3 Ways to Bring Mindfulness Into Therapy

More and more therapists are integrating moment-to-moment awareness into their practice. Here's why—and how.

By Susan M. Pollak, Ronald D. Siegel, Thomas Pedulla

Mindfulness is now the fastest-developing area in mental health.

Many therapists have come to regard cultivating moment-to-moment awareness as a curative mechanism that transcends diagnosis, addresses underlying causes of suffering, and serves as an active ingredient in most effective psychotherapies. The clinical value of mindfulness interventions has been demonstrated for many psychological difficulties, including depression, anxiety, chronic pain, substance abuse, insomnia, and obsessive-compulsive disorder.

And it doesn’t matter which therapeutic approach we take, be it psychodynamic, cognitive-behavioral, humanistic, or any other. Mindfulness practices can be tailored to fit the particular needs of our patients. Though historically mindfulness practices have been presented as one-size-fits-all remedies, as the field matures we’re beginning to understand how these practices affect different individuals with different problems, how to modify them in different clinical situations, and how to work with the inevitable obstacles that arise.

Mindfulness can also enhance emotional well-being of clinicians, helping us develop beneficial therapeutic qualities such as acceptance, attention, compassion, equanimity, and presence that enrich and enliven our work and help us avoid burnout. Once we have developed these qualities in ourselves, we can safely and thoughtfully introduce our patients to practices that lead to a wide variety of clinical benefits.

Here are a few ways that mindfulness can benefit a therapy situation, drawn from our new book, Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy.

1. Mindfulness can be a refuge for the therapist

In the practice of mindfulness, we bring attention to our experience in the present moment. We let go of our regrets and rumination about the past, or our worries about the future, and return our attention to what is happening right now. We start by focusing on the sounds in the room, the sensations of the breath, or the feeling of sitting in a chair with our feet touching the floor. As we develop this skill of being open to and accepting of whatever is emerging, we become more present in our experience and that of others. As we become less distracted and preoccupied with our own concerns, we can listen more fully.

Recent research shows that therapists who practice mindfulness meditation enjoy a variety of benefits with no apparent negative effects. These include a decrease in perceived job stress and burnout, as well as an increase in self-acceptance, self-compassion, and sense of well-being. In addition, clinicians have reported improvements in their relationships with their patients, saying they had a greater capacity for empathy, and experienced an increased ability to be present without being defensive or reactive.

You might be thinking that you are too busy to bring formal mindfulness practice into your clinical day. But even in the busiest clinical settings on the craziest days, there’s always a chance to practice informally. One of our favorite practices can be done before greeting your next patient. It is called “Two Feet, One Breath.” In this practice, you take a moment to pause, feel both feet on the floor, and then feel your inhalation and your exhalation. A simple intervention such as this only takes a moment and can help you center, come into the present moment, and connect with your patient.

As you develop your practice, you’ll become more familiar with what we call “anchors,” places to which you return your attention when the mind has wandered. It’s like coming home after you’ve been away. The anchor offers a sense of safety and comfort. It can also be invaluable during a difficult clinical situation.

Let’s say you’re sitting with a patient who’s angry with you, or who confesses he’s been planning suicide. You find yourself feeling anxious, afraid, or confused. You notice that you begin to clench your jaw and tighten your fists. Your shoulders rise toward your ears. You wonder what to do. Before formulating a response, you could try pausing for a moment to return to your breath, the sensations of sitting, or the sounds in the room. Or, you can silently say to yourself, May we both be well. May we both be free from suffering. May we both live in wisdom and compassion.

Connecting with your breath or your compassionate intention gives you a chance to pause, to come back into the present moment, to dispel the clouds of fear and confusion, and to let your innate wisdom inform what you do next.

2. Mindfulness can deepen the therapeutic relationship

Current studies suggest that in successful treatment alliances, therapists are perceived as warm, understanding, and accepting, approaching their patients with an open, collaborative attitude. Mindfulness can help us develop these qualities.

The foundational skill in mindfulness meditation of concentration or focused attention can be very useful in the therapy hour, where so many factors can cause the mind to wander—for example, when the content of the session threatens us, or an outside worry distracts us, or the patient becomes disengaged, making his or her words less compelling, or we just get tired. Without mindfulness training, we may try to maintain attention by turning up the intensity or volume in order to keep things “interesting.” Through mindfulness practice, we instead learn how to turn up our attention, to practice presence independent of content, to bring our wholehearted attention to whatever is happening.

