Tag Archives: mindfulness

Differentiation of self through the lens of mindfulness

By Kevin Foose and Maria Cicio February 7, 2018

A few years ago, while teaching a course in family therapy, a particularly bright and insightful student named Maria lingered after class one day and asked, “Isn’t differentiation of self similar to mindfulness?” I hadn’t quite thought of it like that before, but it certainly seemed plausible. “Let’s set aside some time to talk,” I suggested. With that single question began many months of conversations.

In 2015, a continuation of those hours of exploration transformed into an “anti-presentation” that was awarded “Best of Show” at the Louisiana Counseling Association Annual Conference. The examination continued the following spring at the American Counseling Association Conference & Expo in Montréal. In the end, it was inquiry rather than answers that animated our informal lyceum. Quest and question are born of a common root. And teaching is thin soup if only the student grows. The current work is an attempt to extend the spirit and tone of those many fruitful hours of meeting.

Attempting to define differentiation

Differentiation of self (DoS), since first being introduced by Murray Bowen in the early years of the family therapy movement, has remained a lofty, elusive and often misunderstood concept. As Bowen’s colleague, Michael Kerr, pointed out, differentiation contains so many unique conceptual facets that it defies simple definition.

Bowen himself, persistently mystified by the consistent misinterpretation of differentiation, noted late in his life in one of his more cantankerous moments that he wished he’d never “discovered” it in the first place. Anthropologist Gregory Bateson once said of Charles Darwin that he didn’t discover evolution, he made it up. The same may be said of DoS. Viewed through this lens, DoS becomes a story (the point of which is to communicate its creator’s intent) steeped in a deep faith in science and the relatively recent emergence of the Western nuclear family.

If we are to accept the premise that differentiation does indeed defy simple definition, or at the very least is so subtle and nuanced that it is open to numerous interpretations, the initial question that emerges is: What in the world are we actually talking about when we talk about differentiation?

Michael Cowen, one of my colleagues at Loyola University New Orleans, provides a useful foundation from which to launch this conceptual ship with his interpretation of differentiation as “the capacity to be aware of one’s own unique pattern of feeling, valuing and thinking, and to decide and act in ways that remain faithful to that awareness.” Cowen’s definition shifts the focus of differentiation away from some thing that one is or has or even does, toward a description of understanding and action. It is a process that, at its core, allows individuals to make distinctions between thoughts and feelings and to remain calm in highly emotional situations. It is the ability to be both a part of and apart from significant relationships, and it places a high premium on the ability to behave rationally. It is not, however, a call for a Spock-like hyper-rationality nor a ringing endorsement of the ruggedly individualistic American mythology.

For the sake of moving forward with consensus, nebulous as it may be, I (Kevin) am inclined to give Bowen the final say in the construction of a working definition of differentiation as “a way of thinking that translates into a way of being.” So the story goes.

If that description of differentiation is to be accepted, the question then becomes, how is one to cultivate such “a way of thinking?” And who might act as a reliable translator? This is the point at which the teaching of the Buddha, in general, and mindfulness, specifically, can offer a helpful perspective from which to view perceptions and human experience.

At first glance, Bowen and Buddha may seem to be a strange pairing. After all, Bowen’s search for understanding led him back to the tumult of his family of origin, whereas Buddha left home seeking transcendence and never returned. Logistically, Buddha’s eightfold path provides a different road map toward liberation and understanding than does Bowen’s eight interlocking theoretical concepts. But the wisdom gained beneath the Bodhi tree may not be as divergent from the family tree as one might think. When differentiation is examined through the prism of mindfulness, significant conceptual convergences begin to emerge. The potential implications for personal growth, insight and clinical practice merit a pause, perhaps a deep breath, and further contemplation.

Mindfulness

Mindfulness is essentially the act of being present. Anchored in continuous awareness of each emerging moment, it is the cultivation of a calm, dispassionate state in which experience can be examined with acceptance and nonjudgment. Mindfulness, not unlike DoS, is a process that provides the possibility of escaping the trappings of emotional reactivity.

