68042 • Integrating Mindfulness into Clinical Practice

Table of Contents

68042 • Integrating Mindfulness into Clinical Practice

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL BACKGROUND

THICH NHAT HANH AND THE MIRACLE OF MINDFULNESS

MINDFULNESS: EAST MEETS WEST

3. SEVEN ATTITUDES OF MINDFULNESS

4. MINDFULNESS PRACTICES OF DAILY LIFE

SEATED AWARENESS

BELLY BREATHING

MUSCLE CLENCH AND RELEASE

MINDFUL WALKING

IMPORTANCE OF PRACTICE

5. MINDFULNESS AS A CLINICAL CONCEPT

MINDFULNESS-BASED STRESS REDUCTION

MINDFULNESS-BASED COGNITIVE THERAPY

DIALECTICAL BEHAVIOR THERAPY

ACCEPTANCE AND COMMITMENT THERAPY

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

12-STEP TRADITIONS

CANCER CARE

RESEARCH SUMMARY AND NEW DIRECTIONS

6. WAYS TO CULTIVATE MINDFULNESS

BREATH WORK

MEDITATION: SEATED AND WALKING

YOGA

DANCING MINDFULNESS

MINDFUL EATING

MINDFUL LISTENING

MINDFULNESS IN ALL ACTIVITIES OF LIFE

7. MINDFULNESS IN THE CLINICAL SETTING: TREATMENT PLAN STRATEGIES

INTEGRATING MINDFULNESS INTO ANY APPROACH

TO BE WITH THE EMOTION/WORD/SOMATIC EXPERIENCE

ANXIETY- AND TRAUMA-RELATED DISORDERS

ADDICTION

DEPRESSION AND GRIEF

8. MINDFULNESS IN CONTINUING CARE

STRATEGIES FOR REINTEGRATION USING MINDFULNESS

ACCESSING RESOURCES WITHIN THE COMMUNITY

9. CONCLUSION

10. RESOURCES

WEBSITES

BOOKS

Works Cited

Evidence-Based Practice Recommendations Citations

68042 • Integrating Mindfulness into Clinical Practice

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

Mindfulness is the ancient meditation practice of staying in the moment and noticing life absent of judgment. Mindfulness has been a buzzword in the helping professions in recent years, and with good reason. Evidence continues to suggest that clinical applications of mindfulness principles can have a direct impact on client health and wellness. In this course, participants will learn about the basics of mindfulness meditation, consider its applications for enhancing quality of life, read about advances in the field regarding the use of mindfulness alongside a plethora of existing practices, and learn specific, simple ways to incorporate mindfulness principles into clinical practice with clients.

68042 • Integrating Mindfulness into Clinical Practice

Education Category. Alternative Medicine

Release Date. 10/01/2023

Expiration Date. 09/30/2026

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2685 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Mindfulness is the ancient meditation practice of staying in the moment and noticing life absent of judgment. Mindfulness has been a buzzword in the helping professions in recent years, and with good reason. Evidence continues to suggest that clinical applications of mindfulness principles can have a direct impact on client health and wellness. In this course, participants will learn about the basics of mindfulness meditation, consider its applications for enhancing quality of life, read about advances in the field regarding the use of mindfulness alongside a plethora of existing practices, and learn specific, simple ways to incorporate mindfulness principles into clinical practice with clients.

Audience

This Introductory course is designed for psychologists who work with clients on a regular basis who may benefit from the integration of mindfulness into their treatment plans.

Accreditations & Approvals

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is recognized by the New York State Education Department's State Board for Psychology as an approved provider of continuing education for licensed psychologists #PSY-0240. This course is considered self-study by the New York State Board for Psychology.

Designations of Credit

NetCE designates this continuing education activity for 7 credit(s).

Course Objective

The purpose of this course is to provide psychologists with an appreciation of the benefits of mindfulness approaches. Many therapeutic mindfulness techniques will be presented that can be safely and effectively incorporated into clinical practice.

Learning Objectives

Upon completion of this course, you should be able to:

1. Outline the history of modern mindfulness.

2. Define mindfulness and the underlying attitudinal and theoretical concepts.

3. Describe the utility of mindfulness in clinical practice and evidence supporting its use for specific clients.

4. Discuss the practice of breath work and potential uses for clients and professionals.

5. Compare and contrast various approaches to mindful meditation, including seated, walking, yoga, and dancing styles.

6. Evaluate the use of mindfulness in the treatment of anxiety, depression, and substance use disorders.

7. Describe how mindfulness techniques may be used in continuing care.

Faculty

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, (she/they) travels internationally speaking on topics related to EMDR therapy, trauma, addiction, expressive arts, and mindfulness while maintaining a private practice and online education operation, the Institute for Creative Mindfulness, in her home base of northeast Ohio. She is the developer of the Dancing Mindfulness approach to expressive arts therapy and the developer of Yoga for Clinicians. Dr. Marich is the author of numerous books, including EMDR Made Simple, Trauma Made Simple, and EMDR Therapy and Mindfulness for Trauma Focused Care (written in collaboration with Dr. Stephen Dansiger). She is also the author of Process Not Perfection: Expressive Arts Solutions for Trauma Recovery. In 2020, a revised and expanded edition of Trauma and the 12 Steps was released. In 2022 and 2023, Dr. Marich published two additional books: The Healing Power of Jiu-Jitsu: A Guide to Transforming Trauma and Facilitating Recovery and Dissociation Made Simple. Dr. Marich is a woman living with a dissociative disorder, and this forms the basis of her award-winning passion for advocacy in the mental health field.

Faculty Disclosure

Contributing faculty, Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Margaret Donohue, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Many professionals have heard the term mindfulness used in clinical or educational settings but may not be quite sure what the term means or how to apply it. Some are students of mindfulness as a meditative practice; others are practitioners looking for relevant ways to apply mindfulness in their practices. This course should be useful for both.

This course will discuss the history of mindfulness, including its foundations and principles. It will explore how to integrate mindfulness skills into clinical treatment planning and how the practice of mindfulness can be used to address specific clinical conditions (e.g., depression, anxiety, trauma, addiction). The course will demonstrate how mindfulness can complement a chosen approach to psychotherapy and how it may be used as part of continuing care. In addition, a variety of mindfulness-based skills and strategies will be offered that can be used to enhance client wellness after the termination of therapy.

To optimally benefit from this course, readers should attempt each skill described, particularly before teaching the skills to clients.

2. HISTORICAL BACKGROUND

THICH NHAT HANH AND THE MIRACLE OF MINDFULNESS

Thich Nhat Hanh, Zen Buddhist author, teacher, and often referred to as the father of mindfulness in the West, states [1]:

Mindfulness is the miracle by which we master and restore ourselves. Consider, for example: a magician who cuts his body into many parts and places each part in a different region—hands in the south, arms in the east, legs in the north, and then by some miraculous power lets forth a cry that reassembles whole every part of his body. Mindfulness is like that—it is the miracle that can call back in a flash our dispersed mind and restore it to wholeness so that we can live each minute of life.

Nhat Hanh's manual The Miracle of Mindfulness, published in 1975, lays out the basic principles of what he calls "engaged Buddhism" [1]. These guidelines first appeared in a long letter of support and advice to a fellow Buddhist monk during the Vietnam War. Writing from exile in France, Nhat Hanh wanted to encourage young Buddhist students in the social work school he founded in the 1960s.

Refusing to align with any political group, these social workers and students were kidnapped, imprisoned, and killed. It was during this time that Nhat Hanh urged them to continue to work in a spirit of compassion and of reconciliation, to not give in to despair. He emphasized the essential discipline of following the breath and cultivating calm mindfulness, of staying aware and present in the moment [1].

Although mindfulness has been practiced for many centuries by Buddhists and other spiritual traditions, its use as a therapeutic tool in Western medicine is a fairly recent phenomenon. Since the 1970s, several mindfulness-based clinical approaches have been developed and have inspired a wave of scientific and scholarly investigation.

In Western medical practice, mindfulness is described as a psychological state, a practice of mindfulness meditation, and a mode of awareness. The current understanding of mindfulness in clinical psychology is that mindfulness is an awareness of experience in the moment, without judgment, and with acceptance. However, it is important to note that acceptance is not a passive, docile, or hopeless state—it means experiencing an event without having an extreme reaction and without suppressing it [2].

MINDFULNESS: EAST MEETS WEST

Interest in mindfulness started in America with the growth of Zen Buddhism in the 1950s and 1960s. Psychotherapists began to integrate meditation techniques into their practices, and researchers experimented with ways to heighten awareness and explored levels of consciousness, including through drugs and meditation [3].

One of the most famous of these researchers was Dr. Richard Alpert, who became known as Ram Dass. He was a psychology professor who worked with Dr. Timothy Leary at Harvard University in the 1960s. Their controversial teachings on the use of lysergic acid diethylamide (LSD) and other psychedelics for expanding consciousness and achieving spiritual awakening are well known in the field. Ultimately, Leary and Alpert were dismissed from Harvard and mainstream academia.

Ram Dass: Be Here Now

In 1971, Ram Dass published a pamphlet, which has since become a classic book in the world of meditation and metaphysical studies, called Remember, Be Here Now [4]. The teaching of "be here now" was given to Ram Dass from his spiritual teacher, Bhagavan Das, who studied in both Buddhist and Hindu traditions. The lessons of mindfulness are potently encapsulated in the phrase "be here now," and the book contains writings, drawings, and musings on the idea of finding peace through present-moment living. The book became a mission statement for a generation of individuals who sought spiritual enlightenment outside the boundaries of conventional religions.

Some people in Western cultures have preconceived notions of mindfulness as being linked to a specific religion or practice. The reality is that mindfulness can be practiced through a variety of outlets. Mindfulness is not only a meditative technique; it also includes yoga stretches or postures as a way to energize and relax the body. Yoga in and of itself has many mental and physical health benefits. Furthermore, mindfulness can be practiced while engaging in a variety of activities, such as walking, eating, dancing, singing, or in making the simple choices of daily living. The practice of mindfulness comes from the Eastern concept of smriti, a Sanskrit word meaning awareness, or in a more nuanced translation, to come back to awareness.

Buddhist in Origin, Universal in Application

In Jon Kabat-Zinn's seminal work Wherever You Go, There You Are, he defines mindfulness as "paying attention in a particular way, on purpose, in the presence of the moment, and non-judgmentally" [5,6]. In later writings, he adds the qualifier "as if your life depended on it" [7]. Thus, the challenge of mindful practice is to be totally in the moment with whatever one is doing as if nothing else mattered, whether that "doing" is the act of sitting down and meditating or moving through the tasks of one's day. By focusing on the here and now, the "being" instead of the "doing," one is capable of both reducing stress levels and developing attitudes that will promote overall wellness.

As a meditation practice, mindfulness is Buddhist in its origins. In fact, mindfulness is considered to be the heart of Buddhist meditation. However, Kabat-Zinn and others who write on mindfulness continue to reiterate that there is nothing exclusively Buddhist about practicing mindfulness. It is a universal approach that can be practiced alongside other philosophies, religious traditions, or even in a secular sense. One can be totally aware and in the moment with Christian or Jewish practices, with facets of nature, or with secular elements of living. If one keeps an open mind and applies the concept in the context of his/her own worldview, mindfulness may be healing [8].

