simple mindfulness techniques that we can use between sessions or following a stressful meeting helps us with rebounding and, in turn, being more fully present for our next [client].”

In addition to using the exercises that she teaches to college students at her counseling center, Knapp-Grosz has another favorite mindfulness technique that she has dubbed “smelly travel.”

“[It’s] one of my all-time favorites that I try to do whenever I travel,” she says. “I really stop and breathe in the smells around me while looking at the beauty before me. Focusing on the smell helps me to imprint the feelings of relaxation and joy of that moment, and I can recall it by using that smell again in the future to stimulate that relaxation and feeling of peace when I need it. For example, I can return to my favorite Hawaiian beach very vividly by smelling Kona coffee. This is the opposite of what happens in PTSD [posttraumatic stress disorder], where a smell elicits the past traumatic memory. Mindful smelling can be used in powerful ways as a stress reliever and is wonderful for anxiety and depression.”

Knapp-Grosz also touts the benefits of mindfulness practices for stimulating creativity. “Sometimes we need to unplug and take a timeout to get our creative juices going again,” she says. “Mindfulness helps us notice things around us that we have shut out. It brings perspective and a new way of viewing all that is around you. Have you ever noticed that some of your best ideas seem to come at that time just before you fall asleep or when you wake up? This is similar in that mindfulness practices quiet all of that day-to-day chatter that keeps us from being aware of all of the innovations around us.”

Counselor, heal thyself

Working with first responders in his Philadelphia-area practice inspired licensed professional counselor Charles Jacob to begin studying vicarious trauma. “For a lot of folks who see terrible things during their 9-to-5 [jobs], it can be incredibly difficult to leave work and go about daily life as if the world is a normal place,” he says. “So many [clients who were first responders] seemed to have a belief in the world that was, well, pretty jaded and hopeless.”

Jacob, an assistant professor in the counseling and family therapy program at La Salle University in Philadelphia, was particularly interested in how working with trauma affects counselors. “Vicarious trauma isn’t unique to counselors, but counselors who work with traumatized populations are certainly more susceptible,” he observes.

The effects of vicarious trauma can cause changes to counselors’ core beliefs about their work, says Jacob, a member of ACA and president of the Pennsylvania Counseling Association. “For example, if I spend the majority of my time working with victims of sexual assault, I may begin to believe that the world is a cruel and unfair place,” he explains. “I may become fixated on the idea that bad things happen to good people so often that the world is a dangerous place, and safety for myself and the people I love is wishful thinking at best. This cynical worldview can lead to depression, anxiety or a general decreased belief in the goodness of humanity. For these folks, the standard self-care prescription doesn’t seem to work as well. In short, a yoga class will not cause me to change my core belief that people are inherently terrible.”

Curious about whether mindfulness might be a useful intervention, Jacob and Rebecca Holczer, a colleague from La Salle, conducted a research study with a group of counselors who worked primarily with trauma survivors. The participants completed two questionnaires, the Trauma Attachment and Belief Scale, which assesses the presence of vicarious traumatization, and the Cognitive and Affective Mindfulness Scale–Revised, which assesses mindfulness qualities. The results, published in the Journal of the Pennsylvania Counseling Association this past spring, indicate that counselors who are naturally more mindful — meaning inherently better at being more present and aware — are less likely to experience vicarious trauma.

“As best we can figure, the combination of awareness and nonjudgment allows [mindful counselors] to empathize with the client without losing their sense of self,” Jacob says. “They care about the problem when they’re in session, but they let it go and move on afterward. They see the problems the client is experiencing more objectively, but no less compassionately.”

Although being mindful is linked with less vicarious trauma, there is no research on particular practices, says Jacob, who is also a licensed psychologist and licensed marriage and family therapist. “We know that mindful people are less susceptible to vicarious trauma, but we’re still trying to make sense of interventions that directly affect the process,” he says.

Research does, however, link meditation and breathing exercises to stress reduction. With that in mind, Jacob and colleagues gave a presentation at the ACA 2016 Conference & Expo that featured mindfulness exercises that counselor practitioners can use to help guard against vicarious trauma.

“In our presentation, we talked about the use of meditation before sessions. The idea here is to reduce the experience of anxiety during the traumatic event [hearing a client’s story that the counselor finds traumatizing] to alter the emotional aspect of the memory of trauma so that it causes less stress later on — similar to the use of beta blockers in the treatment of PTSD.”

“For example,” he explains, “a counselor who meditates for 10 minutes before what they perceive to be a stressful session would hopefully go into the meeting with a reduced heart rate, blood pressure, etc. When presented with a troubling client narrative, there’s a better chance [the counselor] might feel less stress and distress, and have a reduced chance of vicarious trauma, [because] they will remember the event later on as being less stressful.”