In an excellent article examining mindfulness (“Mindfulness: A Proposed Operational Definition” in the September 2004 issue of Clinical Psychology: Science and Practice), a group of Canadian academics, led by Scott R. Bishop, pointed out that the insight that emerges through disciplined contemplative practice creates an open “space between one’s perception and response, ultimately making it possible to respond and interact more reflectively (as opposed to reflexively).” Rather than becoming tangled up in “ruminative, elaborative thought streams about one’s experience and its origins, implications and associations, mindfulness involves a direct experience of events in the mind and body,” wrote Bishop and his colleagues

In other words, we are able to stay tethered in the present, experiencing our life with courage and composure as it actually unfolds in our midst. In this awakened state, our mind is freed from anger, attachment to desire and misperception. Providing an alternative to being swept away in a flood of emotionality and elaborate misinterpretation, we are able to resist the urge to flee into ideations of the imagined future clouded by the residue of the past, or compulsively bend reality to meet idiosyncratic needs.

Mindfulness is the antidote to fear, confusion and anxiety. It is a practice and process that tethers us to the immediacy of our lives with the insight to see “relationships between thoughts, feelings and actions and to discern the meaning and causes of experience and behavior” (as described in “Mindfulness: A Proposed Operational Definition”). Essentially, mindfulness cultivates the ability to interact rather than react.

The greatest hurdle in defining a self or sustaining mindful attention is emotional reactivity. When emotions escalate beyond a critical threshold, a state of mind emerges in which rational thinking evaporates and agitation hijacks the cognitive process. It is impossible to differentiate in such an agitated state. We become prisoners to automatic emotional responses saturated in fear.

Buddha referred to this reactive state as “monkey mind,” in which fear becomes much like a loud, drunken monkey frantically screeching the alarm bells of danger in our brains. The ability to quickly regain composure and quiet the monkey mind is the cornerstone of both differentiation and mindfulness.

The quiet mind is fertile ground for exploring what Buddha called “store consciousness.” Long before Sigmund Freud proposed his theory of the unconscious (again, see Bateson above) or Bowen began his examination of psychobiological cognitive-emotional processes, Buddha was wandering about preaching the Dharma, teaching practices aimed at liberating people from misperception and attachment to mental formations that seemed to be just beyond the reach of everyday awareness.

Vietnamese Buddhist monk Thich Nhat Hanh writes in the introduction of Cultivating the Mind of Love: “In our store consciousness are buried all the seeds, representing everything we have ever done, experienced or perceived. When a seed is watered, it manifests in our mind consciousness. … The work of meditation is to cultivate the garden of our store consciousness.”

Getting back into harmony with our lives

Whatever we “attend” to will grow. And what we don’t attend to will tend to grow out of control without insight into content and coping strategies buried deep in our store consciousness. For multigenerational family systems theory, the seeds in the soil are the early experiences in the family of origin. Differentiation allows for a bit of psychic “weeding” to occur so that intimacy and integrity may grow.

Buddha, too, was attuned to the influence that family members have on one another. Perhaps more poetic, but no less prophetic, a Buddhist teaching examines the importance of the emotional climate of filial bonds, invoking the image of the garden again: “A family is a place where minds come in contact with one another. If these minds love one another, the home will be as beautiful as a flower garden. But if these minds get out of harmony with one another, it is like a storm that plays havoc with the garden.”

It is precisely in those moments when one finds oneself in the “I” of the storm where mindful intention allows the well-differentiated self to stay calm and sift through frenetic cognition that often causes impairment in our lives. The ability to sit in the midst of the tempest and remain present, self-aware and in close emotional contact with others is the essence of what Soto Zen monk Shunryu Suzuki calls “imperturbable composure.”

The well-differentiated self exhibits radical acceptance to what Jon Kabat-Zinn calls the “full catastrophe of living.” In this way, we remain open and curious to the actual events of our lives as they unfold, freeing ourselves from endless cycles of suffering and automatic reactivity. Whether we call this mindfulness or differentiation becomes an exercise in semantics.

Through work and practice, we become available to the full reality of our lives, with the insight and courage to quietly slip through the cracks of our conditioning and allow our ego-cramped consciousness to release its grip on our battered psyche. Quite simply, DoS and mindfulness bring us back into harmony with our lives.

For Buddha, the ultimate act of enlightenment is to wake up. The Dharma teaches that it is possible for any of us to awaken at any moment in our lives. Much like achieving a fully mindful present state, people often find embarking on the path of defining a self to be a daunting task.

Bowen was clear and consistent in his insistence that the fully differentiated self is a theoretical concept that is practically unattainable. It is a guiding light rather than prescription. However, with much work and practice, it is possible to increase one’s level of differentiation. Bowen pointed out that if we can “control the anxiety and the reactiveness to anxiety, the functional level will improve.” The task at hand becomes “getting beyond anger and blaming to a level of objectivity that is far more than an intellectual activity. … The overall goal is to be constantly in contact” with emotional issues involving ourselves and others.