3. SEVEN ATTITUDES OF MINDFULNESS

According to Kabat-Zinn, there are seven primary attitudes that may be acquired and further cultivated through the regular practice of mindfulness [7]. These attitudes are non-judging, patience, beginner's mind, non-striving, trust, acceptance, and letting go. Consider what each of these attitudes mean and how each attitude may apply to overall wellness for professionals and clients.

Being non-judgmental of one's internal processes is at the heart of mindfulness practice. Non-judging refers to thinking, feeling, or responding without the influence of an internal sensor or critic. Non-judging is an attitude of "just noticing" thoughts, emotions, or whatever may surface as relevant. Non-judgment, however, does not endorse behaviors that put oneself or others in harm's way. For instance, consider a recovering addict who is experiencing an intense craving to use a substance following a stressful day. Non-judgment does not advocate that the person should just go out and use, which would certainly be harmful. Rather, non-judgment encourages the person to just notice the craving, pay attention to it, and be with it in a spirit of non-judgment.

By doing this, one is more likely to make the healthier choice to handle something like a craving instead of beating oneself up for having the craving. This scenario plays out time and again with recovering people: negative judgments for having an unhealthy thought or craving lead to shame, which can trigger unhealthy behaviors.

Mindfulness, especially if practiced regularly, helps us to become more patient with ourselves. Patience, which derives from the Latin root (patientia) meaning to undergo, suffer, or bear, is the art of deferring gratification. Patience teaches how to wait with grace. By cultivating this attitude, one can not only learn to defer instant gratification, but also to be gentler with oneself when shame-based responses attempt to sabotage. Thus, mindfulness practice is a way to retrain maladaptive cognitive and emotional responses while being gentle with oneself.

The mindfulness attitude that can significantly impact this retraining of the brain is "beginner's mind." Beginner's mind is approaching each new task with an open mind. Think of the sense of wonder that a child attempting a task for the first time may experience. With this attitude, one can remove an expert's mindset and refrain from living on metaphorical autopilot. Skills like walking meditation are wonderful strategies to work with beginner's mind because one is challenged to take an activity that tends to be automatic, like walking, and break it down to appreciate each individual part as if one is walking for the first time.

Practicing any activity with a beginner's mind is also a very effective way to practice non-striving: thinking, feeling, or acting with focus on the process, not just the outcome. The name of this skill confuses many people, because Western culture tends to associate non-striving with giving up. Non-striving does not imply laziness or sloth. Non-striving is an attitude that encourages one, even in work, to refrain from fighting so hard. In non-striving, whatever happens, happens. Consider the saying, "life is about the journey, not the destination," which epitomizes the spirit of non-striving.

The final three attitudes of mindfulness are also ideal for enjoying the journey without letting the stress of reaching the destination trouble us. First, there is the attitude of trust, or having belief in some unseen entity, such as another person or group or the internal self. One can also practice trust in an outcome that may not be obvious during the journey by believing the outcome is there and it will be reached when it is supposed to be reached.

The next attitude is acceptance, or coming to terms with reality no matter how harsh or unpleasant it may be. Practicing acceptance can be a pathway to peace, and it does not imply one must "like" the reality in order to discontinue fighting. Acceptance is internalizing the attitude of "it is what it is." Finally, there is the attitude of letting go, or releasing one's "grip" on a situation, emotion, person, thing, or outcome. Letting go generally results in a freeing response (or at least the beginnings of one). This response can clear the path for wellness and growth.

According to Kabat-Zinn, these seven primary attitudes are the foundational fruits of mindfulness practice [7]. By internalizing them, a variety of other attitudes can flow into our lives. Kabat-Zinn identifies friendliness, gratitude, gentleness, curiosity, non-attachment, non-reactivity, happiness, and creativity as possible outcomes. Others can include attunement, persistence, confidence, and willingness. Attunement, or being in harmony with another human or entity, is an especially vital skill for helping professionals. By practicing attunement, professionals are able to more effectively read a client's nonverbal signals and sense any subtle shifts in energy or relational dynamics.

4. MINDFULNESS PRACTICES OF DAILY LIFE

In many of his books on mindfulness, Kabat-Zinn recalls meeting a master of Chan (a school of Chinese Buddhism) who espoused, "There are an infinite number of ways in which people suffer. Therefore, there must be an infinite number of ways in which Dharma is available to people" [7]. The English translations of dharma from Sanskrit are numerous, but the one that seems to most resonate for the purpose of helping others with suffering is to think of dharma as the stability and harmony of the universe [9].

People suffer in so many ways, so it is good common sense to have a variety of approaches to help people. One of the foundational principles of trauma-informed, person-centered counseling is meeting people where they are. Because mindfulness can be practiced in a variety of ways, there are numerous exercises available to help any number of clients develop a program of coping skills.

This section will present four separate skills that can encourage the practice of mindfulness through a variety of channels that are a part of daily life: sitting, breathing, relaxing muscles, and walking. As a reminder, it is important to try these skills before teaching them to clients.

SEATED AWARENESS

Instructions

- Shift around in your chair a little bit, or in a seated position on the ground, until you find a position that, for you, symbolizes paying attention.

- Be careful not to slouch your shoulders, but also be aware not to sit so straight that it hurts you to be in this sitting posture.

- Spend some time paying attention to your body and make a mental note of what this posture of awareness feels like for you.

- If your head starts to wander or you feel that you have stopped paying attention, this is an opportunity to practice non-judgment and beginner's mind. When you catch yourself, use this as a chance to bring your attention back to the body posture of awareness.

- Work up to practicing this in three-minute increments. This practice is an effective way to cultivate the attitude of patience.

Modifications

If three minutes is attempted and simply cannot be done, consider adding in another sensory element and practice paying attention to that element (e.g., a scent, a simple sound, or a tactile sensation, like holding a rock). If sitting is not accessible, this same exercise can also be done standing or lying down. Remember to keep the emphasis on awareness [8].

BELLY BREATHING

Instructions

- Put one or both hands on the upper area of your stomach so you can pay attention to the motions you are engaging with your diaphragm.

- As you inhale with your nose, allow your belly to expand as far as it will go.

- Exhale with your mouth, allowing the belly to pull back in.

- Continue this inhale-exhale pattern at your own pace, giving it at least six to seven sets to find a rhythm and style that works. Curiosity and non-judgment are key.

- After finding your rhythm, consider puckering your mouth and really exaggerating your exhale, striving to make it somewhat longer than your inhale. This should help facilitate relaxation.

Modifications

If you feel awkward, or in any way out of control with this suggested pattern, consider starting with an exhale instead of the inhale. If paying attention to the breath on its own is not working, consider adding a count to it (e.g., In-2-3-4…hold…Out-2-3-4). A word or a special phrase (e.g., Sat Nam, amen, peace, help me) may also be added.

Children may be engaged in this practice by having them put something like a bean bag or a flatter stuffed animal on their stomach, so they have a focus point while they observe the rise and fall of the belly [8].

MUSCLE CLENCH AND RELEASE

Instructions

- Make fists.

- As you focus on your clenched fists, bring to mind something that causes stress in your life.

- As you reflect on the stressor, really notice the contraction of your muscles. Feel your fingernails dig into your skin, if possible.

- Whenever it feels too uncomfortable for you to keep holding on, know that you can slowly, mindfully let go at any time.

- Notice your fingers uncurling, and feel the trickle of letting go all through your arms and up to your shoulders.

- Notice how good it feels to let go.

Modifications

Any muscle group can be clenched and released, especially if clenching the fists is too painful or not possible due to context or physical limitations. Clenching and releasing the stomach and feet are other popular choices.

For help with sleep and deeper relaxation, clench and release one muscle group at a time (holding each clench 20 to 30 seconds and then slowly releasing). The entire exercise, known as progressive muscle relaxation, should take about 20 minutes. A relaxing sound (e.g., nature sound, music) may be added in the background or an aromatherapy diffuser may be used to further relaxation [8].

MINDFUL WALKING

Instructions

- Think about looking toward the horizon during the walk instead of down at your feet.

- Consider the art of breaking this walk down into slow motion, as if you are experiencing it for the first time (i.e., beginner's mind).

- Standing tall, let your heel connect with the earth and allow the front part of your foot to point towards the sky.

- Very slowly step down, shifting the weight from your heel to the ball of the foot.

- Shift the weight from the ball to the toes.

- Deliberately repeat this same motion on the other foot.

- Continue taking this walk in this slow, deliberate fashion, observing each sensation with a new awareness. Let your walk truly be an exercise in mindful meditation.

Modifications

This exercise can be done inside or outside. If the exercise is being taught to a client, it is recommended to start at a slow pace. However, the same exercise can be done in the spirit of silence and meditation at a faster pace. A faster pace is good when teaching the idea that one can still achieve mindful awareness even at the regular pace of life.

Reflection

Consider the four exercises covered in this section and think about how "being in the moment" can be practiced with each activity. At this point, what are some other ideas for practicing mindfulness in activities of daily living?

IMPORTANCE OF PRACTICE

Whether working these exercises oneself, or teaching them to clients, it is important to remember the word "practice." No one can be ideally in the moment the first time she or he tries these exercises. As with learning any activity, mindfulness takes practice, especially in order for it to become internalized and a more automatic part of daily living. It is especially important to highlight the practice element with clients, because many clients abandon an activity if they do not experience instant results.

It is normal for clients not to experience an effect right away, which is why starting with a three-minute goal is important. In addition, it may be advisable to teach at least three different mindfulness skills at first, because one usually resonates most strongly in terms of causing a positive response. If a person can find a core skill to work with initially, then he or she may be encouraged to start working with some of the others.

The challenge of mindfulness is that, while it seems so simple on the surface, practicing it can be quite challenging. This is partially because Western society is the very essence of mindlessness—fast-paced and result-oriented, with a focus on "doing" rather than "being." As Kabat-Zinn articulates, the work of mindfulness is some of the hardest work in the world [7].

5. MINDFULNESS AS A CLINICAL CONCEPT

Kabat-Zinn pioneered the meditative benefits of mindfulness and developed a systematic program for helping people with stress, physical illness, and mental disorders. His academic background is in molecular biology, but his work has been widely influential in the medical and mental health professions. In 1979, during his tenure as professor of medicine at the University of Massachusetts Medical School, Kabat-Zinn, a student of Buddhist meditation practices, introduced his stress reduction and relaxation program [5].

Several therapeutic approaches have been developed based on mindfulness meditation precepts. Approaches like mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have gained prominence. Other innovative approaches to therapy, like dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT), make use of mindfulness in their approaches. Indeed, all of these approaches are part of the larger umbrella of mindfulness-based interventions.

MINDFULNESS-BASED STRESS REDUCTION

The history of Kabat-Zinn's stress-reduction program, which came to be known as MBSR, and its teaching protocols are explained in his book Full Catastrophe Living: Using the Wisdom of the Body and Mind to Face Stress, Pain, and Illness[5]. This book is considered a classic in the area of mind-body medicine. While Kabat-Zinn was unlikely the first professional to use mindfulness principles with clients and patients, the results of his program generated attention within his own medical center. MBSR then expanded into the psychological and medical fields at large, cementing his status as a pioneer of modern mindfulness.