The meditation practice requires just 10 minutes at the beginning of the day, Jacob says. He recommends that counselors use a mat on the floor or sit in a chair comfortably, set a timer for 10 minutes and then sit silently and motionless while mentally repeating a personal mantra that syncs with slow, controlled breathing. “Focus only on remaining still, breathing, repeating your mantra and staying focused and present,” Jacob emphasizes.

Jacob and his colleagues also presented a breathing exercise that counselors can use themselves in session. “The basic idea here is that exposure to trauma causes the sympathetic nervous system to kick in,” Jacob explains. “Your heart rate and blood pressure go up and your breathing becomes rapid and shallow. … You can’t control your heart rate, blood pressure or any of those other pesky automatic responses … but you can control your breathing.”

Jacob describes the exercise as a fairly uncomplicated method of slowing down the breathing and holding enough oxygen in the lungs long enough to do good things in the body. “The other plus to this exercise: It’s simple enough for you to do it in front of someone and not look insane,” he says with a laugh.

“In the event that a client begins recounting a trauma that is particularly troublesome for you, first continue focusing on what the client is saying,” Jacob directs. “Then use a slow, controlled breath to inhale through your nostrils until your lungs reach their full capacity — a process that takes about 10 seconds. Hold this breath for approximately one second, and then begin the process of slowly exhaling through a small parting of the lips — no bigger than the diameter of a coffee straw — for the duration of about 20 to 30 seconds. You should notice nothing amazing really … just a slight decrease in heart rate and blood pressure such that the physiological response of anxiety is less and the ability to be aware and present is easier to access.”

Jacob says an additional impetus for his research was his concern that the phrase “self-care” has been getting a little too nebulous in the counseling profession. “We talk about it very generally and very often, but I find that this doesn’t usually provide much direct guidance for struggling clinicians. I really think that making efforts to think and practice differently is our best bet at keeping clinicians safe, healthy and happy.”

 

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Additional resources

To learn more about the topics addressed in this article, take advantage of the following select resources offered by the American Counseling Association:

Journal articles (counseling.org/publications/counseling-journals)

  • “Mind The Gaps: Are Conclusions About Mindfulness Entirely Conclusive?” by Adam W. Hanley, Neil Abell, Debra S. Osborn, Alysia D. Roehrig & Angela I. Canto, Journal of Counseling & Development, January 2016
  • “Effect of a Mindfulness-Based Intervention on Counselor-Client Attunement” by Stefani A. Schomaker & Richard J. Ricard, Journal of Counseling & Development, October 2015
  • “Mindfulness-Based Awareness and Compassion: Predictors of Counselor Empathy and Anxiety” by Cheryl L. Fulton & Craig S. Cashwell, Counselor Education and Supervision, June 2015
  • “Mindfulness-Based Interventions in Counseling” by Amanda P. Brown, Andre Marquis & Douglas A. Guiffrida, Journal of Counseling & Development, January 2013

Book (counseling.org/bookstore)

  • Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice, second edition, edited by Craig S. Cashwell & J. Scott Young

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The Counseling Connoisseur: Mini-mindfulness moments

By Cheryl Fisher November 17, 2016

I wake up in the early morning to the sound of birds chirping delightfully outside my window. I quietly make my way to my yoga room, where the gentle flow of the tabletop waterfall cascades rhythmically, inviting me to my morning meditation. I inhale deeply, letting the stream of thoughts flowing in my mind pass gracefully in and out of consciousness. I then exhale any tension or tightness my body may be holding as I sit in my deep meditation for a delicious 40 minutes.

BEEP BEEP BEEP! The sound of my alarm wakes me from my dream. I roll out of bed, grab my robe and fumble to let the dogs out, stubbing my toe along the way. Following a few expletives, I scoop the dog food into the metal bowls, toss them to the floor and make my way to the steaming shower that must quickly wash away the lingering fog from my still-sleepy brain.

I jump into my clothes, paint on some semblance of a face and pull up my hair. I grab a glass of juice, a packet of instant oatmeal and a yogurt, which will serve as my breakfast and lunch when I make it to the office. I secure the dogs and (as I exit the house) take a deep breath (holding it for the required four seconds), offer a blessing for the day on the exhale and haul it to my Jeep because I am now five minutes late for work!

Research continues to remind us of the role of mindfulness in our experience of overall wellness. Yet, a culture of “busy” permeates, sabotaging earnest attempts at a peace-filled, mindful lifestyle. Jon Kabat-Zinn, in his groundbreaking book Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness, writes, “There is something about the cultivation of mindfulness that is healing, that is transformative and that can serve to give our lives back to us.”