A common thread

Although Bowen and Buddha’s conceptualization of the “self” superficially seems to be the point at which the Venn in the Zen between DoS and mindfulness begins to diverge, it is through interdependence that the deepest synthesis actually occurs. Whether one adopts a scientific or a spiritual perspective, the influence that each of us has upon the other is the thread that ties mindfulness and differentiation together.

Bowen was certain that the self exists. Buddha sent his disciples out into the world in search of the self and sat patiently waiting for the report back. Ralph Waldo Emerson, with his ever-present, transcendental wisdom, offered this: “All that is said of the wise man by Stoic or Oriental or modern essayist … describes his unattained but attainable self.”

Both Buddha’s and Bowen’s philosophical views were undergirded by a belief in the profound effect that each of us has upon one another. Bowen believed that successfully differentiating oneself within the system could have significant influence on all others in that system. He noted that if one is able to successfully define a solid sense of self and defend against requests from others to change back to old ways of being, then the entire system can catapult forward into higher levels of functioning.

The Dharma teaches that when one is awakened with compassion and wisdom, all are touched by the light. In Cultivating the Mind of Love, Hanh examines Buddha’s teachings, exploring the ways in which the Dharma opens each of us to the possibility of deeper understanding and more intimate connection. In his introduction, Hanh invites us to become fully present, and “the rain of the Dharma will water the deepest seeds of your store consciousness. If the seed of understanding is watered … the fruits of love and understanding will grow.”

Examining the teaching of interbeing and the delusion of separateness falsely constructed in the mind, Hanh concludes: “We must vow to practice for everyone, not just for ourselves. … Because of our ignorance and habit energies, we usually perceive things incorrectly. We are caught in our mental categories, especially our notions of self, person, living being and life span. We discriminate between self and nonself. … When we see things this way, our behavior will be based on wrong perceptions. Our mind is like a sword cutting reality into pieces, and then we act as though each piece of reality is independent from other pieces. If we look deeply, we will remove these barriers between our mental categories and see the one in the many and the many in the one, which is the true nature of interbeing. … Everything is touching everything else. … To bring relief to one person is to bring relief to everyone, including ourselves. This insight brings about the kinds of actions that are truly helpful.”

These are hopeful thoughts for troubled times. What is called for in this moment, if one is to view differentiation through the lens of mindfulness, is a “way of thinking that translates into a way of being in the world” that accurately perceives the deep connection that we have with the world surrounding us and the profound effect that each of us has upon one another. So the story goes.

Compassionate listening

Counseling is a reciprocal process of story and interpretation. As a conversational intervention, much attention has been given to the narrative telling of the tale — the “talk” in talk therapy. Often lost in the reciprocity is the transformative power of listening. As Hanh points out, when we listen to another deeply and compassionately, we help that person to suffer less. “One hour like that can bring transformation and healing,” he teaches.

If listening in this way does indeed, as we believe, lead to the alleviation of suffering, the question becomes, how does one engage in the process of compassionate listening?

The calm that accompanies the differentiated self, and a mindful stance tethered in the present, provide a helpful perspective from which to enter into another’s story. It allows one to avoid judgment without abandoning discernment and concern. This way of being allows the counselor to bear witness to the tumultuous content of clients’ troubled narratives without becoming overwhelmed. We can tolerate intense emotion without needing to flee for safety and care without getting carried away.

Deep listening contains the seeds of empathy. The calm that accompanies a well-differentiated presence opens up the space to create the distance necessary to examine problem-saturated narratives. The practice of active listening artfully folds the story continuously back upon itself, returning the client to present-moment awareness. The acceptance that accompanies awareness invites the client to slow down, resist the impulse to avoid the suffering and instead examine the story with compassion. The wisdom to accept that which is beyond our control paradoxically generates the flexibility necessary for transformation to occur.

Pragmatically speaking, compassionate listening is rooted in language. To listen in this manner, it is essential to remain firmly planted in the present, gathering content without getting lost in the labyrinth of past suffering or anxious projections of the future. When listening to stories of suffering, it can be easy to lose sight of the fact that the actual experience is the retelling of the tale here and now, not what occurred there and then. It is imperative to honor our clients’ suffering while also uncovering their strength.