It is important to remember that mindfulness practice and MBSR are not synonymous [10]. MBSR programs must follow the eight-week protocol and ideally be presented by an individual who received training directly from Kabat-Zinn and his team. The MBSR structure contains work in breathing, seated meditation, walking meditation, gentle yoga, and body scanning. Participants are encouraged to practice these skills as homework, and the hope is that over the course of the program, changes in attitudes toward oneself and one's health will change.

Most of the mindfulness research available at present is related to formal MBSR and MBCT, also a systematized program that uses mindfulness practice to help people readjust their negative schema.

Comprehensive meta-analytic research demonstrates a strong effect of the completion of a formal MBSR program on overall psychological well-being, especially in clinical populations [11]. The same review found that general mindfulness meditation practices outside the scope of a systematized MBSR program have the strongest effect for subclinical populations, especially connected to the attitudes of mindfulness and wellness variables. The increased effect sizes for MBSR could be related to the components of the program that are not directly tied to mindfulness meditation [11].

MINDFULNESS-BASED COGNITIVE THERAPY

MBCT is a fairly new approach that combines cognitive-behavioral techniques with the mindfulness skills of MBSR. It was originally developed as a treatment of recurrent depression and has been used for several years in the treatment of depression with good results. MBCT was developed by Segal, Williams, and Teasdale, with the first clinical trial published in 2000. Since then, scientific evidence indicates that MBCT may also be effective in the treatment of other conditions such as bipolar disorder, anxiety, food and eating issues, and psychosis. Like MBSR, the MBCT protocol calls for an eight-week course during which participants learn how to use cognitive methods and mindfulness meditation tools to combat the processes that trigger depression. Better understanding of the association between thoughts and feelings and how to interrupt and change these processes to achieve better mental health are at the core of this therapeutic technique [12].

A meta-analysis to determine the efficacy of MBCT to prevent depression relapse confirmed that the approach had positive results, especially for those with more severe symptoms [13]. One study explored whether MBCT was superior to maintenance antidepressants and found MBCT to be as effective as medication in reducing re-occurrence of symptoms—both MBCT and medication had positive outcomes [14].

Other very popular clinical approaches within the helping professions make use of mindfulness principles in their foundational philosophy. While many have been influenced by the contributions of Kabat-Zinn and his work with MBSR, there is recognition that MBSR's structure may be limiting when working with certain populations in certain clinical settings.

DIALECTICAL BEHAVIOR THERAPY

Dr. Marsha Linehan is best known for her development of the ground-breaking therapy DBT, which is now a first-line option in the treatment of borderline personality disorder. Linehan found that the discipline of behaviorism was not enough to create change in patients with suicidal ideation or attempt—a population that has tried multiple times to change without success. DBT is based on two core principles [15]:

- The need to accept life as it is, not as one believes it should be

- The need to make changes in life, despite and because of the above

DBT is based on the philosophic principle that two things can be true at the same time. This important concept is used to change the black-and-white thinking that defines borderline personality disorder and other personality disorders.

Also, in working with patients with borderline personality disorder, traditional cognitive methods are often missing the necessary component of self-soothing or regulating affect. Linehan found that mindfulness and other meditation strategies worked well to fill in many of the gaps in the cognitive approach. DBT addresses this need with its focus on emotional management and regulation in treatment. Traditional DBT involves a combination of techniques including mindfulness, cognitive-behavioral therapy, relaxation, and breathing exercises [15].

Popular DBT skills that are especially rooted in mindfulness include "radical acceptance," or total acceptance of an experience or situation over which one has no control without trying to change or resist it. Other similar mindfulness concepts used in DBT include "turn the mind" (to accept and to simply be) and "letting go" (to detach from outcomes). It is very common for DBT to be taught in the form of skills groups, recognizing that clients or patients should learn and cultivate skills for tolerating intense affect and practice how to apply them [15].

To date, DBT is the most well-researched treatment for borderline personality disorder and is considered to be a first-line treatment by many clinical entities [16]. The most consistent finding is that DBT is effective in reducing parasuicidal behavior in patients with borderline personality disorder. In addition, these studies found a reduction in anger behavior and better social adjustment. There are also promising research results for DBT with patients with eating disorders and elderly patients with depression [17].

ACCEPTANCE AND COMMITMENT THERAPY

Another popular approach in the helping professions today is ACT, developed by Stephen Hayes and his team in the late 1980s. This modality also blends traditional cognitive analysis strategies with mindfulness principles. Two popular acronyms used to summarize this approach are FEAR and ACT [18]. Distress is caused by FEAR:

- Fusion with your thoughts

- Evaluation of experience

- Avoidance of your experience

- Reason-giving for your behavior

To address this maladaptive response, the healthy alternative is ACT:

- Accept your reactions and be present

- Choose a valued direction

- Take action

ACT has been suggested as a promising approach to treating PTSD and other trauma-based mental health issues. The approach has six core ACT components: creative hopelessness, the problem of control, willingness and defusion, self as context, valued living, and committed action [19].

Further reading in ACT is recommended for those looking to blend mindfulness-approaches with cognitive-behavioral work. As an approach, ACT has a great deal of empirical validation to date [15].

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

Although MBSR, MBCT, DBT, and ACT are the most popular modalities in modern psychology that relate to mindful practice, there is evidence of mindful practice in many other approaches to psychotherapy and helping, even if mindfulness does not seem to be presented as a major focus.

For instance, some may have been introduced to the benefits of mindfulness through eye movement desensitization and reprocessing (EMDR) therapy. Francine Shapiro, who developed EMDR in 1987, was a student of mindfulness and wove many mindfulness concepts into her EMDR protocol [8]. In EMDR, the client is invited to just notice or observe something, such as a thought, a body feeling, a memory, or an emotion, without judgment. Where so many approaches to therapy confront irrational beliefs or promote analysis, mindfulness approaches in therapy encourage clients to just notice [8].

12-STEP TRADITIONS

Even 12-step programs of recovery introduce concepts like living in today (as opposed to projecting to the future or dwelling in the past) and practicing acceptance as a pathway to peace [20]. Many newer approaches, like DBT and ACT, contain elements of 12-step recovery, which traces back to the 1930s. Newer approaches add to the tradition by teaching the path to mindfulness instead of just telling people to live in today or practice acceptance. A hallmark of trauma-informed addiction treatment is not just to rely on slogans and platitudes, but also to work with clients on learning how to put these helpful ideas into practice [21].

CANCER CARE

In oncology settings, mindfulness training is often offered through MBSR or mindfulness-based cancer recovery. These are usually eight-week programs with weekly meetings and home practice of mindfulness techniques and yoga exercises. Issues addressed include loss of control, uncertainty about the future, depression, anxiety, fatigue, pain, and sleep problems.

A 2017 review of 13 studies of various cancer types found consistent positive effects for anxiety, stress, depression, and overall quality of life [22]. A few studies have shown that mindfulness training has greater improvement than other interventions, such as nutrition education and expressive group therapy, and with more long-term sustained benefits [22].

Reflection

Think about your existing paradigm, or approach, to psychotherapy. How might you weave some mindfulness principles into what you already do?

RESEARCH SUMMARY AND NEW DIRECTIONS

There is a vast amount of scholarly research on the use of mindfulness-based interventions in mental health and general health care. In 2012 alone, more than 500 studies were published demonstrating the positive impact of mindful practice on recovery from a wide variety of mental health, addiction, and physical disease conditions. According to Shonin, Van Gordon, and Griffiths, a definitive conclusion about all mindfulness research is difficult because of the imprecise parameters with operational definitions (e.g., some programs have structured protocols, like MBSR and MBCT, whereas others, like DBT, ACT, and mindfulness-based relapse prevention [MBRP] therapy, make use of mindfulness strategies as part of their larger scope) [23].

Another problem exists, at least for the more scientifically minded, in reconciling the precisions of empirical language with the more imprecise, spiritual concepts often used in mindfulness writing that may not lend themselves to specific empirical measure. Nonetheless, Shonin, Van Gordon, and Griffiths conclude that [23]:

Interest and supporting evidence for the clinical application of mindfulness-based interventions has increased substantially in the last decade. [Mindfulness-based interventions] appear to represent cost-effective, acceptable, and non-invasive means for treating a broad spectrum of psychological and somatic illnesses.

A proliferation of research and writing has also emerged addressing the changes that occur in the human brain during the practice of mindfulness. In a 2011 article, Kabat-Zinn summarizes the findings [7]:

It is now becoming apparent that MBSR training also results in structural changes in the brain in the form of thickening of certain brain regions, such as the hippocampus, which plays important roles in learning and memory, and thinning in other regions, for instance, the right amygdala, a structure in the limbic system that regulates our fear-based reactions such as to perceived threats of one kind or another, including the thwarting of our desires.

Evidence Based Practice Recommendation

The Department of Veterans Affairs recommends offering mindfulness-based therapies for patients with chronic multisymptom illness and symptoms consistent with fibromyalgia, irritable bowel syndrome, or myalgic encephalomyelitis/chronic fatigue syndrome.

https://www.healthquality.va.gov/guidelines/MR/cmi/VADoDCMICPG508.pdf

Last Accessed: September 11, 2023

Strength of Recommendation: Weak

A 2015 meta-analysis involving 21 studies found that eight regions of the brain consistently changed in experienced meditators [24]:

- Postrolateral prefrontal cortex (awareness of the thinking process, introspection)

- Sensory cortices and insular cortex (tactile information, pain, body awareness)

- Hippocampus (memory, emotional responses)

- Anterior cingulate cortex and mid-cingulate cortex (self-control, emotional regulation, attention)

- Superior longitudinal fasciculus and corpus callosum (communication between and within brain hemispheres)

While research into mindfulness and meditation is in the early stages, their findings suggest that mindfulness practices are promising in the treatment of clinical disorders as well as supporting better mental health and increased well-being for the general population [24].

6. WAYS TO CULTIVATE MINDFULNESS

For clinical counselors and helping professionals strongly committed to meeting clients where they are along the journey, the wisdom of Kabat-Zinn's Chan master is sage guidance: Just as there are many ways that people suffer in this world, there are many ways to overcome suffering. Mindfulness is universal, and working with clients on mindful practice is a trial-and-error process to help them find the avenue or avenues that will work best to help them stay in the moments of life. There are several mindfulness outlets that people can use in combination to help bring about overall lifestyle change.

The key is in motivating clients to consistently practice their chosen outlets. This section will build upon the four skills covered in the previous section by offering even more options for mindful practice. Then, other physical outlets, like yoga, dance, and other exercises, will be considered, followed by instruction on how to eat mindfully, how to listen mindfully, and how to carry mindful practice into all areas of life. Once again, attempting to practice these skills will enhance one's ability to teach them to clients and may provide good options for self-care.

BREATH WORK

This section will present some additional breath work ideas to work on alone or with clients, building on the foundations of diaphragmatic breathing. Be advised that in the traditions of yoga and mindfulness meditation, there are many more breath exercises to attempt if they are proving useful. Additional resources for breath work techniques and instructions are provided at the end of this course. Whichever specific breath strategy works best, the key when incorporating breath work as a practice in mindfulness is to develop the habit of focusing totally on the breath. The goal is to breathe with single-pointed attention and focus, no matter how much practice it takes to get there. Cultivating this practice makes deeper breathing a more automatic, healthy response in daily life when one is met with a stressor.