A practice of mindfulness extends beyond the individual practitioner and benefits those who surround her or him. Thich Nhat Hanh, Buddhist monk and author of many books, including Planting Seeds: Practicing Mindfulness With Children, offers, “When you are solid, happy and full of photo-1478980236323-01c287f81aedcompassion, you will naturally know how to create a happy family or school environment, and how to water the positive qualities in your children, other family members, students and colleagues at work.”

Although most of us would agree that this sounds divine and long to attain a lifestyle that promotes full presence, many of us struggle with the basic logistics of beginning a mindfulness practice. To devote the suggested 40 minutes a day to meditation would require many of us to eliminate sleep. I am a huge advocate for daily meditation, but I find that a 20-minute practice following my hour at the gym is about all I can devote to it daily. However, there are numerous ways that we can create moments of mindfulness throughout our day.

1) Add intention to routine activities. Routine activities can take on contemplative practice when we set our intention on being fully present in the moment. Walking the dogs, making the bed, even emptying the dishwasher can become moments of mindfulness (if we put the distractions of our phones away). For example, a morning shower is filled with sensory experiences if we allow ourselves to be present to the sensations of the water cascading down the body. We can use that time to do a body scan and note where tension is being held, then allow the warm water to release the tightness and relax our muscles.

2) Breathe through the mundane. Traffic lights are notorious stressors. We can, however, repurpose those few minutes by taking deep breaths, setting aside our agenda for the day, turning off the radio and becoming fully present in our bodies.

3) Seek consciousness through coloring. Adult coloring books have become the latest craze because they allow the individual to focus on a single task. The activity incorporates creativity and color and allows for a few moments of relaxed consciousness. Grab a book and color during breaks at work.

4) Practice jigsaw meditation. Jigsaw puzzles are another way to promote a focused meditation. Dollar stores carry small puzzles that can be placed in break rooms at work, promoting collective consciousness with colleagues. Taking a few quiet moments to focus on this task may be just what the doctor ordered to relieve stress during the day.

5) Delve into devotion moments. Opening a book with inspirational quotes can offer moments of reflection and contemplation. My recent favorite such book, The Meaning of Life by Bradley Trevor Greive, provides brief reflections captured in combination with precious pictures of animals.

6) Make time for teatime. Taking a break for a cuppa tea has long been one of my favorite routines. Tea has been a staple in China for centuries, first being used for medicinal reasons and later for more social purposes. British afternoon tea was offered to break up the extremely long time between breakfast and the fashionably late dinner, which were the only two meals served. Still, a good cup of tea in the afternoon can provide a soothing, fragrant mini-escape from a stressful day.

7) Embrace the Zen of nature. Years ago, I purchased a mini-Zen garden, filled with sand and miniature rocks, for my office. I use a small rake and create swirls and twirls in the sand as I release the tension of the day. I know other colleagues who enjoy the art of bonsai and trim their tiny trees during breaks. Nature is a sacred space that connects with us in meaningful ways. Gardening, taking nature walks, watching a sunrise or sunset — just being present to the outdoors can significantly reduce our stress levels.

8) Blow bubbles. Bubble therapy is one of my personal favorites. It requires one to take a deep breath and skillfully exhale in a way that will not burst the bubble. After a particularly stressful day, I like to take my huge bubble bottle outside and blow to my heart’s content.

9) Make a gratitude list. Counting our blessings appears to offer not only moments of mindfulness but also a shift in brain chemistry. Taking time to reflect on that for which we are grateful can promote an immediate reduction in the experience of external stressors — and the effects can linger long after the moment has dissipated.

10) Connect with others. Animals can provide connection and comfort in the most primal way. For me, watching goldfish pop to the surface during feeding and then swim gracefully among the miniatures in the bowl is therapeutic. However, few things beat a cuddle (and a good tummy rub) with my two 65-pound dogs. We all huddle together and enjoy the connection between human and animal. Of course, although I love my canine cuddles, my ultimate is simply sitting quietly and hugging my spouse for a few moments.

Armed with a handful of ways to incorporate moments of mindfulness, take a deep breath, exhale and enjoy being present in your day.

 

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Cheryl Fisher

Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland, and a visiting full-time faculty member in the pastoral counseling program at Loyola University Maryland. Her current research is titled “Sex, Spirituality and Stage III Breast Cancer.” She is also writing a book, Homegrown Psychotherapy: Scientifically Based Organic Practices, that speaks to nature-informed wisdom. Contact her at cy.fisher@verizon.net.

 

 

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.