The task is to attend to the content of the client’s story while staying deeply connected to the person. Listening in this way allows us to wonder what the client is trying to communicate about his or her struggle through the story. What meaning is seeking to be understood? What are the relational and emotional elements recurring in the client’s words? Compassionate listening is the conduit into the deepest sense of clients’ experiences. It asks, how can we be present to the struggle and help our clients confront the frustrating and most frightening moments of their lives?

At its core, compassionate listening holds the therapeutic space. It widens the client’s interpretation just a bit. It uses the client’s language, symbols and metaphors. It sees as well as hears, deconstructing the story, searching the margins for what has been edited out, pulling the thread of seemingly disjointed pieces and reflecting it back in recognizable form. This way of listening is ultimately a path toward healing that allows for safe passage through suffering. As American Buddhist nun Pema Chödrön points out, mindfulness allows us to choose an alternative course for our lives. A process such as DoS requires us to first notice the true nature of our experience, then disrupt our habitual patterns and do things differently and, finally, practice again and again, one moment at a time.

A client suffers and a change is necessary. The struggle often comes with not knowing how to manifest a healthy change. The client has likely been avoiding, wrestling with and running away from anxiety for years, creating deeply ingrained habits. In the space created by deep listening, the client can experience something different. Clients may be able to look at their anxiety for the first time with compassion and understanding. The paradox is that once they are able to sit with their struggle instead of avoiding it, anxiety loosens its grip on their lives.

DoS, viewed through the lens of mindfulness, creates the clarity and compassion for transformation to occur. Mindfulness aids in the process by creating awareness of our mind-body interaction so that we can become more skillful in our interpersonal, and intrapersonal, relationship(s).

Just as the counseling process makes space for emotions, thoughts, ideas and stories in session, mindfulness creates a similar space for our internal experience to occur. This is the “deep listening” to our own process. Mindful awareness allows for attunement, not only with our clients but with ourselves. It creates systemic and intrapsychic awareness to the ways that we get hooked into metanarratives and mental confines. Emotions no longer run amok, and we are available to be in relationship with others. As clinicians, we must first listen deeply to the mystery and history of our own stories before making contact with someone else’s.

The Beat Zen of Richard Brautigan leads us to a quiet place to begin in his poem “Karma Repair Kit: Items 1-4”:

1. Get enough food to eat,/ and eat it.

2. Find a place to sleep where it is quiet,/ and sleep there.

3. Reduce intellectual and emotional noise/ until you arrive at the silence of yourself,/ and listen to it.

4. ???

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Kevin Foose is an assistant professor in the Department of Counseling at Loyola University New Orleans. He maintains a private practice that focuses on couples and adult individuals. Contact him at kjfoose@loyno.edu.

Maria Cicio is a graduate of the Loyola University New Orleans master’s in counseling program, class of 2015. A licensed professional counselor, she is currently working in community mental health in rural Oklahoma.

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.

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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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.

 

Integrating mindfulness interventions in counseling courses

By Allison Buller October 2, 2017

As a professor of counseling, I am invested in helping students develop the necessary and sufficient skills to become effective psychotherapists. There is a plethora of evidence to support mindfulness as a tool for fostering these skills. Integrating mindfulness training can:

  • Improve how counselors-in-training relate to self and others with more acceptance, genuineness and empathy
  • Help counseling students develop a deeper connection to clients’ experiences and be more present to clients’ suffering
  • Help decrease stress, negative affect, rumination, and state and trait anxiety, and increase positive affect and self-compassion
  • Help students become more aware, patient, mentally focused, empathic, compassionate, attentive, responsive and able to handle strong emotions
  • Help students cultivate therapeutic presence

With all of the good data to support mindfulness in counselor education, I chose to describe a few of my favorite mindful interventions and how I implement them in my counseling courses.

 

Mindfulness interventions

Breathing techniques and guided mindfulness practices are among the key interventions I include in all of my counseling classes. The interventions are secular; therefore, I do not use terminology that would be considered religious or unusual for the university context. I ask students to close their eyes while I guide them through a mindfulness practice of attending to a specific focus for several minutes, such as paying attention to each breath or sending out positive energy to self or others (i.e., stress breath and compassion meditation).