Complete Breathing

Instructions

- Begin with a diaphragmatic breath but continue the inhale into the ribs and then the chest. Placing a hand on the chest can help with awareness.

- At the top of the inhale, cradle the breath in your awareness for a moment; this is a more meditative way to conceptualize holding your breath.

- Gradually release the breath with your exhale, allowing the chest, the ribs, and the belly to pull back in.

- Continue this inhale-exhale pattern at your own pace, completing at least six to seven sets to find a rhythm and style that works for you. Curiosity and non-judgment are key, as with any other breath.

Modifications

The standard pattern with exhales is to keep them slow and deliberate. However, a very powerful variation is a fast, dramatic exhale, like a "sigh of relief." Practitioners should feel free to be as dramatic as they like on the exhale, perhaps bringing the hand to the forehead. This breath is a chance to put letting go of negative energy into practice. When you expand your chest on the inhale, you can bring up "superhero" imagery (especially fun with children) to further the empowering motion.

Breath Controls the Mind

Teaching clients how to mindfully breathe is paramount to clinical practice. Many clinicians trained in cognitive-behavioral approaches to therapy learned that changing behaviors requires a person to change the way that he or she thinks. The traditions of yoga and mindfulness teach that in order to change thoughts, one must first change the breath. One guiding principle comes from the Indian yogi B.K.S. Iyengar, one of the primary figures responsible for bringing yoga to the West. Iyengar advised that the mind controls the body, but the breath controls the mind [25]. Thus, where cognitive approaches to therapy advise to change the thinking in order to change the behavior, Iyengar proposes that to change the thinking, one must first change the breath.

Start with Three Minutes per Day

When breath work is incorporated into clinical practice, it should be one of the first areas covered. In order to be effective, it should become an essential part of one's routine. Giving one's brain some time each morning and each evening to receive deep, mindful breaths is like metaphorically brushing your teeth or washing your face; breath practice delivers the brain the proper oxygen it needs to clear out and balance. This metaphor can be shared with clients to explain the value of regularly practicing breath. Committing to 3 minutes of breath work per day, working up to 10 minutes, will initiate changes in functioning and provide the practitioner with a reachable starting goal.

These three minutes may be worked on together with clients in sessions, or clients can begin practicing breath work in their everyday life, such as while waiting at a traffic light or standing in line at a store. While structured approaches to mindfulness training (e.g., MBSR) recommend longer periods of breath practice, many clients will be overwhelmed by the notion of breathing for 20- or 30-minute stretches at a time; however, 3 minutes is feasible. From a consistency standpoint, people breathing mindfully for 3 minutes at various points in the day can be more helpful, especially as a coping mechanism, than allotting 20 to 30 minutes for mindful breathing and then going on mindless autopilot for the rest of the day.

Some clients will be resistant to doing breath work and will give a variety of excuses and reasons these exercises do not work for them, some of which are legitimate. Clinicians should be prepared with responses to help work through the resistance (Table 1).

Table 1: RESISTANCE TO BREATH WORK AND HOW TO ADDRESS IT

Comment/Resistance

Clinical Response(s)

"I just can't stay focused on my breath."

"It's okay; a lot of people report they can't focus on the breath at first. Are you willing to give it a try again? Whenever you notice your mind start to wander, just notice that it is wandering and bring your attention back to your breath. Even if you have to do this 10 times every minute, just practice bringing your attention back to your breath. Mindfulness is practice, and this is part of what practice means."

Revisit the modifications suggested for belly breathing and complete breathing. Starting with the exhale or adding a count to the breath often helps people improve their focus. For others, music or ambient sound may help maintain focus on the breath.

"Breathing just doesn't work for me."

Engage clients in a dialogue about how they've tried or been exposed to breathing in the past. From there, inform them about how your approach to mindful breathing may be different and see if they are willing to try again.

There is likely a chance that if a client has tried breathing before, he/she gave it less than one minute and, if an effect was not noticed immediately, gave up. To counter this, issue the three-minute challenge. Let the client know that you will breathe with him or her as encouragement (and modeling).

If a client has been exposed to clinical breath work in the past, it was most likely diaphragmatic breath. Consider teaching another breathing technique (e.g., complete breathing).

If a client still has a mental barrier about breathing, try a more direct body intervention, like clench and release/progressive muscle relaxation. Suggesting this as an alternative to breath work automatically makes it more appealing, and as you are guiding a client through these exercises you can insert gentle reminders about noticing the breath as she or he moves or works the muscles.

"I just can't relax when I breathe. It makes me more tense because I worry if I'm doing it right."

Suggest that the client start with the exhale. Starting with an exhale can create negative pressure on the lungs, making the subsequent inhale automatically relaxing.

One of Kabat-Zinn's teachings is: "If you are breathing, there is more right with you than wrong with you." This wisdom serves as an excellent coaching statement for people with hesitation about technique.

"Getting that relaxed makes me nervous. I don't feel comfortable letting my guard down. What if someone sneaks up on me?"

Make sure the client knows that he/she does not have to close the eyes in order to do breath work. Closed eyes during breath work can increase trauma-related claustrophobic responses.

Take the breath work very slowly and gradually. Start with just one or two breaths, and then have the client look around the room, perhaps repeating an affirmation (e.g., "I'm here now. I'm safe."). When the client feels ready, he/she can resume with deeper breathing. Encourage the client to be aware of his or her surroundings, even while doing breath work, and check in at any time.

"I am prone to fainting spells." (Other medical reasons may also be given as reasons or concerns.)

Obtain a release from the client's medical provider. This may help with the client's and clinician's peace of mind.

Take shorter breathing sets (two to three inhale/exhale repetitions) instead of standard sets of five to six repetitions, and instruct the client to check in with his or her body after each attempt. Learning to listen to the body is an important skill in and of itself.

Begin with diaphragmatic (belly) breathing first to determine if the client tolerates the breath work before moving on to some of the fuller breath exercises.

Source: Compiled by Author

Ocean or Ujjayi Breathing

Instructions

- Pucker your mouth as if you are sucking through a straw or about to kiss someone. Attempt to contract the back of your throat slightly.

- Inhale through your nose, expanding your diaphragm and belly.

- Exhale through your nose. Although air may flow out of your mouth, think about doing the work with your nose.

- If your mouth is puckered and throat is contracted, each breath should produce a sound similar to the ocean.

- Attempt to keep the inhales and exhales even in length, especially when first learning the breath.

- Do not attempt more than five full sets during first attempts.

- It is normal to feel somewhat lightheaded, but it should be a "good" lightheaded. If it does not feel good, this indicates that the inhales and exhales were uneven or that too many sets were attempted.

Modifications

Some clients benefit from envisioning different characters with this breath, like Darth Vader or a charging bull. It can also be helpful to use a mirror to see the steam the breath makes, attuning one to the idea of breath as a force. Some clients also like to visualize the inhale in a calming or soothing color and the exhale in a color that represents stress [8].

Lion Breathing

Instructions

- Begin with a healthy inhale (as in complete breathing, start with expansion of the stomach and then the chest).

- Exhale vigorously, allowing the tongue to hang out. Feel the jaw and cheeks loosen. Open the eyes wide to facilitate a feeling of letting go.

- Try at least five sets, although you can continue with this breath as long as it is physically comfortable for you.

Modifications

This is a good exercise to teach to children (or adults who are not too self-conscious to try it). Instruct clients to think of making this face when ugly thoughts about trauma or stress come up, embodying the strength of a lion in the wake of a painful trigger.

MEDITATION: SEATED AND WALKING

The practicing awareness strategy introduced earlier in this course is a form of meditation. Mindfulness meditation is about being in the here and now, however it is practiced. By strict definition, meditation is extended thought, reflection, or contemplation. Contrary to popular misconception, meditation is not about erasing thoughts, but about learning how to be with them more effectively. The word meditation comes from the same Greek root as the words mediate or medicine, which simply imply bringing order back into natural balance.

Misconceptions

There are many misconceptions about meditation, and these misconceptions can be barriers to clients engaging in the practice. Some people equate meditation with blanking the mind and believe that this can allow negative or evil influences to creep in. Others, particularly devoutly Christian individuals, may feel that meditation is specifically Eastern (i.e., only for persons who practice Buddhism). As such, one of the first steps when incorporating meditation into practice is to address any misconceptions that the client may have. Some of this bias comes from legitimately publicized meditation groups that took on cult-like characteristics (a risk with any spiritual tradition), but much of it comes from misinformation. For example, clients may be reassured that meditation is a non-denominational practice. It can be engaged in as a part of any spiritual journey, including Christianity. In fact, there are 41 references to meditation in the Christian Bible [26].

Difference Between Prayer and Meditation

Many religious traditions make use of meditation in one form or another. In addition, step 11 in the classic 12-step program reads: "Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for a knowledge of God's will for us and the power to carry it out." One of the most potent distinctions at a 12-step meeting is that prayer is when one talks to a chosen deity or Higher Power, and meditation is when one sits quietly and listens for the response. When meditation is conceptualized this way, few people argue with its value.

Health Benefits of Meditation

The health benefits of meditation continue to be supported by both case and research evidence. A comprehensive meta-analysis examined 163 studies of various meditation traditions (including mindfulness meditation) and found a strong effect size for meditation in helping with emotionality and relational issues and a moderate effect size for issues related to attention. The effects were similar regardless of the specific meditation tradition practiced [27].

Another meta-analysis specifically compared MBSR and general mindfulness meditation practice on various psychological variables. Researchers found that while MBSR practice shows a greater effect on psychological well-being, general mindfulness practice had a larger effect with subclinical populations as they related to the variables measured in the study (e.g., the attitudes of mindfulness) [12]. In a review of the research available on mindfulness meditation, the author determined that mindfulness meditation is safe and has few associated risks [28].

Some people may experience a transient increase in anxiety when initially attempting meditation, as they let go of usual busy-ness and distractions and become aware of unsettling thoughts and feelings, but this is generally short-lived. In addition, mindfulness meditation and mindfulness-based clinical interventions are low-cost and low-risk mind-body practices that have been shown to positively affect quality of life and biologic outcomes in many different populations, including healthcare professionals and individuals with cancer [28].

The MBSR program makes use of both seated and walking meditation, often alternating between the two in the protocol to encourage clients to experience mindfulness in both planes. The basics of a seated awareness exercise and a walking meditation were outlined previously in this course, and both can be easily practiced in clinical or community settings.

YOGA

If one is open to it, meditation can also be carried into a more dynamic plane of movement and exercise. The ancient practice of yoga is one of the primary components of traditional MBSR. However one practices yoga, whether it is part of a structured MBSR program or as part of a personal fitness and wellness regimen, it is a physical and mental practice that can help cultivate mindfulness.

Yoga is a Sanskrit word meaning union, or more specifically, to yoke. A yoke is a device for bringing two parts together. In yoga, the yoke is the spiritual realm, bringing together body and mind. In psychotherapy and the helping professions, attention has been focused on the importance of holistic care and integrating the human elements of mind, body, and spirit. The practice of yoga is designed to create this union and has been doing so for thousands of years.