Of the many factors that interfere with attention during therapy, one of the most challenging is the arousal of powerful and painful feelings. Most patients discuss difficult experiences of illness, loss, failure, and disappointment. Unless we’re very good at denial, we realize that these misfortunes could easily befall us or our loved ones. Or, we may find ourselves overwhelmed by the pain and sadness we experience simply because we empathize with our patients.

Mindfulness practices can be powerful tools to increase our tolerance for painful emotions, enhancing our ability to remain attentive while sitting with suffering. This is important for a strong alliance, because our patients usually express only those feelings they believe we can tolerate hearing. On the other hand, if we’re able to be with a fuller range of experience, this will help our patients do the same.

Many people are surprised by what happens when they bring attention to physical discomforts in this way. Often they notice that pain sensations are not solid, but pulse and change from moment to moment, and sometimes pass without any special action on our part.

By practicing being with discomfort during this concentration practice, we can gradually become better able to tolerate pain of all sorts, including the pain of difficult emotions. We can step back, seeing our thoughts and feelings as just thoughts and feelings, not as facts. Instead of getting lost in our perspective, we can redirect our attention to the patient and what is unfolding in the present moment.

3. Mindfulness can be a tool for our patients

How can we make mindfulness accessible to the widest possible range of patients? What are some of the challenges that arise and how do we respond to them skillfully?

To help skeptical folks engage with a particular practice, try presenting it as an experiment, suggesting that others in similar circumstances have found it to be useful. Depending on the situation, it can be useful to share information from research studies and possibly your personal experience with the practice. We suggest keeping it short, no longer than three to five minutes, and then ask for a status report by asking, “What are you noticing?”

Feedback is useful in helping adapt or modify the practices for your patients. For example, when they say, “This isn’t working—I can’t get my thoughts to stop,” you’ll want to educate them that mindfulness isn’t about stopping thoughts, but coming into a kinder and more accepting relationship with them. If, however, someone reports, “This was really creepy. I had this image of my father standing over bed when I was a little girl,” you may want to modify the practice or set it aside for the time being and try a different approach.

Especially for those who have a history of trauma, we suggest starting with a meditation like the one above that focuses on sound and being present, rather than following the breath, which can be a trigger for trauma survivors. Our goal in introducing mindfulness practices to patients is not to turn them all into dedicated meditation practitioners, but to help them find balance, kindness, and fulfillment in their lives. When research shows that even a taste of mindfulness can help, we owe it to our patients (and ourselves) to learn the practices and pass them on.

A practice for therapists

1. Start by sitting comfortably, with your back straight and eyes either softly open or closed.

2. Notice that you are breathing and feel the sensations of the breath.

3. If your mind wanders, no problem; just gently bring your attention back to the breath. After following the breath for a few minutes, see if you can locate any discomfort, perhaps an itch or an ache.

4. Instead of automatically shifting to relieve the ache, or scratching the itch, bring your full attention to the discomfort. Notice its texture, and how it changes moment to moment.

5. Stay with the sensations of discomfort as long as you can. Experiment with staying with them for a while.

6. After attending to the discomfort for several minutes, return your attention to the sensations of the breath.

For free downloadable meditations, go to sittingtogether.com.

Susan M. Pollak, MTS, EdD, is Clinical Instructor in Psychology at Harvard Medical School, Cambridge Health Alliance, where she has taught and supervised since the mid-1990s. Thomas Pedulla, LICSW, is a clinical social worker and psychotherapist in private practice in Arlington, Massachusetts, where he works with individuals and leads mindfulness-based cognitive therapy groups. Ronald D. Siegel, PsyD, is Assistant Clinical Professor of Psychology at Harvard Medical School, Cambridge Health Alliance, where he has taught since the early 1980s.

This essay is adapted from Sitting Together: Essential Skills for Mindfulness-Based Psychotherapy. This article originally appeared on Greater Good, the online magazine of UC Berkeley's Greater Good Science Center as part of their Mindful Mondays series, which provides ongoing coverage of the exploding field of mindfulness research. View the original article.

Photo © Flickr.com/Ryan