The movement, breathing and mindfulness components of the class are designed to enhance the students’ capacities for sustained attention, promoting greater awareness of cognitive, physiologic and bodily states and how to regulate those states. In addition, I include a brief period of discussion prior to the guided mindfulness practice in which I offer didactic information about such topics as identifying stressful events, using mindfulness techniques to respond to difficult people, cultivating positive relationships with others and keeping one’s mind and body healthy. This information is often woven into subsequent guided mindfulness practices (e.g., using the breath to relax if something stressful has happened). Students are encouraged to practice these skills outside of class and reflect on their experiences in writing.

I often receive positive feedback from students participating in mindfulness practice. Among the reflections I have received are:

  • “I felt relaxed.”
  • “Calming … I wish we could do this every time.”
  • “Tired in a good way.”
  • “It helped me to feel something different.”

In some cases, students may experience open displays of emotion during meditation (i.e., crying, runny nose, shortness of breath). The generalizability for students happens when they can use these techniques outside of class time. Examples reflected by students using the stress breath technique include:

  • “I used it before seeing my client”
  • “I use it all the time now”
  • “I never knew I didn’t know how to breathe!”
  • “I catch myself using it before tests or presentations.”

Many students acknowledged that the “stress breath” was one of the most useful interventions they learned in class.

Although the majority of student reflections have been positive, some students struggle with the concept of mindfulness:

  • “I don’t know how to clear my mind.”
  • “How do I stop thinking?”
  • “I can’t think about nothing.”

Comments such as these need to be explored, and extended discussions on barriers to mindfulness can offer clarification. Before every practice, I give students the option to “pass or play,” meaning they can choose whether to participate in the mindfulness activity. If they chose not to participate, they are asked to sit and engage in a quiet activity.

 

Integrating mindfulness training

One of the biggest challenges I face in implementing mindfulness training is believing in myself as an experienced practitioner and qualified teacher. Although I have practiced mindful meditation for almost a decade, I am not certificated in yoga or meditation. For all intents and purposes, I am an ordinary professor with a personal practice.

The majority of researchers and practitioners agree that teaching mindfulness requires a dedicated personal practice. In fact, Jon Kabat-Zinn advised, “Don’t turn mindfulness into a commodity.” He believes that mindfulness needs to become a way of life, not just a skill, an intervention or an outlook.

In a 2012 article (“Teaching mindfulness to create effective counselors”) for the Journal of Mental Health Counseling, Jennifer Campbell and John Christopher described it as the sort of teaching that cannot be done from a manual. Instructors must be able to dive deep and connect with themselves through a kind of altered state. The authors recommended that those who do not yet have years of personal experience co-teach with experienced meditation teachers.

Another challenge is finding time during class or in the curriculum for mindfulness training. Time constraints and the pressure to cover course material is an ongoing concern in higher education. At times, implementing mindfulness practice can feel like an indulgence or an overwhelming addition rather than a useful tool. Taking time to implement mindfulness requires discipline and planning. I chose specific times throughout the semester to implement mindfulness training (i.e., before role-play activities, midsemester wellness day, finals week). Every course is different, and the needs of the students vary. Choose what works best for you.

The greatest challenge and best motivator for implementing mindfulness is helping students understand how mindfulness can be used to manage emotional reactivity. Incorporating research literature to support mindfulness as a tool for emotional and mental health is necessary to gain students’ trust. Mainstream information about mindfulness can be overwhelming and confusing. My job as a professor is to clarify the facts and demonstrate the tools.

 

Take-home lessons

I choose to incorporate mindfulness practice in my courses based on positive outcomes relevant in the literature. Many of the students in my counseling courses have never practiced mindfulness or had any training on how to breathe. I find it both humbling and exciting to introduce this practice to students. I am humbled to share the art of meditation and excited to introduce mindfulness to students for the first time. The insights and changes that come with studying and practicing mindfulness carry over into life and work.

My self-efficacy as a mindfulness educator stunted my motivation and confidence to do this kind of work. I erroneously believed that I lacked the qualifications and information required to help others learn to meditate. In essence, I was standing in my own way. Therefore, I conclude this article by appealing to the reader for brazen courage. If implementing mindfulness practice is your intended goal, commit to your own practice, align with like-minded and experienced faculty, and get out of your own way.

 

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Allison Buller is a licensed professional counselor and an assistant professor of counseling and psychology in the Department of Arts and Sciences at the University of Bridgeport. She is also a staff counselor for the university’s counseling center. Contact her at abuller@bridgeport.edu.

 

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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.

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.