Yoga: The Eight-Limbed Path

In the West, yoga is commonly associated with stretching and breathing, although these are only two of the limbs or paths of yoga. Yoga is a true folk practice, passed down through the generations of practitioners in ancient India. Patanjali, who lived in the second century B.C.E., recorded the first writings on yoga, the Yoga Sutras. In its fullest form, yoga is an eight-part path that includes moral or ethical principles such as nonviolence, compassion, and truthfulness. Other limbs or paths are concerned with breath control, poses, and four levels of meditation.

An entire discourse on yoga philosophy is beyond the scope of this course; if this is an area of interest, please use the recommended resources given at the end of this course.

Scientific Research on Yoga

The Harvard Medical School reports that in the past decade, the research on yoga has tripled [29]. As of 2021, more than 2,400 controlled trials that include yoga in the title are listed in the Cochrane Central Register of Controlled Trials [30]. Although the risk of bias is often high in yoga randomized controlled trials, newer studies have lower risk of bias and are better reported [31]. With many newer scientific methods, like measurement of biochemical levels in the brain, magnetic resonance imaging (MRI), and DNA analysis, researchers are able to show how yoga changes the body [29].

Role in Treatment of Psychological Disorders

There is mounting evidence to demonstrate yoga's effectiveness as both a complementary and stand-alone treatment in addressing a variety of mental health disorders, including bipolar disorder, post-traumatic stress disorder, and obsessive-compulsive disorder [32,33,34,35,36,37]. Comprehensive literature reviews of yoga in the treatment of neuropsychological disorders concluded that evidence from randomized trials supports the efficacy of yoga for depression and sleep disorders as a complementary therapy to traditional forms of treatment (e.g., cognitive-behavioral therapy) [35,36,38].

Yoga as Treatment of Trauma and Stress-Related Disorders

Bessel van der Kolk, a pre-eminent scholar and practitioner in the field of post-traumatic stress, advocates for the inclusion of yoga in the treatment of trauma- and stress-related disorders [39]. At his treatment center, the Trauma Center at the Justice Resource Institute in Boston, enrollment in one of the Center's trauma-sensitive yoga classes is compulsory. Furthermore, the Center's research initiatives are committed to studying how yoga and complementary therapies can be best integrated into trauma treatment. van der Kolk was one of a team of experts assembled by the International Society for Traumatic Stress Studies (ISTSS) to establish an "expert consensus" on the effective treatment of complex post-traumatic stress disorder [40].

One of the team's conclusions, supported by literature reviews, is that "optimization of outcomes also includes exploration of novel treatment approaches such as complementary medicine strategies that focus on somatosensory experience and the mind-body relationship, for which there is emerging evidence regarding efficacy" [40]. Many large addiction centers in the United States have been offering adjunctive classes in yoga for decades, and this trend is translating now to smaller, community-based treatment centers.

How Yoga Differs From Other Exercise

It is true that all forms of physical exercise can prove beneficial for helping with overall health and wellness. However, so many forms of sports and exercise in Western cultures are mindless and/or results-oriented. Many people in gyms watch television while walking or running on a treadmill or elliptical machine, with primarily aesthetic goals. In theory, all exercise has the potential to be engaged in mindfully, and runners have shared experiences of mindfulness and spiritual fulfillment when running [41].

As long as physical activity is focused on being in the present, without obsessing about the end result, it can be part of a mindfulness practice. However, Eastern forms of exercise like yoga, tai chi, qi gong, and the martial arts directly promote mindful attention to the physical movements and may be an easier fit. These practices can result in a heightened sense of body awareness and the associated therapeutic benefits, especially for people struggling with trauma, addiction, and eating disorders.

General Health Benefits

According to a Harvard Medical School report, 90% of patient visits may be contributed to stress-related problems. It is the third highest source of healthcare costs, after heart disease and cancer. Yoga has been proven to reduce stress symptoms in healthy people as well as those with depression and anxiety. Other proven areas of benefit include cardiovascular health (lowers blood pressure, heart rate, cholesterol levels), sleep hygiene, and immune health. In addition, yoga increases natural antioxidants, helps in weight management, and increases body strength, flexibility, and balance. Moreover, research suggests yoga can improve or maintain cognitive health in older adults [29].

Even helping professionals who are not convinced that mindful movement practices like yoga can stand alone as treatment for mental disorders should recognize their potency as adjunctive, healthy, complementary activities for clients, as stated by the ISTSS. When working with clients on accessing healthy coping skills and developing a social network support of their recovery, local yoga studios can be a great resource. Yoga studios are set up to offer classes in many different levels of yoga, and many offer other programs, like MBSR, specialty wellness workshops, drum circles, or healthy dance activities (e.g., Zumba, Nia). In addition, fitness centers and gyms often offer yoga classes.

Holy Yoga: A Christianity-Based Yoga Practice

As discussed, some people are resistant to take up Eastern practices, even for exercise, because they somehow feel that they are violating their religious traditions (e.g., Judeo-Christian, Islamic). One response to this concern has been the development of the program Holy Yoga, which takes the breathing and stretching benefits of mindful yoga and practices them alongside Christian spiritual principles [42]. It is unclear if the wider availability of programs like these (and expansion to other religions), along with a growing body of research supporting the efficacy of yoga, will address the concerns of critics.

DANCING MINDFULNESS

In the 1970s, the conscious dance movement began on the West Coast. This approach promotes the gathering of people to dance in a "come as you are" format. Conscious dance classes are not focused on learning specific steps, but rather encouraging dancers to connect their breath to movement in a mindful way.

One such approach is dancing mindfulness, which draws on research from mindfulness work and trauma competency, using the art of dance as the primary medium of discovering mindful awareness. Participants are encouraged to access their body's healing resources while dancing through seven primary areas of mindfulness in motion: breath, sound, body, story, mind, spirit, and integrated experience, with a respect to the attitudes of mindfulness [8]. A small study of women who engaged in a dancing mindfulness practice found improvements in overall health and well-being and growth in emotional and spiritual domains [43].

Instructions

- Spend some time with a mindful breath of your choice, working your way into a body scan.

- Introduce some music into your experience. You can do this by turning on a radio, starting your personal music device, or starting a playlist made in advance along a theme.

- Begin moving organically in a way that connects your breath to the music and to the body. The key is to move with intention and focus on staying in the moment with your movements.

- For your practice to truly be dancing mindfulness, regardless of how long it is, it is important to spend some time in body stillness at the end, letting your breath, the music, and your body integrate the fruits of your practice.

Modifications

Dancing mindfulness can be practiced as an activity with friends or as an activity within a therapeutic setting, as long as people keep a commitment to safe physical and emotional practice. Having a leader to keep the group experience organized and on task with mindful focus is recommended.

Before recommending yoga, dancing, wellness workshops, or even community-led MBSR, it is important to do research regarding local offerings. If one has doubts about whether certain yoga studios would understand the needs of clients, call and ask to speak to the director of the studio or the teacher in question and get a feel for his or her comfort in working with clinical populations.

MINDFUL EATING

In Western culture, especially in the United States, eating is often done automatically or while distracted, and this mindless eating has been linked to obesity and gastrointestinal problems [44]. One solution is to practice mindful eating, an approach used by many eating disorder and weight-loss programs to help participants reorient their relationship to food. The art of mindful eating includes:

- Slowing down

- Carefully paying attention to the food and the sensations it creates in the body

- Being attuned to each sense in order to fully savor the experience

Mindful eating, like other channels of mindfulness, requires practice. Popular food items for completing this exercise include almonds, raisins, and dark chocolate. MBSR, for instance, makes use of raisins as its instruction method. One can also use an item that comes with a wrapper for extra sensory dimensions [8].

Instructions

- Find an edible item that comes in a wrapper, like a starlight mint or a chocolate.

- Hold the item in your hand. Look at it and really observe it. Notice every detail of what you see.

- Roll the item in your hands and notice what the wrapper feels like and what it sounds like.

- As slowly as you are physically able, begin to unwrap the packaging, paying attention to every sense along the way, especially the sound. Place the wrapper aside.

- Look at the edible item in your hand, noticing what it looks like, rolling it in your hand and bringing it up to your nose to smell it.

- Very slowly, bring the item to your mouth and rub it over your lips, noticing whatever you notice, then put it in your mouth. Just allow the item to sit on your tongue for a few minutes. Be curious. Bring the item to the roof of your mouth and roll it around the sides of your mouth.

- Before biting into or ingesting the object, be sure to take some swallows and notice any juiciness or other tastes coming from the item.

- Mindfully take your first bite into the item, noticing what it sounds like, what it feels like, what it tastes like, and even a surge in the smell.

- Continue at this slow pace, savoring each sensation, down to the last swallow.

Modifications

Individuals may practice mindful eating for an entire meal, noting if they are satiated earlier. If trying this with a whole meal seems like too much to handle for now, consider focusing on one item (e.g., committing to eating the mashed potatoes mindfully).

MINDFUL LISTENING

Not feeling heard or listened to is one of the great causes of distress in humans today. This suffering is no surprise when a culture is heavy on talking and slim on actually listening.

To become a better listener, actually making time to practice listening is paramount. In Western culture, music and sounds are more background noise than anything, almost like a soundtrack for fast-paced multitasking. Teaching (and practicing) mindful listening can help build listening skills and be used as a valuable stress reliever.

Instructions

- Start with finding a simple nature sound or series of sounds. This may be a sample recording or ambient sounds in nature (e.g., the park).

- Begin practicing single-pointed concentration on that sound. For the next three minutes, your only job is to listen to that sound. Once again, if your attention wanders, be patient and gentle with yourself. Use these moments as opportunities to draw your attention back to the sound.

- Notice what happens. If a first sound choice is not effective, persist and keep experimenting. There are thousands of sounds and sound combinations you can try until you find what works for you.

Modifications

For some, actual pieces of music may work better than nature sounds. Simple, hypnotic/meditative music may do the trick; for others, more dynamic sounds may engage them more fully. Some may benefit most from music with lyrics. Individuals should try different sounds to find a listening experience that clears any manifestations of stress. For hearing-impaired clients, the benefits of this exercise can be achieved by sitting close to large speakers and feeling the vibrations.

The Internet and online applications make accessing music and nature sounds easy. Even individuals in offices or cities far from the sounds of nature can use modern technology to practice this technique. One smartphone application makes the tranquil sound of a Tibetan singing bowl at random or predetermined intervals to remind the listener to pay attention—quite literally a call to mindful awareness. Even taking a few moments to really absorb the sound of the singing bowl can make a powerful difference.

MINDFULNESS IN ALL ACTIVITIES OF LIFE

One of the most powerful lessons of mindfulness is a resistance to multitasking. This is reflected by a simple approach to everyday tasks. For example, if you are going to do the laundry, really do the laundry. After everything presented so far in this course, consider what this might mean. One of the core lessons of mindfulness in daily living is to be in the moment for every task, giving it total focus. So, for instance, when one is doing the laundry, this will capture one's sole attention, instead of having other projects going on as well.

Those in the high-pressured, multi-tasking generation are likely to fight this wisdom. Yet, in practice, they will often find that staying focused on the task at hand results in less stress. The idea of practicing mindfulness in every activity of daily life can serve as a means for stress relief and overall wellness; living in this manner is a worthy point to discuss with clients. Be prepared to process or coach through any resistances that may come up, because doing the tasks of the day in a mindful fashion can seem impossible to clients at first. As with teaching any mindful practice, it is imperative to advise clients to start small and avoid getting frustrated if the practice is not immediately conquered.

Reflection

Think about one of your activities of daily living that you seem to do on autopilot, like doing the laundry, brushing your teeth, or cooking dinner. The next time you do that activity, do it with single-pointed concentration and notice what happens for you. Practice the art of mindfulness in daily living. Try it for at least one week with three different activities.

7. MINDFULNESS IN THE CLINICAL SETTING: TREATMENT PLAN STRATEGIES

INTEGRATING MINDFULNESS INTO ANY APPROACH

It is very common for beginning helpers to struggle with the concept of silence, interpreting it as a sign that they have done something wrong or that the session has stalled due to their incompetence. However, with practice, one will find it is in the silence where clients do their best work. When words are removed, even for a moment, tremendous insight can emerge. Giving a client permission to be silent, to just sit with something (e.g., a thought, a feeling, a body sensation), is a solid technique. If there is a silent halt in a session, one should honor it and encourage clients to be comfortable when silent and still with their experience; the session will move on when it is supposed to.

This is a way to subtly interweave mindfulness into work with clients. Silence is one of the microskills of counseling that is inherently mindful, and it is one of the simplest ways to integrate mindfulness into clinical work, regardless of one's primary orientation. Giving clients the permission or encouragement to be with that silence and notice what comes up in a non-judgmental way transforms the potency of the skill. The following is an example of how this might play out in a session:

Client P is 26 years of age, a White gay man who is in counseling for issues connected to depression and low self-esteem. He and his counselor have just engaged in an emotional discussion about his father's non-acceptance of his sexual orientation and choices that he has made about his career. The session has gone silent, and by practicing the skill of attunement through reading Client P's nonverbal communication, the counselor chooses to invite the silence.

Counselor: It's okay. You don't have to say anything right now. Why don't you just sit with the silence and notice whatever may come up in you? Don't censor whatever you may get; just go with it.

Client P: (takes a breath) Okay.

For the next several minutes, the two sit in silence, with only the sound of both of their breathing patterns audible. Client P expresses a series of winces and eventually starts to cry.

Client P: Sad. I'm just really sad.

Counselor: Okay, sad. Let's not judge that sadness, P. Just be with that feeling; don't judge it.

TO BE WITH THE EMOTION/WORD/SOMATIC EXPERIENCE

Too often, clinical work gets stifled because, just like modern society, counselors and clients think that there must always be something to say or think about. Therapy has come to be associated with analysis and breaking things down, a place clients come to be called out on their dysfunctional thought patterns and behaviors. While these can be important features of therapy, their excess can thwart the emergence of emotional or somatic material that needs to come to the surface in order to be cleared. One intervention that may be used to counter this tendency, regardless of the modality used in a session, is to invite a client to just "sit with" an emotion, a word, or a somatic experience. Giving her/him permission to just be with something without an internal critic can make room for movement within the session, especially movement of the insight-oriented nature.

Reflection

How comfortable are you with silence in your clinical sessions? What barriers may exists that keep you from being comfortable with silent moments?

Mindfulness approaches may be incorporated in treatment planning with a variety of conditions commonly encountered in clinical work. In general treatment planning, a three-tiered structure that is seen as a consensus in the literature, especially when it comes to addressing trauma- or stressor-related disorders, may be followed.

Stage one begins with stabilizing the client and preparing him or her for deeper healing work. The teaching of coping skills and affect regulation techniques is a vital component of stage one work, and this is an ideal time to begin the introduction of mindfulness strategies for coping.

In stage two, the client is assisted to more deeply process emotional disturbances or issues that he or she is stuck on, blocking optimal health.

Finally, in stage three, reintegration, the client takes the skills that he/she has acquired as part of their therapy into life following termination.

ANXIETY- AND TRAUMA-RELATED DISORDERS

Although the revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) contains a category of trauma- and stressor-related disorders separate from anxiety disorders, for the purposes of discussing clinical mindfulness, anxiety and trauma may be examined together. Not all trauma meets criteria for PTSD. The term "trauma" is from the Greek word meaning wound, and clinically significant trauma may be conceptualized as unhealed emotional wounds that continue to cause functional impairment. In some cases, the result is a PTSD diagnosis, but other times the unhealed wounds manifest as other diagnoses, including anxiety, depression, and adjustment disorders.

Strategies

If the unhealed emotional wound is what the clinician is entrusted to clinically treat, mindfulness strategies are powerful bandages in stage one work. Before any clinician can proceed with the cathartic work of reprocessing associated with healing trauma, it is important to ensure that a client is reasonably able to tolerate the emotional intensity that goes with such work. Developing a coping skills plan with an individual client is usually a trial-and-error process—what works for one client may not necessarily work for another. When helping a client devise his or her coping plan, the following strategies may be helpful:

- Breath work (diaphragmatic first, followed by others)

- Clench and release technique

- Mindful listening (with other sensory variations, if needed)

- Body cuing and/or tactile mindfulness

Body Cue

A skill that may be helpful in the early stage of therapy for any condition, especially anxiety and trauma-related disorders, is the body cue; traditional MBSR and yoga traditions refer to this skill as the body scan. The intention is to encourage the client to begin paying attention to her or his body and to listen to the cues it gives. Whereas traditional, meditative body scans can take a very long time to do properly, use of the body cue is intended to teach clients how to check in with their visceral responses at a moment's notice [8].

Instructions

- Bring to mind something that causes you stress. It does not have to be a major trauma, but something that you identify as stressful.

- Spend a few moments reflecting on that stressor. What does it look like? Does it have a sound or any other sensory qualities?

- Now, notice what is happening in your body. Does the stress seem to be felt in one part of your body or in one organ specifically? Or is the stress felt all over your body? There are no right or wrong answers, just practicing acceptance of what is going on in your body right now. Spend a few moments just sitting with the stressor, noticing the body response in a spirit of non-judgment.

- Begin describing the presence of that stressor in your body: If it had a color, what color would it be? If it had a shape, what shape would it be? If it had a texture, what would that texture be? Are there any other qualities, like temperature, sound, or smell?

- Ask yourself, what does my body need the most right now to help the presence of this body stress? Even if your gut-level answer does not seem to be the healthiest response, practice non-judgment; just notice what your body needs.

Modifications

It can be interesting to consider drawing the experience of stress in one's body. Young people in particular may find this approach more appealing or accessible then having to describe it. Colored pencils, crayons, markers, or other crafting elements can be employed.

Tactile Mindfulness

Unresolved trauma and fears that cause anxiety can produce powerful, visceral responses at the body level. This is a major reason for the strong connection between trauma-related disorders and addiction problems—the physical pleasure of addictive behaviors is soothing. The challenge in working with anxiety, trauma, and addiction is to teach clients healthier ways to work with their bodies. In addition to breath work and muscle work, another strategy that uses an outside object to promote mindful practice, especially through the tactile channel, can be a useful tool. Popular objects to use for this activity include marbles, stones, and gems or crystals [8].

Instructions

- Imagine that this is the first time you are ever looking at this type of object; approach it with the spirit of a beginner's mind. Take the object in your hand and observe the color. Practice patience and spend several minutes just noticing what you notice about the colors and patterns.

- Notice the weight of the object in your hand. Try moving it from hand to hand and notice if there are any differences.

- Roll the object around in your hands. Observe the texture of the object against your skin.

- Notice if you hear any sounds.

- Repeat as many times as necessary, practicing curiosity with each set.

Modifications

Any object can be used for this exercise, especially objects that are meaningful to a client. The key is to think of an object that is ordinarily taken for granted, yet upon examination, contains new wonder. Popular alternatives include thimbles, small toys that might have special significance to a child, and 12-step recovery coins, chips, or tags.

Stage One: Stabilization

It is important to coach clients to use these skills outside the office setting. It is great if a skill works in the office, but it is important for clients to put them to the test in their outside lives. If they are an inpatient or incarcerated, it is important that they test these skills when they are not with a counselor. As a stabilization approach, it may also be good practice to determine if a formal MBSR program or other mindfulness meditation program is available in the community for a client to access as an adjunct to psychotherapy. Stage one stabilization may also be a good time to explore referring a client to yoga or other wellness-based exercise programs, also as a complement to psychotherapy.

Stage Two: Stabilization

If a client becomes accustomed to listening to his or her body responses and honoring them in stage one work, it widens the potential of stage two work. When practicing catharsis-oriented reprocessing stages of therapy, one may observe a major difference between clients who practice mindfulness and those who do not. The clients who practice mindfulness are aware of their own body responses and are willing to notice them in a spirit of non-judgment. The tendency to overanalyze in a cognitive sense falls away, and these clients, quite simply, process more efficiently.

Regardless of the modality used to process trauma, a barrier that many clinicians experience when it comes to trauma is fear of destabilizing clients or making clients feel worse. However, if a client is properly stabilized and equipped with dynamic coping skills for addressing intense emotional responses, the chances of destabilizing a client are significantly decreased.

Helping clients become more mindful of their internal world during stabilization increases the likelihood that they will be able to stop if they have gone too far with processing emotional material in any given session. As such, being mindful helps with both physical and emotional safety. By beginning sessions orienting clients to what mindfulness means and how to listen to and honor the messages of one's physical body and emotional needs, clients become simultaneously aware of their possibilities and limitations.

ADDICTION

In many cases, approaches effective for the treatment of trauma triggers are also effective for the treatment of addiction cravings and responses. As discussed, there is a connection between unresolved trauma and addiction responses because it is a natural tendency to practice avoidance (one of the specific criteria of the PTSD diagnosis) when viscerally threatened. Self-soothing with an instantly gratifying chemical or behavior is a sure way to calm the body, but the escape is only temporary, and for many, the vicious cycle escalates. However, a full discussion of the intricacies and debates of trauma-addiction interaction is beyond the scope of this article.

G. Alan Marlatt, a major figure in the area of treating addictive disorders, and his colleagues developed MBRP, an approach designed as an aftercare program following primary addiction treatment that follows a flow similar to MBCT, with specific focus on relapse prevention [45]. The major goals of MBRP are to:

- Develop awareness of personal triggers and habitual reactions, and learn ways to create a pause in this seemingly automatic process.

- Change one's relationship to discomfort, learning to recognize challenging emotional and physical experiences and responding to them in skillful ways.

- Foster a non-judgmental, compassionate approach toward oneself and one's experiences.

- Build a lifestyle that supports both mindfulness practice and recovery.

Even when not using MBRP's specific protocol, the goals for therapy with recovering addicts are similar. The coping skills developed for both trauma and addiction are centered on working with body-level responses and practicing self-compassion. The definition of non-judgment provided previously in this course essentially outlines the mindful approach in working those in recovery. Similar to work with trauma, addiction work can begin with teaching the following coping skills with a mindful focus:

- Breath work

- Clench and release

- Mindful listening

- Tactile mindfulness

- Body cuing

When working with body cuing during recovery, it is important for clients to begin noticing and describing not only how stress manifests in the body, but how to work with how cravings manifest in the body as well. The following is a script that one can use as a guideline (modified and personalized) to help a client identify his or her cravings and address them in a healthy way using body cuing.

Bring to mind your drug of choice or whatever stressor makes you want to use your drug (or behavior) of choice. Spend a moment being totally aware of that drug or stressor. Notice any sensory details you may notice about it. What does it look like? Does it have any other sensory details, like a sound or a smell? Just notice, non-judgmentally, anything that is connected to this drug or stress.

Take a moment to notice what is happening in your body. There are no right or wrong answers; just notice whatever you may notice. Maybe you feel something in one particular area of your body or maybe you feel something all over. Whatever it is, just honor it and be with it. If whatever is coming up in your body had a color, what color would it be? If it had a shape, what shape would it be? Maybe it has a texture. Maybe it has a sound or a smell. Whatever it is, just notice it and pay attention to it.

Now I would like you to think about one of your healthy coping skills—maybe breathing, working with your muscles, or getting up and taking a walk. Ask your body what healthy outlet it most needs right now. Then, honor your body by engaging in that healthy coping skill and notice what happens. Whatever skill you choose, remember to breathe mindfully and fully throughout the exercise. Just keep noticing what happens.

Learning to listen to one's body and train it to respond in a healthy way is a prime skill for recovering addicts to foster, as the body will give clues before one's mind consciously recognizes an issue. Mindfulness is about responding to stress instead of reacting to stress. A Kabat-Zinn axiom is that while one cannot stop the stress of life (or in this case, the cravings of addictive responses), one can learn how to surf the stresses [6].

DEPRESSION AND GRIEF

A common saying in mindfulness-based classes is that anxiety is about living in the future and depression is about living in the past. The solution is to develop a practice of living in the present moment. However, this can be difficult. In working simple mindfulness strategies with depression and conditions related to unresolved grief, the primary goal is to help a person become more present-focused even while exploring unresolved trauma from the past.

As discussed, one strategy for interweaving mindfulness into a session is to begin and end with three minutes of mindful breathing (of the client's choosing). Even if cognitively oriented methods are used for processing, incorporating this simple breath work will prepare the brain for the work.

A common complaint with depressive disorders is poor energy or motivation. Clients may express mental fatigue, saying "My head hurts from thinking so hard," or "These thoughts running around in my head just will not stop." Mindfulness techniques such as energetic massage and guided imagery can be used to help energize or reorient a client [8].

Energetic Massage

Instructions

- Rub your hands together for at least 30 seconds. Really work up some heat.

- Pull your hands apart and bring them to your forehead. You can close your eyes and place the base of your palms over your eyes, letting the rest of your hands curl to the top of the forehead. Or you can rest the base of your palms on your cheeks and let your fingers go around your eyes.

- Settle in and feel the energy you generated in your hands move into your brain. Just let go and let the energy work in you. Practice non-striving.

- Hold as long as you like.

Modifications

One can bring the energy from the hands to any part of the body that is feeling tense or anxious. Think about bringing the heat energy from the hands to the chest or stomach if any tension or pain is present in those areas.

The "cranial hold" position is an option after generating the energy. To achieve this, horizontally bring one hand to the forehead and the other hand to the back of the head. Consider adding another sense into the process for optimal relaxation, like meditative music or aromatherapy.

Guided Imagery

Guided imagery is another very popular coping skill. While many guided imageries may not work well with mindfulness because they promote using one's imagination as an escape (e.g., safe place, spiral staircase), there are some guided imageries that use the body and can be practiced very mindfully. One such exercise to use for this purpose is called light stream [4].

Instructions

- Imagine that a bright and healing light has begun to form overhead. This light can be whatever color you want it to be, whatever you associate with healing, happiness, goodness, or any of the other attitudes of mindfulness. If you do not like the idea of a light, you can think of it simply as a color or an essence.

- Now, think about this light beginning to move through or over your body, from the top of your head, moving inch-by-inch, slowly, until it reaches the bottom of your feet. This light can be seen as grounding you safely into the earth, if this is comfortable.

- Allow a few moments to just spend time with the presence of this light or essence in your body. Notice if it has any other qualities besides color, like a texture, a sound, or a smell.

- Draw your attention back to where you first cued your body stress. If the distress is still there on some level in your body, think about deepening your breathing so it makes the light or essence more brilliant and intense—so intense that the distress cannot exist within it.

- Keep practicing the exercise, in the attitude of patience, if you do not notice much of a shift the first time.

Modifications

The light/essence can enter anywhere in the body. For instance, if one's anxiety is felt mainly in the chest, it may feel more appropriate to have the light enter there. If the light stream image alone is hard to keep in focus, add another sensory element to enhance the focus (e.g., smell, simple sound or music, tactile sensation). Although most light-stream imagery approaches make use of the language of calming, the client may choose a color or light stream that represents an empowering or energizing quality.

Persons with a spiritual belief system may imagine that the light comes from a spiritual source (e.g., heaven, God/Allah, the universe). Using the variations with spiritual dimensions can be powerful when working with individuals struggling to process an unresolved grief or people who have been wounded by religion or spirituality in the past. The light-stream imagery makes use of the body domain and the spirit domain, if a client wants to go there.

In working with trauma, depression, and grief, it is good practice to start guided imagery with a light-stream exercise, which is naturally more mindful because it is rooted in the body (compared with "place" imageries). As discussed, any intervention done in the spirit of mindfulness is generally safer. If a client tolerates this exercise well, one can progress to incorporation of guided place imageries that may naturally be more emotionally charged and bring up material that is well-suited for stage two processing. Light-stream imagery is also a good skill to bring closure to a session after a client has engaged in emotionally evocative work.

A Note About Grief

Grief is a normal part of the human experience that, if not adapted to sufficiently, can lead to functional impairments. Many clinicians are rightfully tentative to pathologize grief. In the DSM-5-TR, there is a special note in the depressive disorder diagnosis criteria cautioning professionals that some expressions of grief may manifest as clinical depression, and in these cases a diagnosis can be made. Professionals are advised to use their discretion about what constitutes a depressive episode compared to, in DSM-5-TR terms, a typical grief response [46].

However, some find the terms "typical" and "normal" to be problematic clinical constructs. Worden favors the term "adaptation" when describing how people respond in the aftermath of a loss, indicating that one will never be the same after a loss and recognizing that certain people will adapt more healthfully to the experience of loss than others, based on a wide variety of individual and situational variables [47]. These variables can include the nature of the relationship, the value placed on what was lost, an individual's internal resources for coping, and frames of reference for meaning-making and/or spiritual integration of the experience.

Although not a solution for every client, mindfulness strategies can be helpful for many struggling to adapt in the aftermath of a loss. These approaches can be applied in whatever combination will best help the individual more fully embrace the foundational attitudes of mindfulness, especially acceptance, trust, and letting go. The simple strategies covered throughout this course can help an individual endure the proverbial waves of grief when they come.

In some cases, coping with grief is made more difficult by the internal judgments that clients experience, often in reflection of others. Shame obviously plays a significant role in addiction and trauma, but it can be just as significant in complicated grief presentations when a person feels he or she should somehow be over the experience. A mindfulness practice can provide individuals with the tools to deal with whatever emerges emotionally in a non-judgmental manner. Resultantly, the adaptation becomes more effective and ultimately healthier.

Reflection

If you have experienced issues with depression, anxiety, trauma, or addiction, what worked best for you in terms of healing? Looking back on what worked, could any of these activities be described a part of the mindfulness spectrum covered in this course?

8. MINDFULNESS IN CONTINUING CARE

STRATEGIES FOR REINTEGRATION USING MINDFULNESS

Reintegration, the third stage in the three-tiered model for trauma processing, is about equipping clients with the skills they need to live life healthily and happily. Although certain exceptions may apply for clients with chronic mental illness, in general, the goal is to help a client work through his or her issues and adopt the necessary skills to no longer require regular therapy—a lifestyle change.

Mindfulness as a Lifestyle Choice

Originally coined by Alfred Adler, the concept of lifestyle is important to overall mental health and wellness [48]. Lifestyle is the series of choices and patterns that individuals live that are formed in reaction to early life experiences. Lifestyle can be changed at any time, an idea that is easier said than done for most. Mindful practice can play a major role in this area, especially with the focus on responding to stressors of life rather than reacting to them. If mindfulness is practiced in small ways and gradually evolves to embrace the idea that everything in life can be engaged in mindfully, the possibilities for shifts in outlook and overall lifestyle choices are infinite.

Revisit Skills and Reframe Focus

When working with clients, it is important to allow for many sessions to talk about termination, or life after therapy. This can include encouraging dialogue highlighting what has worked during the clinical process and to develop a plan for how clients continue working with these positives in their daily lives. For example, if a client said that learning how to breathe properly really helped him during the process, discuss how he can continue working with breath every day, both in structured practice time and as needed when stressed. If a client credits mindful listening with being a significant stress reliever, discuss how to continue using these strategies in daily life. The great secret to stage three work in the three-tiered approach is to revisit many of the same skills that were built during stage one stabilization and reframe their focus for use in continued lifestyle wellness and development.

ACCESSING RESOURCES WITHIN THE COMMUNITY

Exploring wellness resources available in the community is an imperative part of reintegration work. If a client mentions following through with a recommendation during therapy (e.g., yoga, dance, community meditation group) and finding some benefit, he or she should be encouraged to continue. Although clients may not need therapy for the rest of their lives, everyone can benefit from support, especially support that comes from a community of people who are focused on wellness.

The first step in identifying local mindfulness resources is often a simple Internet search. Because MBSR, as a structured program, has shown results in promoting psychological well-being, make a point to find out where those programs are offered in the local community. In addition, many socially conscious yoga studios offer at least some classes as sliding scale or donation-based in order to bring programming to those who may need it most. Some Veterans Affairs hospitals offer free yoga classes for veterans and their families, and some programs are available in inner city areas to teach yoga and meditation to underprivileged youth.

Reflection

On the Internet, go to a search engine and enter terms like "MBSR" or "yoga," paired with the name of your city or region. What are the results? Are you willing to try these opportunities or attend the classes before sending your clients there?

9. CONCLUSION

When people begin to study mindfulness, many discover that it is a coping response they have automatically used in the past. This course has outlined some approaches to practicing mindfulness in every aspect of life in order to achieve mental health and well-being. Bernhard identifies six primary outcomes that can flow from practicing mindfulness as a guideline for living, even outside formal meditation [49]:

- Mindfulness gives the mind a rest from a fixation on discursive thinking.

- Mindfulness takes us out of ourselves.

- Mindfulness turns a boring activity into an adventure.

- Mindfulness frees us from judgment.

- Mindfulness enables us to make wise choices.

- Mindfulness opens our hearts and minds to the world unfolding before us.

The goal of this course has been to provide practitioners with ideas on how to practice mindfulness in order to experience these outcomes and pass them along to clients, beginning with the foundations of mindfulness, the attitudes of mindfulness practice, and the history of mindfulness and how it emerged as a powerful force in modern health care. Specific techniques for practicing mindfulness in all life activities were provided, including breathing, walking, eating, exercising, listening, and dancing. Next, strategies for integrating mindfulness practice into treatment across the spectrum were explored, especially with conditions like anxiety, trauma-related disorders, depression, and unresolved grief. Finally, ideas for how to help clients continue using mindfulness after they formally terminate therapy were considered, with special attention paid to helping clients access community resources.

10. RESOURCES

WEBSITES

Dr. Andrew Weil

https://www.drweil.com

Center for Healthy Minds

https://centerhealthyminds.org

The Greater Good Science Center at UC Berkeley

https://greatergood.berkeley.edu

American Mindfulness Research Association

https://goamra.org

Trauma Made Simple

https://www.traumamadesimple.com

BOOKS

Bays JC. Mindful Eating: A Guide to Rediscovering a Healthy and Joyful Relationship with Food. Boston, MA: Shambhala Publications; 2009.

Baxter B, Zolotow, N. Yoga for Healthy Aging: A Guide to Lifelong Well-Being. Boulder, CO: Shambala Publications, Inc.; 2017.

Catton T. The Mindful Addict: A Memoir of the Awakening of a Spirit. Las Vegas, NV: Central Recovery Press; 2010.

Dass R. Be Here Now, Remember. San Francisco, CA: The Lama Foundation; 1971.

Dayton T. Trauma and Addiction: Ending the Cycle of Pain Through Emotional Literacy. Deerfield Beach, FL: HCI Communications; 2000.

Emerson D, Hopper E. Overcoming Trauma Through Yoga: Reclaiming Your Body. Berkeley, CA: North Atlantic Books; 2011.

Hanh TK, Cheung L. Savor: Mindful Eating, Mindful Life. New York, NY: Harper One; 2011.

Hanson R. Resilient: How to Grow an Unshakable Core of Calm, Strength, and Happiness. New York, NY: Penguin Random House LLC; 2018

Hawk K. Yoga and the 12-Step Path. Las Vegas, NV: Central Recovery Press; 2012.

Jacobs-Stewart T. Mindfulness and the 12 Steps. Center City, MN: Hazelden; 2010.

Marich J, Paintner CV. Dancing Mindfulness. Woodstock, VT: SkyLight Paths Publishing; 2016.

Marich J. Trauma and the Twelve Steps: A Complete Guide to Enhancing Recovery. Warren, OH: Cornersburg Media; 2012.

Najavits L. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York, NY: Guilford Press; 2002.

Roth G. Women, Food, and God: An Unexpected Path to Almost Everything. New York, NY: Scribner; 2011.

Ryan T. A Mindful Nation: How a Simple Practice Can Help Us Reduce Stress, Improve Performance, and Recapture the American Spirit. Carlsbad, CA: Hay House; 2012.

Tang Y-Y. The Neuroscience of Mindfulness Meditation: How the Body and Mind Work Together to Change Our Behavior. New York, NY: Springer International Publishing; 2017.

Wei M, Groves J. The Harvard Medical School Guide to Yoga: 8 Weeks to Strength, Awareness, and Flexibility. Boston, MA: Da Capo Press; 2017.

Weintraub A. Yoga Skills for Therapists: Effective Practices for Mood Management. New York, NY: W.W. Norton; 2012.

Works Cited

1. Hanh TN. The Miracle of Mindfulness: An Introduction to the Practice of Meditation. Boston, MA: Beacon Press; 1975, 1976.

2. Keng S-L, Smodki M, Robins C. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev. 2011;1041-1056.

3. Time Magazine. The New Mindfulness: Living, Thinking, Being. New York, NY: Time, Inc. Books; 2018.

4. Dass R. Remember, Be Here Now. San Francisco, CA: The Lama Foundation; 1971.

5. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of the Body and Mind to Face Stress, Pain, and Illness. Revised edition. New York, NY: Bantam Books; 2013.

6. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York, NY: Hyperion; 2005.

7. Kabat-Zinn J. Mindfulness for Beginners: Reclaiming the Present Moment-and Your Life. Boulder, CO: Sounds True Books; 2011.

8. Marich J. Creative Mindfulness: 20+ Strategies for Recovery and Wellness. Warren, OH: Mindful Ohio; 2013.

9. Malhotra R. Dharma is Not the Same as Religion. Available at https://www.huffpost.com/entry/dharma-religion_b_875314. Last accessed August 31, 2023.

10. McCown D, Reibel DK, Micozzi MS. Teaching Mindfulness: A Practical Guide for Clinicians and Educators. New York, NY: Springer Publishing; 2010.

11. Eberth J, Sedlmeier P. The effects of mindfulness meditation: a meta-analysis. Mindfulness. 2012;3(3):174-189.

12. Good Therapy. Mindfulness-Based Cognitive Therapy. Available at https://www.goodtherapy.org/learn-about-therapy/types/mindfulness-based-cognitive-therapy. Last accessed August 31, 2023.

13. Kuyken W, Warren FC, Taylor RS, et al. Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis from randomized trials. JAMA Psychiatry. 2016;73(6):565-574.

14. Kyuken W, Hayes R, Barrett B, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomized controlled trial. Health Technol Assess. 2015;19(73):1-124.

15. Linehan M. Skills Training Manual for Treating Borderline Personality Disorder. New York, NY: Guilford Press; 1993.

16. Baer RA (ed). Mindfulness-Based Treatment Approaches: Clinician's Guide to Evidence Base and Applications. London: Elsevier; 2006.

17. Chapman A. Dialectical behavior therapy current indication and unique elements. Psychiatry. 2006;(9):62-68.

18. Hayes SC, Stroshal KD, Wilson KG. Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd ed. New York, NY: Guilford Press; 2011.

19. Walser RD, Westrup D. Acceptance and Commitment Therapy for the Treatment of Post-Traumatic Stress Disorder and Trauma-Related Problems: A Practitioner's Guide to Using Mindfulness and Acceptance Strategies. Oakland, CA: New Harbinger Publications; 2007.

20. Alcoholics Anonymous World Services. Alcoholics Anonymous. 4th ed. New York, NY: Alcoholics Anonymous World Services; 2001.

21. Marich J. Trauma and the Twelve Steps: A Complete Guide to Enhancing Recovery. Warren, OH: Cornersburg Media; 2012.

22. Carlson LE. Mindfulness in Cancer Care: Hype or Help? Available at https://ascopost.com/issues/july-10-2018/mindfulness-in-cancer-care. Last accessed August 31, 2023.

23. Shonin E, Van Gordon W, Griffins MD. Mindfulness-based interventions: towards mindful clinical intervention. Front Psychol. 2013;4:194.

24. Tang YY, Hölzel BK, Posner MI. The neuroscience of mindfulness meditation. Nat Rev Neurosci. 2015;16(4):213-225.

25. Iyengar BKS. Light on Pranayama: The Yogic Art of Breathing. New York, NY: Crossroad Publishing Company; 1985.

26. King James Bible Online. Bible Verses About Meditation. Available at https://www.kingjamesbibleonline.org/Bible-Verses-About-Meditation. Last accessed August 31, 2023.

27. Sedlmeier P, Eberth J, Schwarz M, et al. The psychological effect of meditation: a meta-analysis. Psychol Bull. 2012;138(6):1139-1171.

28. Bauer-Wu S. Mindfulness meditation. Oncology (Williston Park). 2010;24(10):36-40.

29. Wei M, Groves J. The Harvard Medical School Guide to Yoga. Boston, MA: De Capo Press; 2017.

30. Wieland LS, Cramer H, Lauche R, Verstappen A, Parker EA, Pilkington K. Evidence on yoga for health: a bibliometric analysis of systematic reviews. Complement Ther Med. 2021;60:102746.

31. Cramer H, Langhorst J, Dobos G, Lauche R. Associated factors and consequences of risk of bias in randomized controlled trials of yoga: a systematic review. PloS One. 2015;10(12):e0144125.

32. Bhat S, Varambally S, Karmani S, Govindaraj R, Gangadhar BN. Designing and validation of a yoga-based intervention for obsessive compulsive disorder. Int Rev Psychiatry. 2016;28(3):327-333.

33. Uebelacker LA, Weinstock LM, Kraines MA. Self-reported benefits and risks of yoga in individuals with bipolar disorder. J Psychiatr Pract. 2014;20(5):345-352.

34. Mitchell KS, Dick AM, DiMartino DM, et al. A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. J Trauma Stress. 2014;27(2):121-128.

35. Jean M, Umair M, Muddaloor P, et al. The effects of yoga on bipolar disorder: a systematic review. Cureus. 2022;14(8):e27688.

36. Zaccari B, Callahan ML, Storzbach D, McFarlane N, Hudson R, Loftis JM. Yoga for veterans with PTSD: cognitive functioning, mental health, and salivary cortisol. Psychol Trauma. 2020;12(8):913-917.

37. Bhat SGS, Arasappa R, Jagannathan A, Varambally S. Yoga therapy for obsessive compulsive disorder: a case series from India. Asian J Psychiatr. 2021;62:102739.

38. Balasubramanian M, Telles S, Doraiswamy PM. Yoga on our minds: a systematic review of yoga for neuropsychiatric disorders. Front Psychiatry. 2013;3(117):1-16.

39. van der Kolk BA, Stone L, West J, et al. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014;75(6):e559-e565.

40. Cloitre M, Courtois CA, Ford JD, et al. The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available at https://www.istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf. Last accessed August 31, 2023.

41. Hilty B. More than the Physical: Running as a Spiritual Experience[honors thesis]. Boulder, CO: University of Colorado; 2016.

42. Holy Yoga. About Holy Yoga. Available at https://holyyoga.net/about. Accessed August 31, 2023.

43. Marich J, Howell T. Dancing Mindfulness: a phenomenological investigation of the emerging practice. Explore. 2015;11(5):346-356.

44. Mason AE, Epel ES, Kristeller J, et al. Effects of a mindfulness-based intervention on mindful eating, sweets consumption, and fasting glucose levels in obese adults: data from the SHINE randomized controlled trial. J Behav Med. 2016;39(2):201-213.

45. Bowen S, Chawla N, Marlatt GA. Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician's Guide. New York, NY: The Guilford Press; 2011.

46. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text revision. Washington, DC: American Psychiatric Association; 2022.

47. Worden J. Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner. 4th ed. New York, NY: Springer Publishing Company; 2008.

48. Adler Graduate School. Alfred Adler: Theory and Application. Available at https://alfredadler.edu/about/alfred-adler-theory-application. Last accessed August 31, 2023.

49. Bernhard T. Six Benefits of Practicing Mindfulness Outside of Meditation. Available at https://www.psychologytoday.com/us/blog/turning-straw-gold/201106/6-benefits-practicing-mindfulness-outside-meditation. Last accessed August 31, 2023.

Evidence-Based Practice Recommendations Citations

1. Management of Chronic Multisymptom Illness Guideline Working Group. VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness. Washington, DC: Department of Veteran Affairs, Department of Defense; 2021. Available at https://www.healthquality.va.gov/guidelines/MR/cmi/VADoDCMICPG508.pdf. Last accessed September 11, 2023.